Mayo Clinic

Medical Editors

Walter J. Cook, M.D. Kelsey M. Klaas, M.D.

Editorial Director

Paula M. Marlow Limbeck

Senior Editor

Karen R. Wallevand

Managing Editor

Rachel A. Haring Bartony

Senior Product Manager

Daniel J. Harke

Art Director

Stewart (Jay) J. Koski

Illustration, Photography and Production

Jeanna L. Duerscherl, Kent McDaniel, Kevin J. Ness

Editorial Research Librarians

Abbie Y. Brown, Edward (Eddy) S. Morrow Jr., Erika A. Riggin, Katherine (Katie) J. Warner

Copy Editors

Miranda M. Attlesey, Alison K. Baker, Nancy J. Jacoby, Julie M. Maas

Indexer

Steve Rath

Contributors

Katelyn R. Anderson, M.D.; Meghan R. Cain, M.D.; Jennifer L. Fang, M.D.; Jason (Jay) H. Homme, M.D.; Flora R. Howie, M.D.; Robert M. Jacobson, M.D.; Heather L. LaBruna; Anupama Ravi, M.D.; Magdalena Romanowicz, M.D.; Laura H. Waxman

Published by Mayo Clinic Press

© 2020 Mayo Foundation for Medical Education and Research (MFMER)

MAYO, MAYO CLINIC and the Mayo triple-shield logo are marks of Mayo Foundation for Medical Education and Research. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

Note: The information in this book is true and complete to the best of our knowledge. This book is intended only as an informative guide to those wishing to know more about health issues. In no way is this book intended to replace, countermand, or conflict with the advice given to you by your own physician. Information in this book is offered with no guarantees on the part of the authors or Mayo Clinic Press. The authors and publisher disclaim all liability in connection with the use of this book. The names and identifying details of people associated with events described in the book have been changed. Any similarity to the actual person is coincidental. The individuals pictured in the lifestyle photos are models. There is no correlation between the individuals portrayed and the condition or subject being discussed.

Library of Congress Control Number: 2019949851

ISBN-13 (hardcover): 9781893005570
ISBN-13 (ebook): 9780795352829

Printed in the United States of America.

Introduction

Raising a child is one of the most challenging, yet rewarding, experiences you’ll likely ever have. There is perhaps nothing more special than the lifelong bond that forms between a parent and a child.

Mayo Clinic Guide to Your Baby’s First Years is an easy-to-use yet comprehensive how-to manual for caring for your child, from newborn days all the way to toddlerhood. From chapters on month-by-month development to ones on health and safety, this book covers what you need to know. There’s also a wealth of tips for moms and dads coping with the many changes to daily life that come with parenthood.

The pages that follow will provide you with a lot of helpful information. But you’re the one who makes it all happen. A positive attitude, a good support system and plenty of love can go a long way in making the years ahead truly enjoyable.

A project of this scope requires the teamwork of many individuals. A special thanks to all of our colleagues who helped make this book possible.

The Editors

Walter J. Cook, M.D., (left) is a specialist in general pediatric care within the Department of Pediatrics, Mayo Clinic, Rochester, Minn., and an assistant professor at the Mayo Clinic College of Medicine and Science. A father of three, including twins, he has cared for thousands of babies in more than 25 years of pediatric practice.

Kelsey M. Klaas, M.D., (right) is a pediatrician in the Division of General Pediatric and Adolescent Medicine at Mayo Clinic Children’s Center in Rochester, Minn. She is the mother of two young children who brings both a medical and a new parent perspective to the book.

How to use this book

To help you easily find what you’re looking for, Mayo Clinic Guide to Your Baby’s First Years is divided into six sections.

Part 1: Caring for your child

From how to feed your newborn to helping toddlers develop good sleep habits, you’ll find basic baby- and toddler-care tips in this detailed section. You’ll also find tips for clothing your little one, strategies for comforting a crying baby and handling tantrums in the toddler years.

Part 2: Health and safety

Part 2 covers all of the key elements to preventing and dealing with injury and illness. You’ll read about doctor checkups and vaccinations, as well as suggestions for childproofing your home.

Part 3: Growth and development

This section provides monthly insights into your baby’s growth and development. It covers a range of topics including toys and games, separation anxiety, screen time, and preschool readiness. It also covers developmental milestones such as walking, learning new words and connecting with family members.

Part 4: Common illnesses and concerns

Here you’ll find helpful tips for managing conditions that commonly affect young children, such as fevers, colds, ear infections, pink eye and others. You’ll also learn when medication may be appropriate and when it may be best to avoid it.

Part 5: Managing and enjoying parenthood

Caring for a young child can be nerve-wracking and exhausting. The information in Part 5 can help you get through the first three years with the reassurance that you’re doing well.

Part 6: Special circumstances

Most children are born healthy, but sometimes problems can develop. Diseases and disorders that can affect young children, and how they’re treated, are discussed here.

Contents

Introduction

How to use this book

PART 1 Caring for your child

CHAPTER 1 Welcome to parenthood!

Parenting 101

This book

CHAPTER 2 Baby’s first days

Baby bonding

Baby’s looks

First examination

Newborn issues

Circumcision

Screening tests

CHAPTER 3 Feeding your baby

Breast milk or formula?

Breast-feeding

Pumping breast milk

Formula-Feeding

Spitting Up

CHAPTER 4 To solid foods and beyond

Starting solids

Introducing peanut butter, milk and other foods

Family mealtimes

CHAPTER 5 Diapers and all that stuff

Finding the right diaper

Getting equipped

Changing diapers

What’s normal

Diaper rash

CHAPTER 6 Toilet training

Recognizing readiness

Active training

Troubleshooting

CHAPTER 7 Bathing and skin care

Bathing basics

Bathing, step by step

Umbilical cord care

Circumcision care

Nail care

Common skin conditions

CHAPTER 8 Clothing your child

A few shopping tips

Wardrobe essentials

Laundry tips

CHAPTER 9 Sleep and sleep issues

Newborn sleep schedule

Sleep safety

Good sleep habits

Troubleshooting

CHAPTER 10 Comforting a crying baby

Why babies cry

Understanding baby’s cries

Comforting strategies

Colic

Managing colic

Keeping Your Cool

CHAPTER 11 Building a relationship

Nurturing your bond

Understanding temperament

You and your toddler

Setting limits

Playing with your toddler

PART 2 Health and safety

CHAPTER 12 Finding the right medical provider

Getting started

Medical provider options

Factors to consider

Evaluating your options

A team approach

CHAPTER 13 Checkups

Checkup schedule

What to expect at a well-child visit

Questions and concerns

CHAPTER 14 Vaccinations

How vaccines work

Why get vaccinated?

Vaccine safety

Childhood vaccinations

Side effects of vaccines

Weighing the risks and benefits

CHAPTER 15 Child care

Getting started

Child care options

Factors to consider

Contact information

Working together

CHAPTER 16 Traveling with a little one

Heading out

Baby carriers

Strollers

Car seats

Safe car seat use

Preemies and small babies

Air travel

Plan for success

CHAPTER 17 Home and outdoor safety

Nursery safety

Kitchen safety

Feeding safety

Bathroom safety

Garage and basement safety

Front yard and backyard safety

General safety tips

Preventing burns

Preventing falls

Preventing drowning

Be cautious, not panicked

CHAPTER 18 Emergency care

When to seek emergency care

Bleeding

Choking

Cardiopulmonary resuscitation (CPR)

Burns

Electrical shock

Animal or human bites

Drowning

Injury from a fall

Swallowed poison

Inhaled poison

Poison on the skin

Poison in the eye

PART 3 Growth and development

CHAPTER 19 Month 1

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 20 Month 2

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 21 Month 3

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 22 Month 4

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 23 Month 5

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 24 Month 6

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 25 Month 7

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 26 Month 8

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 27 Month 9

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 28 Month 10

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 29 Month 11

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 30 Month 12

Baby’s growth and appearance

Baby’s movement

Baby’s sensory development

Baby’s mental development

Baby’s social development

CHAPTER 31 Months 13 to 15

Toddler’s growth and appearance

Toddler’s movement

Toddler’s sensory development

Toddler’s mental development

Toddler’s social development

CHAPTER 32 Months 16 to 18

Toddler’s growth and appearance

Toddler’s movement

Toddler’s sensory development

Toddler’s mental development

Toddler’s social development

CHAPTER 33 Months 19 to 24

Toddler’s growth and appearance

Toddler’s movement

Toddler’s mental development

Toddler’s social development

CHAPTER 34 Months 25 to 30

Toddler’s growth and appearance

Toddler’s movement

Toddler’s mental development

Toddler’s social development

CHAPTER 35 Months 31 to 36

Toddler’s growth and appearance

Toddler’s movement

Toddler’s mental development

Toddler’s social development

Part 4 Common illnesses and concerns

Infants and medications

Taking your child’s temperature

Caring for a sick child

A to Z Illness Guide

Allergies

Anemia

Asthma

Bronchiolitis

Colds

Cough

Constipation

Crossed eyes

Croup

Diarrhea

Ear infection

Earwax blockage

Fever

Fifth disease

Flu (influenza)

Hand-foot-and-mouth disease

Hives

Impetigo

Insect bites and stings

Jaundice

Lazy eye

Pink eye (conjunctivitis)

Pneumonia

Reflux

RSV

Roseola

Stomach flu (gastroenteritis)

Sty

Sunburn

Swollen scrotum (from a hydrocele)

Teary eyes

Teething

Thrush

Urinary tract infection

Vomiting

Whooping cough

PART 5 Managing and enjoying parenthood

CHAPTER 36Adapting to your new lifestyle

Living on less sleep

Getting comfortable with chaos

Adjusting to your new role

Juggling work and family

Long days, short years

CHAPTER 37Parenting as a team

A new bond

New challenges

Sharing the load

Nurturing your team

Rekindling romance

Agreeing on child rearing

A firm foundation

CHAPTER 38Single parenting

Hard work, added pressure

From surviving to thriving

Rewards and strengths

CHAPTER 39Siblings and grandparents

Siblings

Sibling reactions

Sibling rivalry

If you have multiples

Grandparents

Grandparents as child care providers

CHAPTER 40When to have another child

Deciding on another child

Second pregnancy timing

Spacing pros and cons

PART 6Special circumstances

CHAPTER 41Adoption

Supporting your child’s health

Bonding

Sharing your family story

Handling difficult remarks

Parenting is parenting

CHAPTER 42Caring for multiples

Feeding

Raising strong individuals

Logistics

Taking care of yourself

CHAPTER 43Premature baby

Why premature birth happens

Caring for a premature newborn

Health issues

Taking care of yourself

Bringing baby home

Baby’s checkups

CHAPTER 44Delayed development

What is delayed development?

How is a delay identified?

Possible causes

Diagnosing a developmental delay

What can be done?

Get support

CHAPTER 45Autism spectrum disorder

Understanding autism

Early signs of autism

Identifying autism in early childhood

What happens after a diagnosis

Beyond the first years

CHAPTER 46Other newborn conditions

Blood disorders

Breathing disorders

Central nervous system disorders

Digestive disorders

Facial and extremity disorders

Genital conditions

Heart disorders

Other disorders

Additional resources

PART 1 Caring for your child

CHAPTER 1 Welcome to parenthood!

Congratulations! You are now entering one of the greatest phases of your life — parenthood. There is perhaps nothing in life more special than the bond that forms between a parent and a child. It’s a relationship that will bring endless years of joy, laughter, admiration and satisfaction. The time you spend raising your child will be time that you will cherish forever. In the years to come, you’ll learn more about attachment, love and protectiveness than you ever thought possible.

But be prepared that not every day in your parenthood journey will be grand and glorious. Like everything else in life, there will be ups and downs. You may find that some of the more stressful and exhausting days of being a parent will come early on, when you first bring your new son or daughter home.

Bringing a baby into your house can literally turn your life upside down. The routine you once knew — having time to yourself, getting together with friends, going out for a relaxing dinner or spending the day indulging in your favorite hobby — has been put on hold. In its place is a reality that may feel totally foreign to you. That’s because children don’t arrive with instruction manuals, and parenting is somewhat of a trial-by-fire experience. If you’ve never had to care for a young child before, you may feel nervous, unsure of yourself and a bit lost. That’s to be expected — and is perfectly normal.

Parenting 101

Many parents describe their first year with a new baby as a roller coaster ride. As one new mom put it, “One minute you’re laughing and joking; the next minute you’re crying, not really knowing why.” You may go from adoring your baby and marveling at tiny fingers and toes to grieving your loss of independence and worrying about your ability to care for a newborn, all in the space of a single diaper change.

Given all these changes, the first few weeks after you bring your baby home are likely to be one of the most challenging times of your life. The changes in the daily rhythms of your life can feel chaotic, but you will learn to adapt. It may take months or even more, but you’ll get there — in your own way, in your own time, and with your own missteps and triumphs.

Relish the time As chaotic as it may seem, this is a special time in your life. Appreciate the joy your son or daughter brings to your life, and don’t let your worries overshadow your joys. Baby days won’t last long. Step back and appreciate the moment. For all the strain associated with these first years, parenthood brings an incredible richness to daily living. Nothing can quite compare to the joy of meeting a newborn’s gaze or accompanying the wobbly first steps of a toddler.

Trust your instincts Caring for a child may be totally new territory for you, but have confidence in yourself. You’ll quickly learn the things you need to know to take great care of your child. Also realize that you aren’t expected to know it all. It’s OK to ask questions and seek guidance from friends, family and medical professionals. If you get unsolicited advice, take the advice that “fits” with your parenting style and feel free to forget the rest.

Check your expectations Many new parents start out with unrealistic expectations — that life won’t be much different from before, that parenting is going to be fun every minute of the day, that the new baby will mostly eat and sleep, that they’ll be able to manage everything perfectly. The gap between expectations and reality can lead to stress and disappointment. Throw out any preconceived notions about what life with a little one should be like, and be realistic about the increased demands on your time. That cute, little 8-pound addition to your household can create a lot of extra work.

Be patient For the first few weeks, your life may seem limited to round-the-clock feeding, bathing, diapering and soothing — all on shortened amounts of sleep. You may find it difficult to fit in a shower and do a load of laundry, let alone make dinner. You may fear this is what your life is going to be like forever! It won’t be. Soon your baby will be a toddler, and increased mobility, conversation and independence will bring new adventures. Over time you’ll adjust to each new normal, revive old routines and create new ones. As your child grows older, you’ll find you have a little more time for yourself.

Take care of yourself Childhood care also extends to parents. Taking good care of your child includes taking good care of yourself. The better you feel, the better able you’ll be to care for and enjoy your son or daughter. Get as much rest as you can, eat well and fit in some exercise. Most of all, don’t be afraid to ask for help when you need it.

Cherish relationships Caring for a young child, while wonderful, can be hard on other relationships in your life. If you’re starting the parenting journey with your spouse or partner, you may miss your life as just a couple. You may also find that you have differences of opinion on issues related to caring for your child. Be patient with yourself and your partner. Take time to admire his or her relationship with your child, and you will likely find great inspiration, not only as a parent, but also as a couple.

This book

As you maneuver the ins and outs of parenting, a little guidance and reassurance can be of great help. Mayo Clinic Guide to Your Baby’s First Years is designed to help you find answers to common questions during the first three years of your child’s life. The book is also intended to provide you with reassurance that you’re doing well, and that the emotions and concerns you may be experiencing are the same as those of many other parents.

Dig in by whatever manner works best for you. You can turn the page and begin reading, or you can selectively choose those chapters or sections that are most important to you right now. Keep the book handy so that you can turn to it whenever a concern arises or prepare yourself for the months and years ahead.

Remember that parenting is an adventure. Enjoy the journey!

CHAPTER 2 Baby’s first days

From the moment you first learned you would have a child, you’ve been eagerly anticipating the day you could hold your baby and look into his or her face. And now that day is here!

Labor and delivery — or perhaps a lengthy adoption process — is behind you. Now you finally get to enjoy that precious little person you’ve been waiting so long to meet.

Sometimes, the mental picture you’ve had of your first moments with your baby doesn’t exactly match up with reality. Truth is, newly born babies tend to look a bit messy when they emerge. And you may be exhausted and overwhelmed by the birthing process. Don’t worry. Give yourself a moment to take it all in.

In this chapter, you’ll learn what to expect during your newborn’s first few weeks of life at home — from bonding opportunities to what newborns typically look like. You’ll also learn about standard examinations, procedures and screenings and about some of the common conditions seen in newborns.

Baby bonding

As soon as a baby is born, he or she is ready to be held, cuddled, stroked, kissed, and talked to. These everyday expressions of love and affection promote bonding to the parent. They also help a baby’s brain develop. Just as an infant’s body needs food to grow, his or her brain benefits from positive emotional, physical and intellectual experiences. Relationships with other people early in life have a vital influence on a child’s development. Some parents feel an immediate connection with their newborn, while for others the bond takes longer to develop. Don’t worry or feel guilty if you aren’t overcome with a rush of love at the very beginning. Not every parent bonds instantly with a new baby. Your feelings will become stronger with time.

Bonding moments During those first weeks, most of your time with your new son or daughter is likely to be spent feeding him or her, changing diapers, and helping him or her sleep. These routine tasks present an opportunity to bond. When babies receive warm, responsive care, they’re more likely to feel safe and secure. For example, as you feed your baby and change diapers, gaze lovingly into his or her eyes and talk gently to him or her.

Babies also have times when they’re quietly alert and ready to engage and learn. These times may last only a few moments, but you’ll learn to recognize them. Take advantage of your baby’s alert times to get acquainted and play.

Cuddle and touch your baby Newborns are sensitive to changes in pressure and temperature. They love to be held, rocked, caressed, cradled, snuggled, kissed, patted, stroked, massaged and carried.

Don’t worry about spoiling your newborn Respond to your child’s cues and clues warmly and promptly. Among the signals babies send are the sounds they make, the way they move, their facial expressions, and the way they make or avoid eye contact. Pay close attention to your baby’s need for activity as well as quiet times.

Let your baby watch your face Soon after birth, your newborn will become accustomed to seeing you and will begin to focus on your face. Allow your baby to study your features, and provide plenty of smiles.

Play music and dance To add variety to your baby’s day, put on some soft music with a beat. Hold your baby’s face close to yours, and gently sway and move to the tune.

Establish routines and rituals The first few weeks with your newborn aren’t always predictable. But as much as you can, establish small routines and rituals that help you and your baby get to know each other. For example, spend a few minutes cuddling or rocking after a feeding or look out a window together when you get up in the morning. Repeated positive experiences provide children with a sense of security. Be patient with yourself in these first weeks. Caring for a new child can be daunting, discouraging, thrilling and perplexing — all in the same hour! In time, your skills as a parent will grow, and you will come to love this little one far more than you could have imagined.

Serve and return Everyday face-to-face interactions — what some experts call serve-and-return moments, such as when your baby looks at you and you gaze back — are the best way to stimulate and build the nerve connections and pathways in your baby’s brain. Evidence suggests that these early connections help a child grow and thrive, even in the midst of stress. Talk, read and sing to your baby. These early “conversations” encourage social and emotional development and provide an opportunity for closeness.

Baby’s looks

Considering what they’ve been through during childbirth, it’s no wonder newborns don’t look like those seen on television or on social media. Instead, your newborn may emerge wrinkled and ruddy. If your baby is like most, his or her head may be a bit misshapen and larger than you expected, and the eyelids may be puffy. His or her arms and legs may be curled in, and the hands and feet may be bluish or purplish in color. He or she may be somewhat bloody and likely wet and slippery from amniotic fluid.

In addition, most babies will be born with what looks like skin lotion. Called vernix, it’s most noticeable under your baby’s arms, behind the ears and in the groin. Most of this vernix will be washed off during your baby’s first bath.

Head At first, your baby’s head may appear flat, elongated or crooked. This peculiar elongation is one of the common features of a newly born baby.

Head elongation

A baby’s skull consists of several sections of bone that are flexibly joined so that the head shape can change to correspond to the shape of your pelvis as your baby moves through the birth canal during childbirth. A long labor usually results in an elongated or tall skull shape at birth. The head of a breech baby may have a shorter, broader appearance. If a vacuum extractor was used to assist in the birth, your baby’s head may look particularly elongated. Sometimes you can feel ridges on your baby’s head where the sections of bone have overlapped.

As your baby’s head shape normalizes over the first few days, these ridges will go away and your baby’s head will take on a more rounded appearance.

Fontanels When you feel the top of your baby’s head, you’ll notice two soft areas. These soft spots, called fontanels, are where your baby’s skull bones haven’t grown together yet.

Fontanels

The fontanel toward the front of the scalp is a diamond-shaped spot roughly the size of a quarter. Though it’s usually flat, it may bulge when your baby cries or strains. By the time your child is 2 years old, this fontanel will be filled in with hard bone. The smaller fontanel at the back of the head is less noticeable. This fontanel is about the size of a dime, and it closes much quicker — around six weeks after birth.

Some parents are anxious about touching baby’s soft spots, partly because they don’t like the way they feel. Don’t worry. You won’t hurt your baby if you do touch a fontanel.

A rounded swelling of the scalp is usually seen on the top and back of the baby’s head when a baby is born headfirst. This puffiness disappears within a day or so.

Skin Most babies are born with some bruising, and skin blotches and blemishes are common.

Pressure from your pelvis during labor can cause a bruise on your baby’s head. The bruise may be noticeable for several weeks, and you might feel a small bump that persists for several months. You may also see scrapes or bruises on your baby’s face and head if forceps were used during delivery. These bruises and blemishes generally go away within a couple of weeks.

The top layer of a newborn’s skin flakes off shortly after birth. You may notice plenty of dry, peeling skin the first few weeks. In general, this gets better on its own. In the meantime, apply some petroleum jelly to baby’s skin.

Evidence suggests that daily moisturizing of a baby’s skin during the first six months of life can help prevent the development of eczema. Petroleum jelly is generally the most cost-effective, but other emollients such as Aquaphor or creams such as Cetaphil or Vanicream also work.

There are other common newborn skin conditions, such as milia and baby acne. For pictures and more information on these conditions, see Chapter 7.

Birthmarks Contrary to their name, birthmarks aren’t always present at birth. Some, such as a hemangioma, develop weeks later. And though most are permanent, a few types fade as a child grows. Most birthmarks are harmless, but some may be treated for cosmetic reasons or because of rapid growth or risk of future health problems. See these pictures of common birthmarks.

Salmon patch A salmon patch, sometimes called a stork bite, is a reddish or pink patch that’s often found just above or below the hairline at the back of the neck. The medical term is nevus simplex. Salmon patches may also be found on the eyelids, forehead or upper lip. These marks are caused by collections of tiny blood vessels (capillaries) close to the skin. Salmon patches on the forehead, eyelids or between the eyes usually fade with time, though they may flare with increased blood flow to the head, such as when crying, straining or pushing. Salmon patches on the nape of the neck may not fade, but they’re often covered by hair. Salmon patches don’t require any type of treatment.

Dermal melanosis Dermal melanosis is a typically harmless, large, blue-gray birthmark that’s sometimes mistaken for a bruise. It’s more common in babies of Asian, African or Hispanic backgrounds and typically appears on the lower back. This birthmark usually disappears later in childhood and doesn’t require treatment.

Café au lait spot As the name implies, these birthmarks are light brown, or coffee, colored. Café au lait birthmarks are very common, and they can occur anywhere on the body. They’re usually permanent, but don’t require treatment. However, if your child has more than six café au lait spots, ask his or her medical provider whether further evaluation might be warranted.

Hemangioma Hemangiomas are caused by an overgrowth of blood vessels in the top layers of skin. Usually not present at birth, a hemangioma may begin as a small, pale spot that becomes red in the center. The birthmark enlarges during the baby’s first few months and appears as a bright red, raised spot. It most often disappears without treatment by school age. Large hemangiomas may cover an entire segment of the face or body. Some fast-growing hemangiomas may require laser treatment or medication. Babies with several hemangiomas or hemangiomas at certain locations may need evaluation for an underlying condition.

Congenital nevus A congenital nevus is a large, dark-colored mole that typically appears on the scalp or trunk of the body. It can range in size from less than half of an inch to more than 5 inches across, covering large areas. Children with a large-sized congenital nevus are at an increased risk of developing skin cancer as adults. If your child has this type of birthmark, talk with your child’s medical provider so that he or she can check for skin changes.

Port-wine stain A port-wine stain is a permanent birthmark that starts out pink, but turns darker red or purple as a child grows. Most often, a port-wine stain appears on the face and neck, but it can affect other areas. The involved skin may thicken and develop an irregular, pebbled surface. The condition can be treated, often with laser therapy.

• • • • •

Birthmarks

Café au lait spot A café au lait spot is a pigmented birthmark that is often oval in shape. The name is French for “milky coffee,” which refers to it’s light-brown color. Café au lait spots usually are present at birth, but they may develop in the first few years of a child’s life.

Congenital nevus A congenital nevus is a dark-colored mole present at birth that may vary in size from small to large. It typically appears on the scalp or trunk but can occur on any part of the body.

Dermal melanosis This blue-gray birthmark often appears on the lower back. It’s sometimes mistaken for a bruise. Dermal melanosis usually goes away on its own later in childhood.

Port-wine stain A port-wine stain is a birthmark in which swollen blood vessels create a reddish-purplish discoloration of the skin. Early port-wine stains are usually flat and pink in appearance. As the child gets older, the color may deepen to a dark red or a purplish color.

Salmon patch Also called a stork bite, this mark is caused by tiny blood vessels (capillaries) visible through the skin. Salmon patches are most common on the forehead, eyelids, upper lip and back of the neck.

Port-wine stain A port-wine stain is a birthmark in which swollen blood vessels create a reddish-purplish discoloration of the skin. Early port-wine stains are usually flat and pink in appearance. As the child gets older, the color may deepen to a dark red or a purplish color.

Hemangioma A hemangioma is an abnormal buildup of blood vessels in the skin. Hemangiomas are bright red and often raised. They typically appear on the neck or facial area.

• • • • •

Facial appearance When you first look at your baby, his or her nose may seem flattened. This is from pressure inside the birth canal. Within a day or two, the nose will take on a more rounded appearance. His or her cheeks may also have marks or bruises if forceps were used during the delivery. This, too, will improve in a short time.

Eyes It’s perfectly normal for your newborn’s eyes to be puffy. Some infants have such puffy eyes that they aren’t able to open their eyes wide right away. This will improve within a day or two.

You may also notice that your baby sometimes looks cross-eyed. This, too, is normal, and your child will outgrow the condition within several months.

Sometimes babies are born with red spots on the whites of their eyes. These spots result from the breakage of tiny blood vessels during birth. The spots are harmless, and they won’t interfere with your baby’s sight. They generally disappear in a week to two.

Like a newborn’s hair, his or her eyes give no guarantee of their future color. Although most newborns have dark bluish-brown, blue-black, grayish-blue or slate-colored eyes, permanent eye color may take six months or even longer to establish itself.

Hair Your baby may be born bald or with a full head of thick hair — or almost anything in between! Don’t fall in love with your baby’s hair too quickly. The hair color your baby is born with isn’t necessarily what he or she will have six months down the road. Blond newborns, for example, may become darker blond as they get older, or their hair may develop a reddish tinge that isn’t apparent at birth.

You may be surprised to see that your newborn’s head isn’t the only place he or she has hair. Downy, fine hair called lanugo covers a baby’s body before birth and may temporarily appear on your newborn’s back, shoulders, forehead and temples. Most of this hair is shed in the uterus before the baby is born, making lanugo especially common in premature babies. It disappears within a few weeks after birth.

First examination

From the moment your little one is born, he or she is the focus of everyone in the room. Often, your medical team will ask you about your preferences after delivery. If your baby appears well, he or she may be placed directly on your chest and covered with a blanket. Alternatively, the medical team may wipe your baby clean, suction his or her mouth and nose, and check his or her heart rate. Sometimes, babies need to be brought to a warmer in the delivery room for a more thorough examination right after delivery.

All newborns look somewhat bluish-gray for the first several minutes, especially on their lips and tongue. Within five to 10 minutes they become pinker, though baby’s hands and feet may still remain bluish, which is normal. Your baby’s umbilical cord is clamped with a plastic clamp, and you or your partner may be given the option to cut it.

In the next day or two, the medical team will conduct newborn examinations, administer screening tests, and give some vaccines and preventive treatments designed for newborns.

Apgar score One of the first examinations of your baby will be done to determine his or her Apgar score. An Apgar score is basically a quick evaluation of a newborn’s health, which is given at one minute and five minutes after a baby is born. Developed in 1952 by anesthesiologist Virginia Apgar, this brief examination rates newborns on five criteria: color, heart rate, reflexes, muscle tone and respiration.

Each of these criteria is given an individual score of zero, 1 or 2. The scores are totaled for a maximum possible score of 10. Higher scores indicate healthier infants, but don’t get too caught up in the numbers. Your medical provider will tell you how your baby is doing, and even those babies with lower scores often turn out to be perfectly healthy.

Other checks and measurements Soon after birth, your newborn’s weight, length and head circumference are measured. Your baby’s temperature may be taken, and breathing and heart rate measured. Usually within 12 hours after birth, a physical exam is conducted to detect any problems or abnormalities.

Your child’s blood sugar (glucose) also may be checked within the first hour or two after birth, especially if your baby is somewhat larger or smaller for his or her age or if he or she seems overly sleepy or has trouble getting started eating.

A baby whose blood sugar is too low may be more sleepy than what’s usual and won’t feed well. Assistance may be given to encourage eating and improve the baby’s blood sugar (see this discussion).

Treatments and vaccinations The following steps are generally taken shortly after birth to prevent diseases and conditions that may occur in newborns.

Eye protection To prevent the possibility of infections being passed from mothers to babies, all states require that infants’ eyes be protected immediately after birth. Gonorrheal eye infections were a leading cause of blindness until early in the 20th century, when treatment of babies’ eyes after birth became mandatory. An antibiotic ointment or solution is placed onto the baby’s eyes. These preparations are gentle to the eyes and cause no pain.

Vitamin K injection In the United States, vitamin K is routinely given to infants shortly after they’re born. Vitamin K is necessary for normal blood coagulation, the body’s process for stopping bleeding after a cut or bruise. Newborns have low levels of vitamin K in their first few weeks. An injection of vitamin K can help prevent the rare possibility that a newborn would become so deficient in vitamin K that serious bleeding might develop. This problem is not related to hemophilia.

Hepatitis B vaccination Babies can contract hepatitis B from their mothers during pregnancy and birth. Protection against hepatitis B begins with a vaccine given shortly after birth.

Hepatitis B is a viral infection that affects the liver. It can cause illnesses such as cirrhosis and liver failure, or it can result in the development of liver tumors. These conditions are more likely to develop in people who are infected with the virus as a child.

Newborn issues

Some babies have a bit of trouble adjusting to their new world. Fortunately, most of the problems they experience in the first few days after birth are generally minor and soon resolved.

Jaundice More than half of all newborn babies develop jaundice, which is a yellow tinge to the skin and eyes. Signs generally develop after the first 24 hours and peak about five to seven days after birth. The condition may last several weeks.

A baby develops jaundice when bilirubin, which is produced by the breakdown of red blood cells, accumulates faster than the liver can break it down and pass it from the body.

Jaundice may occur for a few reasons:

Bilirubin is produced more quickly than the liver can handle.

The baby’s developing liver isn’t able to remove bilirubin from the blood.

Too much of the bilirubin is reabsorbed from the intestines before the baby gets rid of it in a bowel movement.

Treatment All newborns are screened for jaundice, either using a skin sensor or with laboratory testing. Mild jaundice generally doesn’t require treatment, but more-severe cases can require a newborn to stay longer in the hospital. Jaundice may be treated in several ways:

You may be asked to feed the baby more frequently, which increases the amount of bilirubin passed out of the body via bowel movements.

A doctor may place your baby under a bilirubin light. This treatment, called phototherapy, is quite common. A special lamp helps rid the body of excess bilirubin.

Rarely, if the bilirubin level becomes extremely high, intravenous (IV) fluids or a specialized blood transfusion may be required.

Eating problems Whether you choose to breast-feed or bottle-feed, during the first few days after your baby’s birth you may find it difficult to interest your newborn in eating. The first feedings can sometimes be difficult. If this is the case, you’re not alone. Remember, your baby is learning and so are you. See the next chapter for advice on how to reduce the stress of early feedings.

If things aren’t going well or if you’re concerned that your baby isn’t getting enough nourishment, talk to your baby’s nurse or doctor. Some babies are slow eaters the first few days, but soon they catch on and breast-feed or bottle-feed with enthusiasm.

Over the first week, a newborn may lose up to 10 percent of his or her birth weight and will typically gain that weight back in the first two weeks of life.

Infection A newborn’s immune system isn’t adequately developed to fight infection. Therefore, any type of infection can be more serious for newborns than for older children or adults.

If things don’t seem right — if your newborn seems too fussy or too sleepy — or if your newborn has a fever (a temperature of 100.4 F or higher), don’t delay seeking care. This may mean going to the emergency room if the illness occurs in the middle of the night.

Serious bacterial infections, which are uncommon, can invade any organ or the blood, urine or spinal fluid. Prompt treatment with antibiotics is necessary, but even with early diagnosis and treatment, a newborn infection can be life-threatening.

For this reason, medical providers are often quick to treat a possible or suspected infection. Antibiotics often are given early and stopped only when an infection doesn’t seem likely. Although the majority of the test results come back showing no evidence of infection, it’s better to err on the side of safety by quickly treating a baby than to risk not treating a baby with an infection soon enough. If a mom tested positive for group B streptococcus near the end of her pregnancy or was diagnosed with an infection in labor, this may influence the decision to start the baby on antibiotics in the hospital.

Viral infections can occur in newborns, although they’re less common than are bacterial infections. Certain newborn viral infections such as herpes, varicella, HIV and cytomegalovirus may be treated with antiviral medication.

Hernias It’s not unusual for a baby to be born with a hernia. Hernias can occur either in the groin area (inguinal hernia) or near the bellybutton (umbilical hernia).

An inguinal hernia (left) results when a portion of the small intestine protrudes through the lower abdominal wall. With an umbilical hernia (right), the small intestine protrudes through an opening in the abdominal wall near the bellybutton.

Inguinal hernia An inguinal hernia is more common in boys than in girls. An inguinal hernia is caused by a weakness in the lower abdominal wall that allows the intestines to bulge outward. The hernia appears as a swelling in the lower abdomen or groin and is generally painless. Sometimes the hernia is visible only when an infant is crying, coughing or straining during a bowel movement.

An inguinal hernia may be small at first, but it tends to gradually enlarge so that an operation is eventually needed to repair the weak spot. An inguinal hernia usually won’t go away by itself.

Umbilical hernia An umbilical hernia occurs when part of the intestine protrudes through an opening in the upper abdominal muscles near the bellybutton. It may be especially evident when an infant cries, causing the baby’s bellybutton to protrude. This is a classic sign of an umbilical hernia.

Most umbilical hernias close on their own by the time a baby reaches 1 year old, though some take longer to heal. Umbilical hernias that don’t disappear by age 4 or those that appear later in a person’s life may require surgical repair to prevent complications.

Circumcision

If you have a baby boy, one of the decisions you’ll face soon after birth is whether to have him circumcised. Circumcision is an elective surgical procedure performed to remove the skin covering the tip of the penis. Knowing about the procedure’s potential benefits and risks can help you make an informed decision.

Issues to consider Although circumcision is common in the United States, it’s still somewhat controversial. According to the American Academy of Pediatrics, current evidence of the medical benefits of circumcision outweigh the risks. However, the benefits may be low for most baby boys, so it is an elective procedure.

Consider your own cultural, religious and social values in making this decision. For some people, such as those of the Jewish or Islamic faith, circumcision is a religious ritual. For others, it’s a matter of personal hygiene or preventive health. Some parents choose circumcision because they don’t want their son to look different from his family or peers.

As you decide what’s best for you and your son, consider these potential health benefits and risks.

Benefits of circumcision Some research suggests that circumcision provides certain benefits. These include:

Decreased risk of urinary tract infections. Although the risk of urinary tract infections in the first year is low, studies suggest that such infections may be up to 10 times more common in uncircumcised baby boys than in those who are circumcised. Uncircumcised boys are also more likely to be admitted to the hospital for a severe urinary tract infection during the first three months of life than are those who are circumcised.

Decreased risk of cancer of the penis. While this type of cancer is very rare, circumcised men show a lower incidence of cancer of the penis than do uncircumcised men.

Decreased risk of some sexually transmitted infections. Studies have shown a lower risk of human immunodeficiency virus (HIV), human papillomavirus (HPV) and herpes simplex virus (HSV) infections in circumcised men. However, safe sexual practices are much more important in the prevention of sexually transmitted infections than is circumcision.

Prevention of penile problems. Occasionally, the foreskin on an uncircumcised penis may narrow to the point where it’s difficult or impossible to retract (phimosis). A narrowed foreskin can also lead to inflammation of the head of the penis (balanitis). While circumcision can help prevent these issues, they can still occur from the remaining foreskin in some circumcised boys.

Ease of hygiene. Circumcision makes it easy to wash the penis. But even if the foreskin is intact, it’s still quite simple to keep the penis clean. Normally the foreskin adheres to the end of the penis in a newborn, then gradually stretches back during early childhood.

Before circumcision (left), the foreskin of the penis extends over the end of the penis (glans). After the brief operation, the glans is exposed (right).

Risks of circumcision Circumcision is generally considered a safe procedure, but there are some minor drawbacks to consider:

Risks of minor surgery. All surgical procedures, including circumcision, carry certain risks, such as excessive bleeding and infection. There’s also the possibility that the foreskin may be cut too short or too long, or that it doesn’t heal properly.

Pain during the procedure. Circumcision does cause pain. Typically a local anesthetic is used to block the nerve sensations. Talk to your medical provider about the anesthesia process.

Cost. Some insurers don’t cover the cost of circumcision. If you’re considering circumcision, check whether your insurance company will cover it.

Complicating factors. Sometimes, circumcision may need to be postponed, such as if your baby is born prematurely, has severe jaundice or is feeding poorly. It also may not be feasible in certain situations, such as in the rare instance when baby’s urethral opening is in an abnormal position (hypospadias; see this discussion). Other conditions that may prevent circumcision include ambiguous genitalia or a family history of bleeding disorders.

Circumcision doesn’t affect fertility. There’s no evidence to suggest that sexual function or satisfaction is negatively affected by circumcision. Whatever your choice, negative outcomes are rare.

How it’s done If you decide to have your son circumcised, his medical provider can answer questions about the procedure and help you make arrangements at your hospital or clinic. Usually, circumcision is performed before you and your son leave the hospital. At times, it’s done in an outpatient setting. The procedure itself takes about 10 minutes.

Typically, your son lies on his back with his arms and legs restrained. After the penis and surrounding area are cleansed, a local anesthetic is injected into the base of the penis. A special clamp or plastic ring is attached to the penis, and the foreskin is cut away. An ointment, such as petroleum jelly, is applied. This protects the penis from adhering to the diaper.

If your newborn is fussy as the anesthetic wears off, hold him gently — being careful to avoid putting pressure on the penis. It usually takes about seven to 10 days for the penis to heal.

Circumcision care The tip of your son’s penis may seem raw for the first week after the procedure. Or a yellowish mucus or crust may form around the area. This is a normal part of healing. A small amount of bleeding also is common the first day or two.

Clean the diaper area gently, and apply a liberal amount of petroleum jelly to the end of the penis with each diaper change. This will keep the diaper from sticking while the penis heals. If there’s a bandage, change it with each diapering. At some hospitals, a plastic ring is used instead of a bandage. The ring will remain on the end of the penis until the edge of the circumcision has healed, usually within a week. The ring will drop off on its own. It’s OK to wash the penis as it’s healing. See this discussion for cleansing instructions.

Problems after a circumcision are rare, but call your baby’s medical provider in the following situations:

Your baby has trouble urinating 12 to 18 hours after the circumcision.

Bleeding or redness around the tip of the penis is persistent.

The penis tip is significantly swollen.

A foul-smelling drainage comes from the penis tip, or there are crusted sores that contain fluid.

The ring is still in place two weeks after the circumcision.

Screening tests

Before your baby leaves the hospital, a small amount of his or her blood will be taken and sent to the state health department or a private laboratory working in collaboration with the state laboratory. This sample, which may be taken from a vein in your baby’s arm or a tiny nick on the heel, is analyzed to detect the presence of rare but important genetic diseases. This testing is referred to as newborn screening. The purpose of the testing is to identify babies who might be at risk and enable families to access relevant treatment and resources. Results are generally available in one to two weeks.

Occasionally, a baby needs to have the test repeated. Don’t be alarmed if this happens to your newborn. To ensure that every newborn with any of these conditions is identified, even borderline results are rechecked. Retesting is especially common for premature babies.

Each state independently operates its newborn screening program, resulting in slight differences between the tests offered. Current national recommendations include a panel of tests to check for 35 core disorders and 26 secondary disorders. Some states check for additional diseases. You also may request a specific genetic test if you feel your child may be at risk of a certain genetic disorder.

Newborn screening Some of the diseases that can be detected by the panel include:

Biotinidase deficiency This deficiency is caused by the lack of an enzyme called biotinidase. Signs and symptoms of the disorder include seizures, developmental delay, eczema and hearing loss. With early diagnosis and treatment, all signs and symptoms can be prevented.

Congenital adrenal hyperplasia (CAH) This group of disorders is caused by a deficiency of certain hormones. Signs and symptoms may include lethargy, vomiting, muscle weakness and dehydration. Infants with mild forms are at risk of reproductive and growth difficulties. Severe cases can cause kidney dysfunction and even death. Lifelong hormone treatment can suppress the condition.

Congenital hypothyroidism About 1 in 3,000 babies has a thyroid hormone deficiency that slows growth and brain development. Left untreated, it can result in mental retardation and stunted growth. With early detection and treatment, healthy development is possible.

Cystic fibrosis Cystic fibrosis causes the body to produce abnormally thickened mucous secretions in the lungs and digestive system. Signs and symptoms generally include salty-tasting skin, poor weight gain, and, eventually, persistent coughing and shortness of breath. Affected newborns can develop life-threatening lung infections and intestinal obstructions. With early detection and treatment, infants diagnosed with cystic fibrosis now often live longer and in better health than infants diagnosed in the past.

Galactosemia Babies born with galactosemia can’t metabolize a sugar found in milk (galactose). Although newborns with this condition typically appear otherwise healthy, they may develop vomiting, diarrhea, jaundice and liver damage within a few weeks of their first milk feedings. Left untreated, the disorder may result in mental disabilities, blindness, growth failure and, in severe cases, death. Treatment includes eliminating milk and all other dairy products from the diet.

Homocystinuria Caused by an enzyme deficiency, homocystinuria can lead to eye problems, mental disabilities, skeletal abnormalities and abnormal blood clotting. With early detection and management — including a special diet and dietary supplements — growth and development should be normal.

Maple syrup urine disease (MSUD) This disorder affects the metabolism of amino acids. Newborns with this condition typically appear healthy, but by the first week of life they experience feeding difficulties, lethargy and poor growth. Left untreated, MSUD can lead to coma or death.

Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency This rare hereditary disease results from the lack of an enzyme required to convert fat to energy. Babies with MCAD deficiency develop serious vomiting, lethargy that can worsen into coma, seizures, liver failure and severely low blood sugar. With early detection and monitoring, the condition can be effectively managed.

Phenylketonuria (PKU) Babies with PKU retain excessive amounts of phenylalanine — an amino acid found in the protein of almost all foods. Without treatment, PKU can cause mental and motor disabilities, poor growth rate, and seizures. With early detection and treatment, growth and development should be normal.

Sickle cell disease This inherited disease prevents blood cells from circulating easily throughout the body. Infants with sickle cell disease experience an increased susceptibility to infection and slow growth rates. The disease can cause bouts of pain and damage to vital organs such as the lungs, kidneys and brain. With early medical treatment, the complications of sickle cell disease can be minimized.

Hearing screening While your baby is in the hospital, he or she may have a hearing test. Although hearing tests are not done routinely at every hospital, newborn hearing screening is becoming widely available. The testing can detect possible hearing loss in the first days of a baby’s life. If possible hearing loss is found, further tests may be done to confirm the results.

Two tests are used to screen a newborn’s hearing. Both are quick (about 10 minutes) and painless and can be done while your baby sleeps. One test measures how the brain responds to sound. Clicks or tones are played through soft earphones into the baby’s ears while electrodes taped on the baby’s head measure the brain’s response. Another test measures specific responses to sound waves that enter a baby’s ear. As clicks or tones are played into a baby’s ear, a probe placed inside the ear canal measures the response.

Critical congenital heart defect (CCHD) screening Before leaving the hospital, your baby will likely also be screened for any heart defects. Ultrasounds can identify many heart defects during a pregnancy. However, some issues may be missed or cannot be detected until after a baby is born.

For this test, an oxygen sensor (pulse oximeter) is placed on your baby’s hands or feet. The test is quick and does not cause discomfort to your baby. If the oxygen levels are low or different on the right and left sides, your baby’s medical provider will most likely recommend additional testing.

CHAPTER 3 Feeding your baby

If it seems like all you do at first is feed your baby, you know what? You’re right! Newborns may not eat a lot, but they eat often. And in those first few weeks with your new son or daughter, much of your life will revolve around satisfying his or her hunger. Just when you think you have a moment to relax or perhaps fit in a shower, wouldn’t you know it, your little one wants to eat again!

At first, all of these feedings may seem exhausting. For almost every new parent, early days with a newborn can be demanding and sometimes stressful. Both you and your baby are adapting to a new reality, and that typically takes time.

Throughout this adjustment, remember that feeding your newborn is about more than just nourishment. It’s a time of cuddling and closeness that helps build the connection between you and your baby. You want to make every feeding a time to bond with your baby. Cherish this time before your baby is old enough to start feeding himself or herself. That time will come soon enough.

Breast milk or formula?

Some families know right from the start what they’ll feed their babies — breast milk or formula — while others struggle.

Most child health organizations advocate breast-feeding, and “Breast is best” is a commonly used phrase. There’s no doubt, breast-feeding is a wonderful way to nourish a newborn — breast milk provides numerous benefits. Mayo Clinic experts agree.

However, medical providers also realize that not all women are the same, and people’s life situations are different. Depending on your circumstances, certain factors may lead you to choose infant formula instead of breast milk. Or you may opt for a combination of both breast milk and formula. Some women simply aren’t able to breast-feed.

If you’re worried that you’re not being a good mother or putting the needs of your child first if you don’t breast-feed, don’t. Such negative thinking isn’t good for you or for your baby.

Feeding, regardless of how it’s delivered — breast milk or formula, breast or bottle — promotes intimacy.

Know that both options will provide your child the nutrition he or she needs to grow and thrive.

Questions to ask If you haven’t had your baby yet and you’re debating between breast milk and formula, you might consider these questions:

What does your medical provider suggest? Your medical provider will likely be very supportive of breast-feeding unless you have specific health issues — such as a certain disease or disease treatment — that make formula-feeding a better choice.

Do you understand both methods? Many women have misconceptions about breast-feeding. Learn as much as you can about feeding your baby. Seek out expert advice if needed.

Do you plan to return to work? If so, how will that impact breast-feeding? Does your place of work have accommodations available where you can use a breast pump, if that’s your plan?

How does your partner feel about the decision? The decision is ultimately yours, but it’s a good idea to take your partner’s feelings into consideration.

How have other mothers you trust and respect made their decisions? If they had it to do over again, would they make the same choices?

Breast-feeding

Breast-feeding is highly encouraged by experts because it has many known health benefits for babies and moms. The longer you breast-feed, the greater the chances that your baby will experience these benefits, and the more likely they are to last.

Benefits for babies Breast milk provides babies with:

Ideal nutrition. Breast milk has just the right nutrients, in just the right amounts, to nourish your baby completely. It contains the fats, proteins, carbohydrates, vitamins and minerals that a baby needs for growth, digestion and brain development. Breast milk is also individualized; the composition of your breast milk changes as your baby grows.

Protection against disease. Breast milk provides antibodies that help your baby’s immune system fight off common childhood illnesses. Breast-fed babies may have fewer colds, ear infections and urinary tract infections than do babies who aren’t breast-fed. Breast-fed babies may also have fewer problems with asthma, food allergies and skin conditions, such as eczema.They may be less likely to experience a reduction in the number of red blood cells (anemia). Research suggests that breast-feeding might also help to protect against sudden infant death syndrome (SIDS), and it may offer a slight reduction in the risk of childhood leukemia. Breast milk may even protect against disease long term. Studies suggest that adults who were breast-fed as infants may have a lowered risk of heart attack and stroke, and may be less likely to develop diabetes.

Protection against obesity. Research indicates that babies who are breast-fed are less likely to experience obesity as adults. Formula-fed infants generally have a higher calorie intake than do babies fed breast milk. And breast milk itself appears to have components that help control hunger and energy balance.

Easy digestion. Breast milk is easier for babies to digest than is formula or cow’s milk. Because breast milk doesn’t remain in the stomach as long as formula does, breast-fed babies spit up less. They have less gas and less constipation. They also have less diarrhea, as breast milk appears to kill some diarrhea-causing germs and helps a baby’s digestive system grow and function.

Benefits for moms For nursing mothers, the benefits include:

Faster recovery from childbirth. The baby’s suckling triggers your body to release oxytocin, a hormone that causes the uterus to contract. This means that the uterus returns to its pre-pregnancy size more quickly after delivery.

Suppressed ovulation. Breast-feeding delays the return of ovulation and, therefore, menstruation, which may help extend the time between pregnancies. However, breast-feeding is not a guarantee against pregnancy. You can still become pregnant while breast-feeding.

Possible long-term health benefits. Breast-feeding may reduce your risk of getting breast cancer before menopause. Breast-feeding also appears to provide some protection from uterine and ovarian cancers.

Convenience. Many mothers find breast-feeding to be more convenient than bottle-feeding. It can be done anywhere, at any time, whenever your baby shows signs of hunger. Plus, no equipment is necessary. Breast milk is always available — and at the perfect temperature. Because you don’t need to prepare a bottle and you can nurse lying down, nighttime feedings may be easier.

Cost savings. Breast-feeding can save money because you don’t need to buy formula, and you may not need bottles.

Challenges Admittedly, breast-feeding can also present some challenges and inconveniences. Drawbacks to breast-feeding for nursing moms include:

Exclusive feeding duties. At first, newborns nurse every two to three hours, day and night. That can be tiring for you, and your partner may feel left out. But, you can also express milk with a breast pump, if desired, which can let others take over some feedings.

Certain dietary restrictions. If you’re breast-feeding, the general rule is to avoid drinking alcohol before nursing. The alcohol level in breast milk is basically the same as in your bloodstream. One standard drink — such as 5 ounces of wine or 12 ounces of beer — takes about two to three hours to leave the bloodstream (and therefore breast milk). If you do drink alcohol, wait at least a couple of hours before breast-feeding. “Pumping and dumping” — pumping after drinking alcohol and discarding the breast milk — doesn’t affect the amount of alcohol in breast milk. Blood alcohol levels will only go down with time.

Sore nipples. Some women may experience sore nipples and, at times, breast infections. These may be avoided with the right positioning and technique. A lactation consultant or your medical provider can advise you on proper positioning.

Other physical side effects. When your lactating, your body’s hormones may keep your vagina relatively dry. Using a water-based lubricating jelly can help treat this problem. It may also take time for your menstrual cycle to once again establish a regular pattern.

Milk production As an expectant mother, your milk-producing (mammary) glands prepare for nursing even before your baby is born. By about the sixth month of pregnancy, your breasts are ready to produce milk.

Your milk supply gradually increases between the third and fifth days after your baby’s birth. As the milk-producing glands fill with milk, your breasts will be full and sometimes tender. They may also feel lumpy or hard (engorged).

Milk is released from the glands when your baby nurses. The milk is propelled down milk ducts, which are located just behind the dark circle of tissue that surrounds the nipple (areola). The sucking action of the baby compresses the areola, forcing milk out through tiny openings in the nipple.The baby’s sucking stimulates nerve endings in the areola and nipple, sending a message to the brain to release the hormone oxytocin. Oxytocin acts on the milk-producing glands in the breasts, causing the ejection of milk to the nursing baby. This release is called the let-down reflex, which may be accompanied by a tingling sensation.

Although your baby’s sucking is the main stimulus for the let-down reflex, other stimuli can have the same effect. For example, hearing a baby cry — or even thoughts of your baby or the sounds of rippling water — may set things in motion. The timing of this reflex can sometimes be inconvenient if you’re not ready to breast-feed at the moment.

Regardless of whether your plan is to breast-feed, your body produces milk after childbirth. After that, your milk supply is based on demand. If you decide not to breast-feed, your milk supply eventually goes away. If you do breast-feed, the more frequently your breasts are emptied, the more milk they produce.

• • • • •

What goes in, comes out

While you’re breast-feeding, keep in mind that the foods and other items you ingest can be passed on to your baby through your breast milk.

A few things to remember while breast-feeding:

Avoid or limit alcohol. If you do have an occasional drink, keep it to a minimal amount and do it right after breast-feeding (see this discussion).

Limit caffeine. Drink mainly caffeine-free beverages.

Check your medications. Most are safe to take, but consult your baby’s medical provider first.

Only rarely do the foods you eat cause your baby to be fussy or gassy. Babies can get fussy for many reasons, and they can experience gas from the air they swallow when they cry or eat. However, if you suspect your child may be intolerant to something you ate, try eliminating the food for a while and see how your baby responds.

• • • • •

Getting started The time to begin breast-feeding is right after your baby is born. If possible, put baby to your breast in the delivery room. Early skin-to-skin contact is known to improve breast-feeding outcomes.

Breast-feeding may be a natural process, but that doesn’t mean it comes easily to all mothers. Breast-feeding is a new skill for both mom and baby. Nothing can really prepare your nipples for a nursing baby. If this is your first child, you may feel uncertain holding your baby — let alone putting him or her to your breast. It may take a few attempts before you and your baby get the hang of it.

While you’re in the hospital, ask a lactation consultant or nurse to assist you. These experts can provide hands-on instruction and helpful hints. After you leave the hospital or birthing center, you might want to arrange for a public health nurse who is knowledgeable about infant feeding or a certified lactation consultant to visit you for additional one-on-one instruction.

It’s a good idea to take a class on breast-feeding. Often, information on breast-feeding is offered as part of childbirth classes, or you may be able to sign up for a class. Most hospitals and birthing centers offer classes on feeding a newborn.

Supplies to have on hand If possible, purchase a couple of high-quality nursing bras. They provide important support for lactating breasts. What distinguishes nursing bras from regular bras is that both cups open to the front, usually with a simple maneuver that you can manage unobtrusively while you hold your baby.

You may also want nursing pads, which sit inside the bra to absorb milk that leaks from your breasts. Options include disposable pads or washable and reusable versions. Avoid those with plastic shields, which prevent air circulation around the nipples. Nursing pads can be worn continuously or on occasion. Some women don’t bother with the pads, but most women find them helpful.

Get comfortable When it’s feeding time, find a quiet location and take advantage of this time with your baby. Get into a position that’s comfortable for both you and baby. If you’re taking a seated position, it helps to sit up straight. Put a pillow behind the small of your back and one under your arms for support. A nursing pillow that wraps around your body can also make breast-feeding more comfortable by raising your baby to your breast.

Hold your baby across your body so that he or she faces your breast, with his or her mouth near your nipple. Make sure your baby’s whole body is facing you — tummy to tummy — with ear, shoulder and hip in a straight line. Place your free hand up under your breast to support it while squeezing lightly to point the nipple straight forward.

Different women find different nursing positions most comfortable. Experiment with the positions illustrated here to see which works best for you.

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Feeding positions

Cross-cradle hold Bring your baby across the front of your body, tummy to tummy. Hold your baby with the arm opposite to the breast you’re feeding with. Support the back of the baby’s head with your open hand. This hold allows you especially good control as you position your baby to latch on. With your free hand, support your breast from the underside in a U-shaped hold to align with baby’s mouth.

Cradle hold Cradle your baby in your arm, with your baby’s head resting comfortably in the crook of your elbow on the same side as the breast you’re feeding with. Your forearm supports your baby’s back. Use your free hand to support your breast.

Football (clutch) hold In this position, you hold your baby in much the same way a running back tucks a football under his arm. Hold your baby at your side on one arm, with your elbow bent and your open hand firmly supporting your baby’s head faceup at the level of your breast. Your baby’s torso will rest on your forearm. Put a pillow at your side to support your arm. A chair with broad, low arms works best.

With your free hand, support your breast from the underside in a C-shaped hold to align with baby’s mouth. Because the baby isn’t positioned near the abdomen, the football hold is popular among mothers recovering from C-sections. It’s also a frequent choice of women who have large breasts or who are nursing premature or small babies.

Side-lying hold Although most new mothers learn to breast-feed in a sitting position, at times you may prefer to nurse while lying down. Use the hand of your lower arm to help keep your baby’s head positioned at your breast. With your upper arm and hand, reach across your body and grasp your breast, touching your nipple to your baby’s lips. After your baby latches on firmly, you can use your lower arm to support your own head and your upper hand and arm to help support your baby.

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A good latch When your baby connects or latches well to your breast, he or she can nurse effectively and your breast feels little discomfort. To help your baby get a good latch, hold your baby close and brush your nipple against your baby’s cheek to trigger the rooting reflex — the motion your baby makes while searching for your nipple. If your baby is hungry and interested in nursing, his or her mouth should open and he or she will turn toward your breast. When this happens, bring your baby’s mouth to your nipple. You want your baby to receive as much nipple and areola as possible and your baby’s lips to flare out with chin and cheeks touching your breast.

As your baby starts suckling and your nipple is being stretched in your baby’s mouth, you may feel some surging sensations. After a few suckles, those sensations should subside. If they don’t, or if you have pain, sandwich the breast more and draw baby’s head in more closely.

If that doesn’t produce comfort, gently remove baby from your breast, taking care to release the suction first. To break the suction, gently insert the tip of your finger into the corner of your baby’s mouth. Slowly push your finger between your baby’s gums until you feel the release. Repeat the procedure until your baby has latched on properly. You want there to be a firm bond of suction.

You’ll know that milk is flowing and your baby is swallowing if there’s a strong, steady, rhythmic motion visible in your baby’s cheek. Also, listen for the “k” sound of your baby’s swallowing. If your breast is blocking your baby’s nose, elevating your baby slightly, or angling the baby’s head back and in, may help provide a little breathing room. If your baby attaches and sucks correctly — even if the arrangement feels awkward at first — the position is correct.

Once nursing begins, you can relax the supporting arm and pull your baby’s lower body closer to you.

Your know your baby has a good latch when you feel little discomfort in your breast, your baby’s lips flare out, and your baby’s chin and cheeks touch your breast.

How often should you nurse? Because breast milk is easily digested, breast-fed babies usually are hungry every few hours at first. During those early days, breast-feeding may start to feel like a marathon session!

Most newborns eat eight to 12 times a day — about every two to three hours. By six to eight weeks after birth, your baby will probably begin to go longer between feedings. During growth spurts, your baby may take more at each feeding or want to breast-feed more often. Trust your body’s ability to keep up with the increased demand.

How long should a nursing session be? In general, let your baby nurse as long as he or she wants. The length of feedings may vary considerably. However, on average, a nursing session may take about half an hour for most babies.

Offer your baby both breasts at each feeding. Allow your baby to end the feeding on the first side. Then, after burping your baby, offer the other side. See burping positions here. Alternate starting sides to equalize the stimulation each breast receives.

You want baby to finish one breast before switching to the other side because the milk that comes first from your breast, called the foremilk, is rich in protein for growth. But the longer your baby sucks, the more he or she gets the hindmilk, which is rich in calories and fat, and therefore helps your baby gain weight and grow. So wait until your baby seems ready to quit before offering him or her your other breast.

Is my baby getting enough? A baby’s need for frequent feeding usually isn’t a sign that baby isn’t getting enough; it more likely reflects the easy digestibility of breast milk. If your baby is satisfied after feeding and is growing, you can be confident that you’re doing well.

If you’re concerned that baby may not be getting enough milk, ask yourself:

Is baby gaining weight? Steady weight gain is often the most reliable sign that a baby is getting enough to eat. Although most babies lose weight soon after birth, it’s typically regained — and then some — within 10 days to two weeks.

Can I hear baby swallowing? Listen carefully and you’ll be able to hear your baby swallowing. Also look for a strong, steady, rhythmic motion in your baby’s lower jaw, or even a bit of milk dribbling out of your baby’s mouth.

How do my breasts feel? When your baby is latched on successfully, you’ll feel a gentle pulling sensation on your breast, rather than a pinching or biting sensation on your nipple. Your breasts may feel firm or full before the feeding, and then softer or emptier afterward.

What about baby’s diapers? By the fourth day after birth, expect your baby to have six to eight wet diapers a day. Also expect regular bowel movements. The stool will be dark and sticky for the first couple of days, eventually becoming seedy, loose and golden yellow.

Does baby seem healthy? A baby who seems satisfied after feedings and is alert and active at other times is likely getting enough milk. Also look for a healthy skin tone.

Breast care As you start to breast-feed, you may experience some occasional problems. Though these can be uncomfortable, they often go away with time or can be easily treated.

Fullness A few days after your baby is born, your breasts may become full, firm and tender, making it challenging for your baby to grasp your nipple. This swelling, called engorgement, also causes congestion within your breasts, which makes your milk flow slower. So even if your baby can latch on, he or she may be less than satisfied with the results.

To manage engorgement, express some milk using a breast pump or by hand before trying to breast-feed. Support with one hand the breast you intend to express. With your other hand, gently stroke your breast inward toward your areola. Then place your thumb and forefinger at the top and bottom of the breast just behind the areola. As you gently compress the breast between your fingers, milk should flow or squirt out of the nipple. Taking a warm shower also may result in let-down of milk and provide some engorgement relief. You can also use a breast pump to express some milk.

As you release your milk, you’ll begin to feel your areola and nipple soften. Once enough milk is released, your baby can comfortably latch on and nurse. Frequent, lengthy nursing sessions are the best means to avoid engorgement.

Nurse your baby regularly and try not to miss a feeding. Wearing a nursing bra both day and night will help support engorged breasts and may make you feel more comfortable.

If your breasts are sore after nursing, apply an ice pack to reduce swelling. Some women find that a warm shower also relieves breast tenderness. Fortunately, the period of engorgement is usually brief, lasting no more than a few days after delivery.

Nipple discomfort At first, you may experience some initial nipple discomfort as baby latches on, but the discomfort should subside as your baby feeds. For some women, though, breast-feeding can be downright painful. If so, the first step is to check that your baby is latching on correctly.

Sore or cracked nipples are usually caused by incorrect positioning and latching. At each feeding, you want to make sure that the baby has the areola and not just the nipple in his or her mouth. You also want to be certain that the baby’s head isn’t out of line with his or her body. This position causes pulling at the nipple.

To care for your nipples, express milk onto your nipples and let them air-dry after each feeding. You don’t need to wash your nipples after nursing. There are built-in lubricants around the areola that provide a natural salve. Soap and water with daily bathing is fine. Afterward, let your nipples air-dry.

Blocked milk ducts Sometimes, milk ducts in the breast become clogged, causing milk to back up. Blocked ducts can be felt through the skin as small, tender lumps or larger areas of hardness. Because blocked ducts can lead to an infection, you should treat the problem right away.

The best way to open up blocked ducts is to let your baby empty the affected breast, offering that breast first at each feeding. If your baby doesn’t empty the affected breast, express milk from it by hand or by breast pump. It may also help to apply a warm compress before nursing and to massage the affected breast. If the problem doesn’t go away with self-treatment, call a lactation consultant or your medical provider for advice.

Breast infection Infection (mastitis) can occur if some milk remains in your breasts after feedings. Infection may also result when germs gain entry into your milk ducts from cracked nipples and from your baby’s mouth. These germs are not harmful to your baby; everyone has them. They just don’t belong in your breast tissues.

Mastitis starts with flu-like signs and symptoms such as a fever, chills and body aches. Redness, swelling and breast tenderness then follow. If you develop such signs and symptoms, call your medical provider. You may need antibiotics, in addition to rest and more fluids.

Keep nursing if you’re taking antibiotics. Treatment for mastitis doesn’t harm your baby, and emptying your breasts during feedings will help to prevent clogged milk ducts, another possible source of mastitis. Applying cold compresses to your breasts after feedings can help soothe swelling. Your medical provider may also recommend taking an over-the-counter pain reliever.

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Vitamin D

Talk with your baby’s medical provider about vitamin D supplements for your baby. Breast milk likely won’t provide enough vitamin D and infant formula may not either. Your baby needs vitamin D to absorb calcium and phosphorus. Too little vitamin D can cause rickets, a softening and weakening of bones.

Since sun exposure — an important source of vitamin D — isn’t recommended for babies younger than 6 months, supplements are the best way to prevent vitamin D deficiency in infants.

The American Academy of Pediatrics recommends that babies who are breast-fed or formula-fed receive 400 international units (IU) of liquid vitamin D a day — starting in the first few days after birth. Continue giving your baby vitamin D as long as you breast-feed. If you’re using infant formula, continue giving vitamin D supplements until your son or daughter drinks at least 32 ounces of formula a day.

As your baby gets older and you add solid foods to his or her diet, you can help your baby meet the daily vitamin D requirement by providing foods that contain vitamin D — such as eggs and fortified foods, although most babies won’t consistently eat these foods during their first year. After age 12 months, you can also offer whole cow’s milk.

When giving your baby liquid vitamin D, make sure you don’t exceed the recommended amount. Carefully read the instructions that come with the supplement and use only the dropper that’s provided.

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Support If you’re having problems breast-feeding, or you’re worried that baby isn’t getting enough milk, ask for help. If you sense something isn’t right, or if breast-feeding seems too painful, don’t be afraid to contact your baby’s medical provider or a lactation consultant.

Most hospitals have lactation consultants on staff who can answer your questions or help you resolve any problems you may encounter.

Breast-feeding may feel awkward at first, but you’ll get the hang of it. Friends who’ve breast-fed may have valuable insights and provide needed support. You might also consider seeking out a lactation consultant in your area. Look for someone with an International Board Certified Lactation Consultant (IBCLC) credential.

Weaning There will come a time when it’s best for baby and you to transition from the breast to a cup. Your baby is growing up and he or she is ready to take the next big step. Or, if your child is not ready for a cup, you may need to transition your child from the breast to a bottle.

You may have mixed emotions about weaning. But you can smooth the transition by taking a gradual approach and offering plenty of love and affection. Choose the right time and do what you can to make it a growing experience.

Timing You may wonder when’s the best time to start weaning. There really isn’t a right or wrong answer. Experts recommend exclusively breast-feeding babies for the first six months and continuing until your baby is 1 year old. Breast milk contains the right balance of nutrients for your baby and boosts your baby’s immune system. Still, when to start weaning your child is a personal decision.

It’s often easiest to begin weaning when your baby initiates the process — which may be sooner or later than you expect. The process of weaning often begins naturally at 6 months old, when solid foods are typically introduced and feeding sessions start to become less frequent.

Some children begin to gradually turn away from breast milk and seek other forms of nutrition and comfort at around age 1, when they’ve begun eating a wide variety of solid foods and may be able to drink from a cup. Other children may not initiate weaning until their toddler years, when they become less willing to sit still during breast-feeding.

You may also decide when to start the weaning process yourself. This may be more difficult than following your child’s lead — but can be done with some extra care and sensitivity.

Resist comparing your situation with that of other families, and consider rethinking any deadlines you may have set for weaning when you were pregnant or when your baby was a newborn.

You might consider delaying weaning if your child isn’t feeling well or is teething. He or she will be more likely to handle the transition well if you’re both in good health.

You might also consider postponing weaning if a major life change has occurred, such as moving to a new home or starting a new job. You don’t want to add more stress at what may already be a stressful time for you and your child.

Some research suggests that exclusive breast-feeding for at least four months may have a protective effect for children who have a family history of food allergies. If food allergies run in your family, talk to your child’s doctor about the potential benefits of delaying weaning.

Method When you start the weaning process, take it slow. Eliminate one breast-feeding session a day every two to three days. Slowly tapering off the number of times you breast-feed each day will cause your milk supply to gradually diminish and prevent any discomfort from engorgement.

Children tend to be more attached to the first and last feedings of the day, when the need for comfort is greater — so it might be helpful to drop a midday breast-feeding session first. You might also choose to wean your baby from breast milk during the day but continue breast-feeding at night. It’s up to you and your child. When eliminating a breast-feeding session, offer an alternate activity, such as a book, toy or other fun activity.

Depending on your approach, weaning could take days, weeks or months. Remember, however, that slower is better. Rushing the weaning process may be upsetting for your child and cause engorgement for you.

Ongoing nutrition If you wean your child before age 1, substitute breast milk with iron-fortified formula. Ask your child’s medical provider to recommend a formula. Don’t give your child cow’s milk until after his or her first birthday. You can wean your child to a bottle and then a cup or, if your child seems ready, directly to a cup.

If you’re introducing your child to a bottle for the first time, do so at a time when your child isn’t extremely hungry and may have more patience. It also may help if a separate caregiver introduces the bottle, since some children may refuse a bottle when the opportunity to breast-feed is nearby.

Choose a bottle nipple with a slow flow at first. If you use a bottle nipple with a fast flow, your child may become frustrated with the slower flow of milk during breast-feeding (or overwhelmed by the fast flow from the bottle).

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Going back to work

With a little planning and preparation, you can do both — breast-feed and return to work. Some nursing mothers work from home, while some arrange to have their babies brought to them for feedings or they go to the babies. Most, though, rely on the help of a breast pump.

Using a double breast pump is the most effective way to pump. A double breast pump requires about 15 minutes of pumping every three to four hours. If you need to increase your milk supply, nurse and pump more often.

Some women pump primarily at home. You might pump after the morning feeding and after the feeding when you return from work. As long as all of your milk produced in 24 hours is removed either by your baby or from pumping, you’ll maintain a good supply.

Many women also pump while at work, storing the milk and saving it for the next day. If you’re planning to pump at work, talk to your employer as early as possible. Ask about access to a clean, private space (not a bathroom) with a comfortable chair and an outlet. You’ll also need a cooler bag, refrigerator or freezer in which to store expressed milk and a place to rinse out pump parts. For the most part, employers are becoming more aware of the needs of working mothers and are willing to work together to help new moms stay productive.

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Pumping breast milk

If you’re returning to work or would like to share feeding duties with your partner, pumping breast milk is a useful option. It allows your baby to continue receiving your breast milk even when you’re not there.

It may help to nurse exclusively during the first few weeks so that you and your baby learn how to breast-feed and so that your milk supply becomes well established. Once you feel confident that the two of you are doing well with breast-feeding, you can begin to introduce your baby to breast milk in a bottle. However, some women begin pumping soon after birth and do just fine.

Initially, pump a few times after regular feedings to start building a small stockpile. Consider replacing one or two daytime feedings with a bottle of breast milk. Keep in mind that the feel of a bottle nipple in a baby’s mouth is different from that of the breast. The way a baby sucks from a bottle nipple also is different. So it may take some practice to make the switch. It may also help to have someone besides you offer the bottle, since baby is likely to associate your voice and scent with breast-feeding.

Choosing a pump Most mothers who breast-feed find using a breast pump easier than expressing milk manually. A lactation consultant or your baby’s medical provider can help you determine what type of pump — manual or electric — is best for you, and offer help and support if problems arise. In deciding on a pump, here are some factors to consider:

How often will you use the breast pump? If you’ll be away from the baby only occasionally and your milk supply is well established, a simple hand pump may be all you need. They’re small and inexpensive. If you’re returning to work full time, or planning to be away from your baby for more than a few hours a day, you may want to invest in an electric pump.

Will you need to pump as quickly as possible? A typical pumping session lasts about 15 minutes a breast. If you’ll be pumping at work or in other time-crunched situations, you’ll likely want an electric pump that allows you to pump both breasts at once.

How much can you afford to spend? While manual models generally cost less than $50, electric pumps that include a carrying case and insulated section for storing milk may cost more than $200. Some hospitals or medical supply stores rent hospital-grade breast pumps. Health insurance plans generally cover the cost of breast-feeding support and supplies. Your insurer may specify what type of breast pump is covered.

Is the pump easy to assemble and transport? If the breast pump is difficult to assemble, take apart or clean, it’s bound to be frustrating, which may reduce your enthusiasm for pumping. If you’ll be toting the pump to work every day, or traveling with the pump, look for a lightweight model. If you’ll need to pump away from a power outlet, look for pumps that can run on batteries instead of being plugged in. Some breast pumps come in a carrying case with an insulated section for storing expressed milk. Additionally, some electric models are quieter than are others. If it’s important to be discreet, make sure the noise level is acceptable.

Is the suction adjustable? What’s comfortable for some women may not be for others. Choose a pump that allows you to control the degree of suction.

Storing breast milk Once you start pumping, it’s important to know how to safely and properly store your expressed breast milk.

Container Store expressed breast milk in capped glass or plastic containers that have been cleaned in a dishwasher or washed in hot, soapy water and thoroughly rinsed. Consider boiling the containers after washing them if the quality of your water supply is questionable.

If you store breast milk for three days or less, you can also use a plastic bag designed for milk collection and storage. While economical, plastic bags aren’t recommended for long-term breast milk storage because they may spill, leak and become contaminated more easily than hard-sided containers. Also, certain components of breast milk may adhere to the soft plastic bags during long-term breast milk storage, which could deprive your baby of essential nutrients.

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Storing breast milk

| Room temperature | Insulated cooler with ice packs | Refrigerator (40 F) | Freezer (0 F or colder)
Fresh | Best within 4 hours, especially in warm temperatures; acceptable up to 6 hours | Up to 24 hours | Best within 4 days; acceptable within 8 days if cleanly expressed and stored in back of refrigerator | Best within 9 months; acceptable within 12 months if stored in back of deep freezer
Thawed, previously frozen | 1 to 2 hours | — | Up to 24 hours | Never refreeze
Left over from a feeding | Use within 2 hours after feeding
Source: Centers for Disease Control and Prevention, American Academy of Pediatrics

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Method You can store expressed breast milk in the refrigerator or freezer. Using waterproof labels and ink, label each container with the date and time. Include your baby’s name if you’re delivering containers to your baby’s care provider. Place the containers in the back of the refrigerator or freezer, where the temperature is the coolest. Use your earliest milk first.

To minimize waste, fill individual containers with the amount of milk your baby will need for one feeding. Also consider storing smaller portions — 1 to 2 ounces — for unexpected situations or delays in regular feedings. Keep in mind that breast milk expands as it freezes, so don’t fill containers to the brim.

You can add freshly expressed breast milk to refrigerated or frozen milk you expressed earlier in the same day. However, be sure to cool the freshly expressed breast milk in the refrigerator or a cooler with ice packs for at least one hour before adding it to previously chilled milk. Don’t add warm breast milk to frozen breast milk because it will cause the frozen milk to partially thaw. Keep milk expressed on different days in separate containers.

During storage, expressed breast milk will typically separate. The thick, white cream will rise to the top of the container. Before feeding your baby, gently swirl the contents of the container to ensure that the creamy portion of the milk is evenly distributed.

The sooner you use the milk, the better. Some research suggests that the longer you store breast milk — whether in the refrigerator or in the freezer — the greater the loss of vitamin C in the milk. Other studies have shown that refrigeration beyond two days may reduce the bacteria-killing properties of breast milk, and long-term freezer storage may lower the quality of breast milk’s lipids.

Thawing Thaw the oldest milk first. Simply place the frozen container in the refrigerator the night before you intend to use it. Or place the container under warm running water or in a bowl of warm water. Avoid letting the water touch the mouth of the container.

Never thaw frozen breast milk on a counter at room temperature, which enables bacteria to multiply in the milk. Also, don’t heat a frozen bottle on the stove or in the microwave. These methods can create an uneven distribution of heat and destroy the milk’s antibodies. Use thawed breast milk within 24 hours. Discard any remaining milk. Don’t refreeze thawed or partially thawed breast milk.

Thawed breast milk may smell or taste different from freshly expressed milk due to the breakdown of milk fats, but it’s still safe for your baby to drink. The milk may separate, so you may need to gently swirl the thawed milk so that it’s mixed evenly.

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Feeding tips

As your baby matures, he or she will gradually need fewer daily feedings and eat more at each feeding. Soon, a feeding pattern will begin to emerge. In the meantime, whether you breast-feed or formula-feed, here are a few pointers to keep in mind.

Consider feedings a time to bond For babies, feeding is as much a social activity as a nutritional one. Your baby’s growth and development are based, in part, on the powerful bond that forms during feedings. Take the opportunity to put away your phone or tablet and turn off the television. Hold your baby close during each feeding. Look him or her in the eyes. Speak with a gentle voice. Don’t miss this chance to build your baby’s sense of security, trust and comfort.

Feed on cue The size of your infant’s stomach is very small, about the size of his or her fist, and the time it takes to become empty varies from one to three hours. Feeding on cue requires you to watch for signs that baby is ready to eat: your baby makes sucking movements with his or her mouth or tongue (rooting), sucks on his or her fist, or makes small sounds. Crying is a late cue for hunger. You will soon be able to distinguish between cries for food and those for other reasons, such as pain, fatigue or illness.

It’s important to feed your baby promptly when he or she signals hunger. This helps your baby learn which kinds of discomfort mean hunger and that hunger can be satisfied by sucking, which brings food. If you don’t respond promptly, your baby may become so upset that trying to feed at this point may prove more frustrating than satisfying.

Let baby set the pace Avoid rushing your baby during a feeding. Let your baby determine how much and how fast to eat. Many babies, like adults, prefer to eat in a relaxed manner. It’s normal for an infant to suck, pause, rest, socialize a bit and then return to feeding. Some newborns are speedy, efficient eaters, consistently whizzing through feedings. Other babies are grazers, preferring snack-sized feedings at frequent intervals.

Your baby will let you know when he or she has had enough to eat. When your baby is satisfied, he or she will stop sucking, close his or her mouth, or turn away from the nipple. Baby may push the nipple out of his or her mouth with his or her tongue, or your baby may arch his or her back if you try to continue feeding. If, however, your baby needs burping or is in the middle of a bowel movement, his or her mind may not be on eating. Wait a bit, and then try offering the breast or bottle again.

Feeding a sleepy newborn Most newborns lose weight in the first few days after birth. Until your newborn regains this lost weight — usually within one week after birth — it’s important to feed him or her frequently, even if he or she would rather drift off to sleep. You’ll no doubt have times when your baby signals that he or she is hungry, only to doze off once you begin feeding. Try these tips to feed a sleepy baby:

Watch for and take advantage of your baby’s alert stages. Feed at these times.

If your baby falls asleep while feeding, gently wake and encourage him or her to finish eating.

Give your baby a massage by walking your fingers up his or her spine.

Partially undress your baby. Because your baby’s skin is sensitive to temperature changes, the coolness may wake him or her long enough to eat.

Stroke a circle around your baby’s lips with a fingertip a few times.

Rock your baby in a sitting position. A baby’s eyes often open when he or she is positioned upright.

Once your newborn establishes a pattern of weight gain and reaches his or her original birth weight, it’s generally OK to wait for feedings until he or she wakes up.

Be flexible Don’t expect your baby to eat the same amount every day. Babies vary in how much they eat, especially if they’re experiencing a growth spurt. At these times, your baby will need and demand more milk and eat more frequently. It may seem like your baby can’t get full. During these times, you may need to put your baby to your breast or offer a bottle more often.

Babies often don’t eat at precise intervals throughout the day. Most babies bunch (cluster) their feedings at various times of the day and night. It’s common for a baby to eat several times within a few hours and then sleep for a few hours.

Stick with breast milk or formula Don’t give your newborn water, juice or other fluids. Introducing these liquids before your baby is 6 months old is unnecessary and can interfere with his or her desire for breast milk or formula, which may lead to malnourishment and risk potentially dangerous electrolyte imbalances.

Consider supplements If you’re feeding your baby iron-fortified formula, he or she is likely getting the recommended amount of iron. If you’re breast-feeding your baby, start giving your baby an iron supplement at age 4 months. Continue giving your baby the supplement until he or she is eating two or more servings a day of iron-rich foods, such as fortified cereal or pureed meat. If you offer mixed feedings — breast milk and formula — and the majority of your baby’s feedings are from formula, the supplement probably isn’t necessary. Talk to your baby’s medical provider. He or she may also recommend a fluoride supplement depending on your water supply and a vitamin D supplement (see this discussion).

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Formula-Feeding

Some parents prefer to feed their infants formula rather than breast milk. This is a personal choice, and there are many reasons why new parents opt for formula rather than breast milk. In a few cases, breast-feeding just isn’t possible.

If you choose not to or you aren’t able to breast-feed, be assured that your baby’s nutritional needs can be met with the use of infant formula. And your baby will still be happily bonded to you as a parent.

Pros and cons Parents who formula-feed usually feel the main advantages are:

Shared feeding duties. Using a bottle with formula allows more than one person to feed the baby. For that reason, some nursing mothers feel they have more freedom when they’re bottle-feeding. Both parents may like bottle-feeding because it allows them to share more easily in the feeding responsibilities.

Convenience. Some parents feel formula is more portable, especially on outings and in public places. They don’t have to find an out-of-the-way location to breast-feed.

Some of the challenges of formula-feeding include:

Time-consuming preparation. Bottles must be prepared for each feeding. You need a steady supply of formula. Bottles and nipples need to be washed. If you go out, you may need to take formula with you.

Cost. Formula is costly, which may be a concern for some parents.

The right supplies Make sure you have the right supplies on hand. Staff at the hospital or birthing center can provide bottle-feeding equipment and formula the first few days after your baby’s birth and show you how to bottle-feed your newborn.

You don’t need a ton of equipment for formula-feeding. Generally, it’s helpful to have several 4-ounce bottles for the early months, and several 8-ounce bottles as your baby grows and wants more at a time. Some extra nipples, rings and caps and a bottle brush for cleaning are also nice to have on hand.

In addition to buying the right equipment, consider taking a class on infant feeding, if you haven’t taken one already. Often, information on feeding a newborn is offered as part of childbirth classes. If you’ve never bottle-fed a baby before, taking a class will help you feel more comfortable when you bring your baby home.

Bottles Bottles generally come in two sizes: 4 ounces and 8 ounces. The 4-ounce bottles come in handy at the beginning when babies don’t drink much more than that. The 8-ounce bottles should carry you through to weaning once your baby reaches a year old. Bottles may be glass, plastic or plastic with a soft plastic liner. Some bottles have a curved design to try to reduce the amount of air a baby swallows.

Nipples Many types of nipples are on the market, which have openings sized according to a baby’s age: newborn, 3-month-old, 6-month-old, and so on. The flow rate from the nipple is appropriate to the baby’s age.

It’s important that formula flows from the nipple at the correct speed. Milk flow that’s either too fast or too slow can cause your baby to swallow too much air, leading to stomach discomfort and the need for frequent burping. Test the flow of the nipple by turning the bottle upside down and timing the drops. One drop a second is about right.

Choosing a formula If you’re planning to feed your baby infant formula, you may have many questions. Is one brand of infant formula better than another? Are generic brands OK? Is soy-based formula better than cow’s milk formula?

A wide variety of infant formulas are on the market. The majority of them are based on cow’s milk. However, never use regular cow’s milk as a substitute for formula. In processing formula, the milk has been changed dramatically to make it safe for babies. This processing includes treating formula by heat to make the protein in it more digestible. More milk sugar (lactose) is added to make the concentration similar to that of breast milk, and the fat (butterfat) is removed and replaced with vegetable oils and animal fats that are more easily digested by infants.

Infant formulas aren’t just easy to digest. They must contain the right amounts of carbohydrates, fat and protein to meet baby’s needs. The Food and Drug Administration (FDA) monitors commercially prepared infant formula. Each manufacturer must test each batch of formula to ensure it has the required nutrients and is free of contaminants.

Infant formula is designed to be an energy-dense food. More than half its calories are from fat. That fat is made up of fatty acids specifically selected because they’re similar to those found in breast milk. These fatty acids help in the development of your baby’s brain and nervous system, as well as in meeting his or her energy needs.

Types Commercial infant formulas are regulated by the FDA. Three major types are available:

Cow’s milk formulas. Most infant formula is made with cow’s milk that’s been altered to resemble breast milk. This gives the formula the right balance of nutrients — and makes the formula easier to digest. Most babies do well on cow’s milk formula. Some babies, however — such as those allergic to the proteins in cow’s milk — need other types of infant formula.

Soy-based formulas. Soy-based formulas can be useful if you want to exclude animal proteins from your child’s diet. Soy-based formulas may also be an option for babies who are intolerant or allergic to cow’s milk formula or to lactose, a sugar naturally found in cow’s milk. However, babies who are allergic to cow’s milk may also be allergic to soy milk.

Protein hydrolysate formulas. These are meant for babies who have a milk or soy allergy. Protein hydrolysate formulas are easier to digest and less likely to cause allergic reactions than are other types of formula. They’re also called hypoallergenic formulas.

In addition, you can find specialized formulas that are made for premature infants and babies who have specific medical conditions.

Forms Infant formulas typically come in three forms. The best choice depends on your budget and convenience needs:

Powdered formula. Powdered formula is the least expensive. It must be mixed with water.

Concentrated liquid formula. This type of formula also is mixed with water.

Ready-to-use formula. Ready-to-use formula is the most convenient type of infant formula. It doesn’t need to be mixed with water. It’s also the most expensive option.

Generic vs. brand name All infant formulas sold in the United States — both generic and brand name — must meet the nutrient standards set by the FDA. Although manufacturers may vary in their formula recipes, the FDA requires that all formulas contain the minimum recommended amount — and no more than the maximum amount — of nutrients that infants need.

Additional ingredients It’s important to buy iron-fortified infant formula. Your baby needs iron to grow and develop, especially during infancy. If you’re not breast-feeding, using iron-fortified formula is the easiest way to provide this essential nutrient.

Some infant formulas are enhanced with docosahexaenoic acid (DHA) and arachidonic acid (ARA). These are essential fatty acids found in breast milk and certain foods, such as fish and eggs. Some studies suggest that including DHA and ARA in infant formula can help infant eyesight and brain development, but other research has shown no benefit.

In addition, in an effort to mimic the immune benefits of breast milk, some infant formulas now include probiotics — substances that promote the presence of healthy bacteria in the intestines. The data on probiotic-supplemented formulas is limited and long-term benefits or complications of the formula are unknown.

At this point, there’s insufficient evidence to recommend the use of enhanced formulas. In addition, they tend to be more expensive than regular formula. If you think your child might benefit from formula supplemented with probiotics or another substance, talk to your baby’s medical provider for additional information and guidance.

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Milk allergy

A person of any age can have a milk allergy, but it’s more common among infants. A milk allergy occurs when the body’s immune system mistakenly identifies the protein in milk as something the body should fight off. Some infants have a severe reaction to milk, such as hives, vomiting or trouble breathing within minutes or up to two hours of eating milk products. These types of reactions can be life-threatening and should prompt immediate medical attention.

More commonly, babies may have milk protein intolerance, which is different from an allergic reaction but can still cause problems such as bloody stools, diarrhea and possibly reflux. Avoiding milk and milk-based foods — including in your diet if you’re breast-feeding — is usually enough to resolve symptoms. Fortunately, most children outgrow milk protein intolerance by age 1 and milk allergy by age 3.

Cow’s milk is the usual cause of milk allergy; however, milk from sheep, goats and water buffalo also can cause a reaction. And some children who are allergic to cow’s milk are allergic to soy milk, too.

Because most formula is derived from cow’s milk, infants who are formula-fed may have a higher risk of developing a milk allergy than those who are breast-fed. However, the milk protein in dairy products that triggers the allergic reaction can cross into breast milk and may bother a breast-feeding baby. Researchers don’t fully understand why some infants develop a milk allergy and others don’t.

If you use formula and your son or daughter has a milk allergy, your doctor may advise you to switch to another type of formula that’s less likely to cause an allergic reaction. If you’re breast-feeding, restrict the amount of dairy products you consume.

• • • • •

Preparation Whatever type and form of formula you choose, proper preparation and storage are essential, both to ensure the appropriate amount of nutrition and to safeguard the health of your baby.

Wash hands and supplies Wash your hands before handling formula or the equipment used to prepare it. All equipment that you use to measure, mix and store formula should be washed with hot, soapy water and then rinsed and dried before every use. Sterilize new bottles, nipples, caps and rings before using them for the first time. Boil the utensils in water for five minutes. Use a pot that’s large enough to hold the utensils and cover them completely with water. Remove the utensils from the water using a clean set of tongs. Allow the utensils to air-dry.

After the first use, there’s no need to sterilize your utensils as long as you wash and rinse them well. Use a bottle brush to wash bottles. Brush or rub the nipples thoroughly to remove any traces of formula. Rinse well. You can also clean bottles and nipples in the dishwasher.

To help prevent fungal growth, you can rinse nipples daily in equal parts vinegar and water and allow them to air-dry. Also make sure the nipples are open. Hold each nipple upside down and fill it with water, then look for the water to drip slowly out of the nipple.

Mix it up To prepare a bottle of formula, follow carefully the instructions on the label. For ready-to-use formula, shake the container and pour the recommended amount into the bottle. When using powder formula or liquid concentrate, always add the exact amount of water specified on the label. Measurements on bottles may be inaccurate, so pre-measure the water before adding it to the formula. Using too much or too little water isn’t good for your baby. If formula is too diluted, your baby won’t get enough nutrition for his or her growth needs and to satisfy his or her hunger. Formula that’s too concentrated puts strain on the baby’s digestive system and kidneys, and could dehydrate your baby.

You can use any type of safe, drinkable water — tap or bottled — to prepare liquid-concentrate or powdered formula. If you’re concerned about the safety of your tap water, bring cold tap water to a rolling boil for one minute only, then cool the water to room temperature for no more than 30 minutes before using it.

• • • • •

Look before you buy

Don’t buy or use outdated infant formula. If the expiration date has passed, you can’t be sure of the formula’s quality.

While checking the expiration date, also inspect the condition of the formula container. Don’t buy or use formula from containers with bulges, dents, leaks or rust spots. Formula in a damaged container may be unsafe.

• • • • •

Warm, if needed Warming formula isn’t necessary for nutritional purposes, but your baby may prefer it warm. To warm formula:

Place a filled bottle in a bowl or pan of hot, but not boiling, water and let it stand for a few minutes — or warm the bottle under running water.

Shake the bottle after warming it.

Turn the bottle upside down and allow a drop or two of formula to fall on your wrist or the back of your hand. The formula should feel lukewarm — not hot.

Don’t warm bottles in the microwave. The formula may heat unevenly, creating hot spots that could burn your baby’s mouth.

Store safely Store unopened formula containers in a cool, dry place. Don’t store formula containers outdoors or in a car or garage, where temperature extremes can affect the quality of the formula.

If you’re using ready-to-use formula, cover and refrigerate any leftover formula from a freshly opened container. If you prepare and fill several bottles of liquid-concentrate or powdered formula at once:

Label each bottle with the date that the formula was prepared.

Refrigerate the extra bottles until you need them — don’t freeze them.

Put the bottles toward the back of the refrigerator, where it’s coldest.

Discard any prepared formula that’s been in the refrigerator more than 24 to 48 hours.

Discard any formula that remains in the bottle after a feeding. If you’re unsure whether a particular container or bottle of formula is safe, throw it out.

Getting into position The first step to bottle-feeding is to get comfortable. Find a quiet place where you and your baby can relax and not be distracted.

Cradle your baby in one arm, hold the bottle with the other and settle into a comfortable chair, preferably one with broad, low armrests. You may want to put a pillow on your lap under the baby for support. Pull your baby in toward you snugly but not too tightly, cradled in your arm with his or her head raised slightly and resting in the bend of your elbow. This semiupright position makes swallowing easier.

Using the nipple of the bottle or a finger of the hand holding it, gently stroke your baby’s cheek near the mouth, on the side nearest you. The touch will cause your baby to turn toward you, often with an opened mouth. Then touch the nipple to your baby’s lips or the corner of the mouth. Your baby will open his or her mouth and gradually begin sucking.

When feeding your baby, position the bottle at about a 45-degree angle. This angle keeps the nipple full of milk. Hold the bottle steady as your baby feeds. If your baby falls asleep while bottle-feeding, it may be because he or she has had enough milk, or gas has made your baby full. Take the bottle away, burp your baby (see these illustrations), then start to feed again.

Always hold your baby while feeding. Never prop a bottle up against your infant. Propping may cause your baby to vomit and may lead to overeating. In addition, never give a bottle to your baby when he or she is lying on his or her back. This may increase your baby’s risk of developing an ear infection.

Although your baby doesn’t have teeth yet, they’re forming beneath the gums. Avoid making a habit of putting your baby to bed with a bottle. Formula lingers in the mouth of a baby who falls asleep while sucking a bottle. The prolonged contact of sugar in milk with teeth can cause tooth decay.

What’s the right amount? During the first few weeks, your baby will likely drink about 1 to 3 ounces at each feeding. You’ll know that your young one is getting enough formula if by the end of the first week he or she has about six to eight wet diapers a day. He or she may also experience one or two bowel movements a day.

As he or she grows, the amount of formula your baby consumes will gradually increase. In general, during the first month, expect six to 12 feedings in a 24-hour period — about every two to four hours. By six months, your baby will probably consume 6 to 8 ounces at each of four or five feedings a day.

Weaning Infant formula is generally recommended until 1 year of age, followed by whole milk until age 2 — but talk with your child’s medical provider for specific guidance. Reduced-fat or skim milk generally isn’t appropriate before age 2 because it doesn’t have enough calories or fat to promote early development. Experts recommend weaning your baby from a bottle to a cup by no later than 18 months.

• • • • •

Burping positions

Lay baby facedown across your lap, and gently rub and pat baby’s back.

While sitting baby upright and supporting his or her chin and back, gently rub and pat baby’s back.

Lay baby facedown across your shoulder, and gently rub and pat his or her back.

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Spitting up

Spitting up is a rite of passage for many babies. Although it’s messy, you probably don’t need to worry. Spitting up rarely signifies a serious problem. As long as your baby seems comfortable and is gaining weight, there’s generally little cause for concern. If you keep a burp cloth within reach at all times, you’ll be well prepared.

Reflux Normally a valve between the esophagus and the stomach (lower esophageal sphincter) keeps stomach contents where they belong. Until this valve has time to mature, spitting up may be an issue — especially if your baby eats too much or too quickly. Spitting up tends to peak at age 4 months, and most babies stop spitting up by 12 months.

Minimal spitting up doesn’t hurt. It isn’t likely to cause coughing, choking or discomfort — even during sleep. Chances are your baby won’t even notice the fluid dripping out of his or her mouth.

What you can do To reduce spitting up, consider these tips:

Keep your baby upright. Position baby’s head higher than the rest of the body when feeding. Follow each feeding with 15 to 30 minutes in a sitting position. Hold your baby in your arms, or try a front pack, backpack or infant seat. Avoid active play and infant swings while the food is settling.

Try smaller, more frequent feedings. Feeding your baby too much at once can contribute to spitting up. If you’re breast-feeding, limit the length of each nursing session. If you’re bottle-feeding, offer your baby slightly less than usual.

Take time to burp your baby. Frequent burps during and after each feeding can keep air from building up in your baby’s stomach. Sit your baby upright, supporting your baby’s head with one hand while patting his or her back with your other hand (see these illustrations). Babies don’t burp after every feeding, though, so you don’t need to prolong the burping process.

Check the nipple. If you’re using a bottle, make sure the hole in the nipple is the right size. If it’s too large, the milk will flow too fast. If it’s too small, your baby might get frustrated and gulp air (see this discussion).

Experiment with your diet. If you’re breast-feeding, your baby’s doctor might suggest that you eliminate dairy products or certain other foods from your diet.

Pay attention to baby’s sleep position. To reduce the risk of sudden infant death syndrome (SIDS), it’s important to place your baby to sleep on his or her back. Placing a baby to sleep on his or her tummy is rarely recommended to prevent spitting up.

When it’s more serious More severe spitting up may indicate something more serious. Contact your baby’s medical provider if your baby:

Isn’t gaining weight

Spits up so forcefully that stomach contents shoot out of his or her mouth (vomits)

Spits up green or yellow fluid, blood, or a material that looks like coffee grounds

Resists feedings

Has blood in his or her stool

Has other signs of illness, such as fever, diarrhea or difficulty breathing

Some babies experience infant gastroesophageal reflux (see this discussion). Special feeding techniques or medication may be helpful.

CHAPTER 4 To solid foods and beyond

When your child is first born, breast milk or formula is the only food he or she needs. Eventually, though, your baby will begin to develop the coordination to move solid food from the front of his or her mouth to the back for swallowing. At the same time, your baby’s head control will improve and he or she will learn to sit with limited support. These are essential skills for eating solid foods.

As you expand your child’s diet to meet his or her nutritional needs, you’ll also have an early opportunity to encourage healthy eating habits. By setting up a regular schedule for meals and snacks, you’ll create a predictable and comfortable routine that your child can rely on. By making family meals a priority, even when your child is young, you’ll encourage sociability and togetherness. You can promote this further by keeping mealtimes relaxed and keeping cellphones, televisions and other devices turned off during meals.

These early habits will help your child develop a lifetime appreciation for nourishing his or her body with a variety of healthy foods in the context of a safe and comforting setting. That’s what healthy eating is all about and it’s never too early to start.

Starting solids

So when are babies ready for solid foods? It varies a bit, based on a child’s development. Signs that your baby might be ready include being able to sit in a high chair or booster chair, hold his or her head upright, show an interest in food and open his or her mouth for a spoon.

The American Academy of Pediatrics (AAP) recommends waiting until a child is at least 4 months old before introducing solid foods to complement breast milk or formula, and preferably holding off until a child is closer to 6 months old. If you have questions about starting solid foods, check with your child’s medical provider.

First foods Single-grain baby cereal has traditionally been used, and is fortified to meet infants’ nutritional needs after 6 months of age. But there’s no one “right” first food. Pureed meats also are a good choice as they are rich in iron and zinc, essential nutrients that are present at birth but whose levels decrease steadily over the first few months (see “The importance of iron” here).

You can also add in pureed vegetables and fruits. Pureed beans and leafy dark green vegetables contain iron, and the vitamin C in many fruits and vegetables helps iron absorption. Formula or breast milk can be mixed in to thin the puree, if needed.

Studies show that children who are introduced to vegetables and flavorful foods early on are more likely to eat these foods later in childhood. Avoid seasoning your infant’s food with added salt or sugar.

Getting started Use a small spoon — one that will fit into your baby’s mouth — and begin with very small amounts. At first, your little one may frown, sputter and spit it out. This isn’t necessarily because he or she doesn’t like it, but rather because he or she may not be familiar with moving the tongue backward yet. Wait for your baby to open his or her mouth for the spoon — don’t force food in. If he or she repeatedly uses his or her tongue to push the spoon away, this may be an indication that your baby isn’t ready for solids yet.

Don’t be surprised if your baby puts fingers to mouth to help swallow the food. He or she may also try to bat away the spoon. Expect it to be a messy experience! To prevent baby from getting frustrated when he or she is very hungry, try alternating between breast milk or formula and spoonfuls of food. Some parents skip pureed food entirely and let baby lead the learning process by self-feeding appropriate finger foods offered by the parent (see the discussion here).

Once your little one gets used to solids, he or she may be ready for a few tablespoons of food a day, including finger foods. By the end of the first year, most children obtain about half of their nutrition from breast milk or formula and half from complementary foods.

Taste and texture Babies also react to how food feels and tastes in their mouths. While you don’t have to follow a particular sequence of food groups, it may help to introduce different tastes and textures gradually. Offer single-ingredient foods at first, and wait three to five days between each new food. If your baby has a reaction to a particular food — such as diarrhea, a rash or vomiting — you’ll know the culprit. Spacing out new foods also gives your child a chance to get used to a new taste and texture. It often takes quite a few tries (up to 15 or more!) for a new food to gain acceptance.

Pureed foods Foods that are soft and runny may be easier for your baby to manage at first. One option is to mix 1 tablespoon of a single-grain, iron-fortified baby cereal with 4 to 5 tablespoons of breast milk or formula. Or, add breast milk or formula to pureed meat, vegetables, or fruit to attain a similar consistency. Though it will be quite runny, resist the urge to serve it from a bottle. As your baby learns to manage this consistency, serve foods with a thicker pureed consistency. Keep in mind that some babies eat such foods with gusto right from the start. Others are less enthusiastic. Be patient and keep trying.

Finger foods By about 9 months, most babies can handle small portions of finger foods, such as well-steamed vegetables, soft fruits, well-cooked pasta, cheese, graham crackers and tender meats.

As your baby approaches his or her first birthday, mashed or chopped versions of whatever the rest of the family is eating will likely become your baby’s main fare. Continue to offer your child breast milk or formula with and between meals.

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Baby-led feeding

A growing trend in Europe, Australia and the U.S. is allowing children who are 6 months or older to feed themselves solid foods (baby-led weaning or feeding), to encourage exploration of food and to let them regulate how much food they eat. The key part is letting babies guide the food into their own mouths. Preliminary studies conclude that this method may decrease food fussiness. There was no difference in weight between self-fed babies and spoon-fed babies.

The main concern with babies feeding themselves is the risk of choking. But evidence suggests that self-feeding is as safe as being spoon-fed, as long as appropriate precautions are taken. To prevent choking while eating, make sure your child is seated in an upright position and is always supervised. Don’t leave your baby unattended. Offer foods that are easy to pick up and are either mashable in your baby’s mouth or easy to gnaw on without breaking up into small pieces that block your child’s airway. Think steamed carrots, roasted sweet potato or cooked chicken, cut into pieces about the length of an adult’s pinky finger. Avoid foods that are small, coin-shaped, slippery, crunchy, sticky or tough.

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Juice Juice, while a popular beverage, is not a necessary part of a baby’s diet. Whole fruits have more nutritional value than juice. If you choose to give your child juice, be sure to use 100% fruit juice after 12 months of age, and limit the amount to no more than 4 ounces a day.

Too much juice may contribute to weight problems, tooth decay and digestive issues, such as diarrhea. You also don’t want juice to take the place of more-nutritious solid foods, breast milk or formula.

What’s off-limits Don’t offer cow’s milk, citrus, honey or corn syrup to your child before he or she is 12 months old. Cow’s milk doesn’t meet an infant’s nutritional needs — it isn’t a good source of iron and too much can lead to iron deficiency anemia. Citrus can cause a painful diaper rash, and honey and corn syrup may contain spores that can cause a serious illness known as infant botulism.

In addition, don’t offer your child foods that could pose a choking hazard. Such foods include:

Small, slippery foods, such as whole grapes, hot dogs or hard candy

Dry foods that are hard to chew, such as popcorn, raw carrots and nuts

Sticky or tough foods, such as plain peanut butter or chunks of steak

If you haven’t done so yet, consider taking an infant cardiopulmonary resuscitation (CPR) course. This is strongly recommended for all parents and very helpful in case of a choking episode.

• • • • •

Foods for baby

By your baby’s first birthday, he or she should be able to eat most of the foods served to the rest of the family. Just make sure food isn’t too hot or a choking hazard and avoid giving foods that are heavily spiced, salted or sweetened.

If you want to prep food for your baby, use a blender or a food processor to puree the food or cut the food into small, bite-size pieces. For softer foods, you may be able to simply mash them with a fork. Here are some examples of foods to try:

Apples, peeled and cut in eighths

Orange sections, peeled and loose membrane removed

Peaches, ripe and peeled

Small pieces of banana

Egg, boiled, scrambled or poached

Soft cheese

Soft custards or puddings

Yogurt

Cooked, soft carrots and other vegetables

Well-cooked macaroni, pasta, egg noodles and rice

Pieces of toast or bagels

Tender meats — fish, tuna, lamb, chicken, turkey, and some beef and pork

Spaghetti with meat sauce

Pancakes and waffles

Whole-grain crackers and cereals

• • • • •

Introducing peanut butter, milk and other foods

Some foods can cause problems if they’re not introduced at appropriate times.

Peanuts and other allergenic foods To help prevent food allergies, parents were once told to delay feeding infants eggs, fish and peanut butter. But today researchers say postponing the introduction of highly allergenic foods beyond 4 to 6 months of age hasn’t been shown to prevent eczema, asthma, allergic rhinitis or food allergy.

In fact, recent evidence suggests that introduction of peanut butter or peanut-containing foods as early as 4 months may help prevent the development of peanut allergy. This is especially true for babies at increased risk of peanut allergies, such as those with eczema, an egg allergy or a family history of food allergies.

If your baby’s started eating solid foods already and hasn’t shown signs of any food allergies, you can introduce a bit of peanut butter thinned with breast milk, formula or pureed food. (Avoid giving thick peanut butter from the jar or whole nuts.) If your baby tolerates it, you can gradually increase the amount given. When introducing other allergenic foods, stick to textures your baby eats and likes.

If your baby has eczema or food allergies run in your family, talk to your baby’s medical provider before introducing peanut butter. The provider may recommend having your baby tested for peanut allergy first.

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The importance of iron

Iron is a nutrient that’s essential to your child’s growth and development. Iron helps move oxygen from the lungs to the rest of the body and helps muscles store and use oxygen. Babies are born with iron stored in their bodies, but a steady amount of additional iron is needed to fuel a child’s rapid growth and development. Infant formulas are fortified with iron. But if you breast-feed your baby, start him or her on an iron supplement at 4 months of age. If your baby was born early, your provider likely recommended beginning an iron supplement earlier. As your baby grows and begins to eat other foods:

Serve iron-rich foods. When you begin serving your baby solids — typically between ages 4 months and 6 months — feed him or her foods with added iron, such as iron-fortified baby cereal and pureed meats. For older children, good sources of iron include red meat, chicken, fish and tofu.

Don’t overdo milk. Once your little one turns a year old and starts drinking milk, don’t allow him or her to drink more than 24 ounces of milk a day. Too much milk can inhibit the body’s absorption of iron.

Enhance iron absorption. On the other hand, vitamin C helps promote the absorption of dietary iron. You can help your child absorb iron by offering foods rich in vitamin C — such as cantaloupe, strawberries, bell peppers, tomatoes and dark green vegetables.

• • • • •

Cow’s milk Around your baby’s first birthday, you may gradually introduce your child to whole cow’s milk. Of course, continue to breast-feed your baby as long as you wish. Cow’s milk isn’t a replacement for breast milk or formula. But as your baby gains nutrients from a wider variety of foods, dairy milk can be an important source of vitamin D, calcium, fat and protein.

The AAP recommends that children be given whole milk until age 2. Low-fat milk — such as 2%, 1% and skim — doesn’t provide enough fat for your child’s developing brain and shouldn’t be given until your child is 2 years old unless specifically recommended by your child’s medical provider.

Alternative milks — such as soy, nut and plant-based milks — are typically fortified with vitamin D and calcium, but most contain lower fat content than whole cow’s milk. Talk with your child’s medical provider before introducing milk if you have questions and especially if your child was diagnosed with a milk protein intolerance or allergy. Limit your child’s milk intake to no more than 16 to 24 ounces a day. Higher intake may crowd out other necessary foods and is associated with iron-deficiency anemia.

• • • • •

Teething and dental care

Your baby’s first teeth may erupt by 6 to 7 months. Your baby may be fussy at this time, which may interfere with eating. Teething causes your baby’s gums to swell. When your baby makes the effort to suck, more blood rushes into the already swollen gum. This may cause your baby to squirm, whimper and refuse to eat. You may try rubbing your baby’s gum before feeding (for more on teething, see the discussion here).

Once there are teeth, there’s the potential for dental decay. Dental cavities typically occur due to prolonged exposure to sugars in foods and drinks. To reduce the risk of dental damage:

Avoid putting your baby to bed with a bottle of juice or milk. Sugar from milk and juice stays in the mouth longer when a baby drinks from a bottle. This may lead to an increase in dental cavities.

Wean your baby from a bottle by 18 months.

Limit sugary foods and drinks to mealtimes. Avoid carbonated, sugared drinks in general. Offer water between meals for toddlers.

Clean your baby’s teeth twice daily by brushing them with a small smear — or an amount about the size of a grain of rice — of fluoridated toothpaste.

• • • • •

Family mealtimes

Mealtimes are an important part of family life. They offer family members a chance to come together to share not just food but companionship. Whenever possible, have your baby eat at the same time as the rest of the family. This helps your baby get used to the process of eating — sitting down, choosing foods to eat, resting between bites and stopping when full — and socializing with others.

These early experiences will help your child learn good eating habits that last a lifetime. Research shows that families that eat together regularly tend to eat more nutritious foods and are less likely to encounter childhood obesity or eating disorders. Children are also more likely to have better behavior, a stronger vocabulary and greater academic success.

Tips for babies To help mealtimes be a pleasant experience for everyone, consider these suggestions.

Stay seated At first, you may feed your baby propped on your lap. As soon as your baby can sit easily without support, use a highchair with a broad, stable base. Buckle the safety straps, and keep other children from climbing or hanging on to the highchair.

Encourage exploration Your baby is likely to play with his or her food between bites. Although it’s messy, this hands-on approach helps fuel your baby’s brain development. Placing a dropcloth on the floor can help. Offer your baby new foods to try. To increase the chances of acceptance, offer one new food along with an established favorite. Most babies can and should eat from all food groups as soon as 7 to 8 months of age.

Introduce utensils Offer your baby a spoon to hold while you feed him or her with another spoon. As your baby’s dexterity improves, encourage your baby to dip the spoon in food and bring it to his or her mouth. After your baby turns a year old, his or her use of utensils will continue to develop. Give your child the chance to practice.

Offer a cup Feeding your baby breast milk or formula from a cup at mealtime can pave the way for weaning from a bottle. When your child reaches 9 months, he or she may be able to drink from a cup on his or her own, but spills are likely until about 15 months or so. You may want to begin with a nonspill cup, often called a “sippy” cup.

Dish individual servings Early on, your baby may eat just a few spoonfuls of food at a time. If you feed your baby directly from a jar or container, bacteria and saliva from the spoon can quickly spoil any leftovers. Instead, place 1 tablespoon of food in a dish and refrigerate the rest. The same goes for finger foods. If your baby finishes the first serving, offer another.

Know when to call it quits When your baby has had enough, he or she may turn away from the food, lean backward, or refuse to open his or her mouth. Don’t force extra bites. As long as your baby’s growth is on target, you can be confident that he or she is getting enough to eat.

When babies are allowed to decide how much food they want to eat and how fast to eat it, they become fairly adept at it. And doing so allows them to regulate their food intake based on how hungry they are, which contributes to a healthy weight now and later.

Tips for toddlers As your child moves into toddlerhood, you may notice a drop in his or her appetite. Your child may become fussy about what he or she eats, run away after a few bites, or resist coming to the table at mealtimes. This is normal — and frustrating!

After the first year of life, your child’s growth rate slows and he or she doesn’t require as many calories. To keep encouraging healthy eating habits in your growing child, follow these steps.

Minimize distractions Make the most of family mealtimes. Turn off TVs, phones and other electronic devices. This helps your toddler — and everyone else — focus on the meal and each other. Even if your child isn’t using words yet, he or she enjoys the back-and-forth communication going on and the feeling of being part of the family. This sort of stimulation is important to your child’s mental, social and emotional development.

Keep portions small As your child gets older, avoid giving too much at once, which can seem overwhelming. Put a small amount — about the size of your child’s fist — of each food group on the plate, then offer seconds if your child wants more.

Don’t sweat the picky eater Picky eating habits are common in the toddler years and through preschool. But these behaviors generally ease with age. You’re not responsible for making your child like certain foods, but you can present multiple opportunities for your son or daughter to learn about food and try different kinds. Include your child in shopping for food, feeling the shape and texture of different food items, watching food being prepared, and maybe even having a taste.

Avoid power struggles If your child turns away from a certain food, don’t push. Simply try again another time. Repeated exposure helps ensure variety in your child’s diet. The harder you push your child to eat, the less likely he or she is to comply. Offer a selection of nutritious foods at each mealtime and let your child choose what he or she wants to eat.

Focus on the positive Praise your child’s attempts at eating and trying new foods, but avoid giving undue attention when he or she doesn’t eat. Focusing on your child’s positive eating behaviors — and mostly ignoring other behaviors — helps reinforce the positive behaviors and keeps mealtimes pleasant. Avoid using food as a means of punishment or reward — such as withholding dessert or using it as a bribe — as this can set the stage for an unhealthy relationship with food and will only reinforce the idea that desserts are more desirable.

Change it up Sometimes, it’s not the food a picky eater objects to so much as the presentation. Your child might object to mixing foods or having one food touch another on a plate. If this is the case, try changing things up. For example, offer an array of bite-sized portions arranged in a row — maybe an assortment of cooked macaroni, cannellini beans, steamed broccoli florets and soft, diced peaches. These are all nutritious and your child can pick and choose what he or she likes. Even if they don’t all get eaten, point out the color and texture of the foods. Touching, smelling and playing with food are all exploratory toddler behaviors that precede a willingness to accept the food.

Be patient Often, toddlers will want to eat a particular food for days, then suddenly refuse to eat the same food at all. Don’t worry too much about these food “jags.” Focus on providing healthy options, and try to offer at least one food that your child is familiar with and likes with each meal.

Keep in mind that most children consume the right balance of nutrients over the course of the week. A child’s pickiness won’t change overnight, so take small steps and make note of what works.

• • • • •

Infant and toddler eating behaviors

Age
Behaviors
Feeding tips

7 to 12 months

Grasps food with hands

Takes food from a spoon with lips

Eats soft foods or foods with tiny lumps without gagging

Offer soft foods such as iron-fortified infant cereal or pureed meat thinned with a bit of liquid

Offer a variety of new foods, one at a time

Don’t force feed

12 to 24 months

Self-feeds finger foods

Drinks from a sippy cup without help but maybe not without spilling

Appetite decreases as growth slows

May seem uninterested in food for periods of time

May be a cautious, curious or rebellious eater

Consider weaning from the bottle before 18 months; this avoids risk of overeating and dental decay

Provide safe finger foods

Offer whole milk to drink with meals

Allow exploration of food using all the senses

24 to 36 months

Appetite is often unpredictable

May shift favorite foods without warning

May eat better than usual at one meal and nothing at the next

May struggle to eat independently

Allow and encourage self-feeding, even if it takes awhile

Offer new foods repeatedly

Offer whole milk unless otherwise specified by medical provider

Offer water between meals and snacks

• • • • •

CHAPTER 5 Diapers and all that stuff

There’s a lot to look forward to in your baby’s first years, but changing diapers may not be at the top of the list. It’s no small task — the average child goes through about 5,000 diaper changes before being toilet trained. You might wonder, what diapers are best? What should I do about diaper rash? And, is it normal that my baby has yellow or green poop?

A bit of prep and info can help make diaper duty more pleasant and less worrisome. Consider diaper changing as another opportunity to bond with your baby. After all, caring for your child in this way, day after day, offers a moment for you and your baby to pause and connect.

Keep in mind that the routine of diaper changes will only last so long. The next chapter has everything your need to know about toilet training.

Finding the right diaper

Several types of diapers are available — cloth or disposable, brand name or generic — and they come in many sizes and styles. Some babies are comfortable in a lot of different types of diapers, while others need a particular kind that works just right for their body. If your baby doesn’t fit well in the diapers you have, or if he or she seems irritated by the diaper, don’t be afraid to try something new.

Disposable These diapers are commonly used, and they’re highly absorbent and convenient. However, the cost of using disposable diapers adds up, especially if you have more than one baby.

The materials used in disposables usually keep your baby’s skin drier for a longer period of time. But the downside of this absorbency is it can be harder to monitor how much your baby has urinated, which may be important to know when your baby is a newborn.

Disposables are also convenient — you throw them away after each use. However, disposable diapers generally aren’t considered biodegradable. At best, they may degrade over a very long period of time. An estimated 18 billion diapers a year are sent to landfills. Fortunately, more disposable diaper companies are making efforts to have less of a negative impact on the environment by using different materials, fewer dyes and better packaging.

Cloth Cloth diapers have become increasingly common in recent years, as new brands and styles offer more effective and convenient options. Cloth may be more comfortable on your baby, and cloth diapering also saves a lot of money over time. However, cloth diapers are typically less absorbent than are disposables, and they require more work.

Cloth diapers typically have two parts. There’s an inner layer, which is usually made from a soft cotton material, as well as an outer cover that’s made from a type of plastic, cotton or terry cloth. Some parents like that these materials don’t contain chemicals, materials or fragrances that can irritate babies. Today’s cloth diapers are usually fastened with snaps or fabric fasteners, not pins. Cloth diapers typically aren’t as absorbent as disposables, so they need to be changed quickly after they become dirty to prevent irritation to your baby’s skin.

Depending on how many diapers you buy, cloth diapers need to be washed anywhere from a couple of times a week to daily. Some people hire a diaper-washing service to drop off clean diapers and pick up dirty diapers for washing. Some cloth diapers also come with an optional disposable insert, so you can throw away the dirty part of the diaper. There are even some biodegradable disposable inserts that can be composted or flushed down the toilet.

With the rise in cloth diaper use, there also are more accessories to make it easier, including sprayers that attach to your toilet so that you can rinse off urine and stool from dirty diapers, and wet bags to contain the diapers before they’re washed.

Sizes Most disposable diaper packages are labeled with a size that corresponds to your baby’s weight. Though the range varies based on the brand, newborn sizes typically go up to 10 pounds, and size 1 is for babies who weigh about 8 to 14 pounds. Preemie diapers are usually for babies who weigh less than 6 pounds.

Some cloth diapers come in different sizes — such as newborn, small, medium or large — while other styles can be adjusted to fit your growing baby.

Amount If you use disposable diapers, you’ll need 80 to 100 a week, at least during the newborn period. Older infants typically require fewer. If you plan to buy cloth diapers, the number you’ll need depends on how often you plan to wash them. Some people buy enough that they only need to be washed every third day or so, and others buy a smaller quantity and wash daily.

• • • • •

Swim diapers

As your baby gets older, there may come a time you want to take him or her to the swimming pool. Infants in the pool with their parents often wear swim diapers or swim pants. It’s not clear how well these products contain stools in a pool. Even if they appear to contain everything, some contaminants and germs can leak through. If your baby has diarrhea or is sick, he or she should not go into a pool. Doing so could contaminate the water and make other babies and children sick. If your baby is healthy and you take him or her to the pool, change the swim diapers as needed.

• • • • •

Getting equipped

Diaper changes will be easier if you have everything you need on hand.

Changing station It helps to have one or two places where you always change your baby’s diaper. This way, you can keep all your materials together and readily available in the designated location. If you use a changing table, make sure it has a wide, sturdy base that has compartments for storing diaper supplies. Remember to always keep one hand on your baby during changes. Another option is to change your baby using a changing pad on the floor. You can store supplies in the lower drawer of a crib or in a nearby dresser for easy access.

Diapers Keep an adequate stock of diapers on hand. If you primarily use disposables, it may help to have some cloth diapers around in case you run out. If you mainly use cloth, keep a stack of disposables handy for those days when you haven’t had a chance to do the wash.

Wipes You can buy pre-moistened baby wipes, use a moistened cloth, or make your own wipes using a homemade solution. If you use pre-moistened baby wipes, choose wipes for sensitive skin that don’t contain alcohol or fragrance. This will help prevent irritation. It’s not necessary to use wipes with every change. Urine is rarely irritating, so if your baby has only peed, letting the area dry or wiping it with a moist cloth may be sufficient. Unless your package of wipes specifies that they’re flushable, wipes must be thrown away.

Dry cloths You may want to have some dry, soft cloths on hand so that after you’re finished wiping your baby, you can gently pat his or her bottom dry if you don’t have time to let it air dry. Air exposure can trigger babies to urinate, and your baby may urinate while you’re changing the diaper. If your baby is a boy, you can avoid being sprayed with urine by covering his penis loosely with a dry cloth while you clean the rest of his bottom.

Diaper pail or wet bag Diaper pails store dirty diapers and wipes, and wet bags are made to store dirty cloth diapers and reusable wipes before they’re washed. There are a variety of types of pails and bags available. Look for one that’s convenient, sanitary and holds in odors.

Ointment You don’t need to apply an ointment unless your baby tends to develop diaper rashes. But it’s nice to have a product on hand so that if your baby does develop a rash, you won’t have to immediately run out to buy something.

• • • • •

Homemade baby wipes

Pre-moistened baby wipes are common in the United States, but they aren’t always necessary, and they’re often overused. Some pre-moistened wipes contain ingredients that can be irritating to babies’ bottoms. One way you can eliminate your baby’s exposure to these ingredients, and save money, is to make your own baby wipes.

There are a variety of ways to make homemade wipes, but here are some suggestions to get you started. After reading through the options, decide which approach you feel would work best for you.

Wipes There are a few different options you can consider for wipes. See what you like best:

Buy rolls of soft paper towels. Cut the rolls in half so that you have two shorter rolls. You’ll have a nice size for wipes.

Buy a stack of reusable wipes, which are often made of flannel or some other form of cotton. Or, purchase some thin baby washcloths that you will use as wipes.

Make your own reusable wipes. Purchase soft flannel, terry cloth or fleece fabric and cut it into 5-inch squares. Then sew the edges so that the fabric won’t unravel in the wash.

Moistener There are options on what you can use.

Water

Homemade solution. Here’s one recipe:

2 tablespoons baby wash

2 tablespoons olive oil

2 cups water

Container Use whichever method is easiest for you.

Round plastic storage container. Pour your homemade solution in the bottom of the container. Set a half roll of paper towels inside the container and place the cover on the container. The paper towels will absorb the liquid, and then you can tear off each sheet as you need it.

Spray bottle. Keep fresh water or your homemade solution in a spray bottle. If you use a solution, wet down your wipes with water first, and then spray each wipe with a couple of squirts of solution.

If you create your own baby-wipe solution, you may want to check with your baby’s medical provider to ensure the baby wash or other ingredients in the solution don’t contain any potentially harmful or irritating substances. Products can be absorbed into your baby’s body through the skin, so it’s important that you’re comfortable with all the ingredients.

• • • • •

Changing diapers

By the time your child is toilet trained, you’ll be a diaper-changing pro. In the meantime, the following steps and pointers can help make diaper changing a successful venture for both you and baby.

Mindset Changing diapers is an unavoidable part of parenting, but it may help to think of this necessary task as an opportunity for closeness and communication with your baby. Your warm words, gentle touches and encouraging smiles help make your baby feel loved and secure, and soon your infant will be responding with gurgles and coos.

Frequency Because newborns urinate frequently, it’s important to change your baby’s diapers every two or three hours for the first few months, especially if you use cloth diapers. But you can wait until your baby wakes up to change a wet diaper. Urine alone doesn’t usually irritate a baby’s skin. However, the acid in a bowel movement can, so change a messy diaper as soon as your baby awakens.

Preparation Have your wipes and a new diaper ready and within arm’s reach. It may help to pull out or prepare the number of wipes you think you’ll need for the job, and open the diaper to lay it flat. Make eye contact and tell your baby that you’re going to change his or her diaper. Lay your baby gently on his or her back. If you change the baby anywhere but the floor, remember to keep your hand on your baby at all times.

Remove old diaper Unfasten the fabric fastener, tape or snaps on the diaper your baby is wearing, and pull down the front side of the diaper. If your baby has had a bowel movement, you can use the clean inside front of the diaper to pull much of the stool off your baby’s skin. Set the diaper off to the side beyond your baby’s reach.

Clean baby’s bottom During the cleaning, carefully grasp and hold your baby’s legs at the ankles with one hand. Using a cloth that’s been moistened with warm water or pre-moistened wipes, clean from baby’s front to back. Remember to check and clean out folds, where hidden stool can hide. You can place dirty wipes in the middle of the inside of the dirty diaper to keep the mess consolidated.

Changing baby girls Remember to wipe from the front side to the back side to avoid getting stool (or more stool) in the vaginal area. Baby girls have more folds and places for poop to hide, so it’s important to clean them thoroughly. However, girls also often have a normal white discharge in the folds of the labia, and it’s not necessary to remove that. Too much scrubbing can cause irritation.

Let dry When finished with the cleaning, gently pat your baby’s bottom with a soft cloth so that the skin is dry when you put the new diaper on.

Place new diaper As you lift your baby’s legs from the ankles, slide the new diaper underneath his or her buttocks. The side with tabs should be in the back, underneath your baby. Pull the front of the diaper up between your baby’s legs, and place it so that the front side and back side of the diaper will be at about the same level around your baby’s body. Then fasten the tape, fabric fastener or snaps so that the diaper fits snugly around your baby’s waist. If you’re using disposable diapers, make sure that none of the elastic around the legs has folded underneath itself. If you’re using cloth, make sure the inner layer is tucked inside the outer layer.

Changing baby boys Baby boys can have a tendency to urinate up and out of their diapers, causing leaks and wet clothes. As you put a new diaper on your baby boy, try positioning his penis downward to prevent these leaks. Also, you may want to fold the diaper down and in for extra protection on his front side.

• • • • •

Putting on a disposable diaper

Step 1. When opening the diaper, make sure the tape, which is at the back of the diaper, is at the top, or away from you. Slide the diaper under your baby until the top edge (the edge with the tape) lines up with your baby’s waist.

Step 2. Bring the front of the diaper up through the legs, without twisting it to one side.

Step 3. Hold one side in position while removing the tab from the tape. Pull the tape forward and stick it to the diaper front. Repeat for the other side, making sure the diaper is snug around your baby’s legs and not twisted to one side.

Step 4. For a newborn, fold down the top of the diaper so that it won’t rub against the healing umbilical cord. Disposable diapers should fit snugly around the waist, with room enough for only one finger.

• • • • •

Discard old diaper If you’re using disposables, you can roll up the dirty diaper from the front to the back — with any wipes in the middle of the diaper — and then fasten the tabs around the sides of the rolled up diaper. Toss the diaper in a diaper pail. If you’re using cloth diapers and cleaning them yourself, dump any stool into your toilet, rinse the diaper off and place it in a designated holding spot — such as a wet bag or diaper pail — until you wash your load of diapers. Some families use diaper sprayers, which attach to the toilet. They can often be purchased in a baby store or online.

Wash your hands When you’re finished with the diaper change and baby is in a safe place, wash your hands with soap and water. Hand-washing is important. It can prevent the spread of bacteria or yeast to other parts of your baby’s body, to you or to other children.

• • • • •

The umbilical cord

For the first few days that you’re changing your baby’s diapers, you’ll need to work around baby’s umbilical cord stump. It’s best to expose the stump to as much air as possible as it dries up and eventually falls off. It’s also important to keep the umbilical cord stump clean and away from contact with urine and stool. Most newborn diapers are designed with a small cutout so that the diaper sits below the cord and doesn’t rub it. If your diapers don’t have this feature, fold the top down so that the diaper is positioned below the cord.

• • • • •

What’s normal

New parents often wonder what’s normal when it comes to their baby’s urination and bowel movements. For newborns especially, there’s a range of what’s considered normal for color, consistency and frequency. But there also are guidelines that help you know what to expect and when there’s cause for concern.

Urine In a healthy infant, urine is light to dark yellow in color. Sometimes, as highly concentrated urine dries on the diaper, it creates a chalky, pinkish color, which may be mistaken for blood. This is normal and not a cause for concern. Keep in mind that concentrated urine is different from blood in that it dries to a powder, and it’s not as red in color.

By the time a baby is 3 or 4 days old, he or she should have at least four to six wet diapers a day. As your baby gets older, he or she may have a wet diaper with every feeding.

Stools Your baby’s first soiled diaper will probably occur within 48 hours of birth. During the first few days, a newborn’s stools will often be thick and sticky — a tar-like, greenish-black substance called meconium. After the meconium is passed, the color, frequency and consistency of your baby’s stools will vary depending on how your baby is fed — with breast milk or formula. Once solid foods are introduced, the frequency and consistency of stools may change also.

Color If you’re feeding your baby breast milk, your baby’s stools will likely resemble light mustard with seed-like particles. They’ll be soft and even slightly runny. The stools of a formula-fed infant are usually tan or yellow and firmer than those of a breast-fed baby, but no firmer than peanut butter.

Occasional variations in color and consistency are normal. Different colors may indicate how fast the stool moves through the digestive tract or what the baby ate. The stool may be variations of the colors green, yellow, orange or brown.

The color isn’t that significant unless the stool has blood — shown as red or coal-black streaks — or if it is a whitish-grey color instead of closer to yellow-brown. A whitish-grey color could be a sign that the stool is lacking bilirubin products, which are normal byproducts from the body breaking down excess red blood cells. These very pale stools could indicate that your baby’s body isn’t eliminating waste properly. If you see blood or whitish-grey stools, contact your child’s medical provider.

• • • • •

Diaper surprises

You might occasionally notice a surprising but often harmless substance in your baby’s diaper. These substances may appear as:

Gel-like materials Clear or yellow-tinted beads or particles may come from diaper materials that have become overly wet with urine.

Small crystals A newborn baby’s kidneys may make clear crystals if baby is relatively dehydrated. This can also leave a tinted orange or pink stain in the diaper.

Pink or small bloodstains A newborn baby girl may have some pink or bloodstains in her diapers in the first few weeks. This is generally from exposure to her mother’s hormones right before birth. It isn’t usually a problem, and it goes away with time.

• • • • •

Consistency Mild diarrhea is common in newborns. The stools may be watery, frequent and mixed with mucus. Constipation isn’t usually a problem for infants. Babies may strain, grunt and turn red during a bowel movement, but this doesn’t necessarily mean they’re constipated. Constipation may develop in some babies when solid foods are introduced (see this discussion).

Frequency The range of normal is quite broad and varies from one baby to another. Babies may have a bowel movement as frequently as after every feeding or as infrequently as once a week, or they may have no consistent pattern.

Blood If your baby’s stools appear to contain blood — whether you see red or coal-black coloring, streaks, flecks or otherwise — contact your child’s medical provider and have the problem checked out. Actual blood in stools is always a cause for concern, but don’t panic; sometimes the problem isn’t serious.

For example, newborns may have ingested some of their mother’s blood during delivery, or they may be taking it in while breast-feeding if the mother has cracked or bleeding nipples. Flecks or streaks of blood in stools may also be a sign of an allergy to the protein in cow’s milk, which may be found in formula or breast milk. For older babies, red or black in stools could be from certain foods, including tomatoes, beets, spinach, cherries and grape juice.

Diarrhea If you notice that your baby’s stool becomes more watery than normal and you observe a gradual or sudden increase in how often or how much he or she is pooping, contact your child’s medical provider.

There are many possible causes of diarrhea. Some foods may cause diarrhea. Diarrhea may also be an indication of an illness. And antibiotics are a common cause. Antibiotics wipe out both the good and bad bacteria in the gut.

If antibiotics are the culprit and your child is 9 months or older, you might consider feeding your child foods that contain probiotics, such as yogurt. Probiotics, found in certain fermented foods, are microorganisms that contain “good bacteria.” Probiotics may help bring a healthy bacterial balance back to your child’s gut and improve digestion.

Probiotics are also available as over-the-counter supplements. However, because not a lot is known about the supplements, and studies with young children are limited, Mayo Clinic pediatricians don’t routinely recommend their use. If you have questions about probiotics, talk to your child’s medical provider.

Constipation Constipation in infants is defined by consistency of stools rather than by frequency. A baby is constipated when bowel movements are hard and perhaps even ball shaped. Babies may become more prone to constipation once they start eating solid foods regularly. If your baby’s stools are hard and formed, you can offer a couple of ounces of water in a sippy cup with meals. This water doesn’t replace breast milk or formula but can help give your baby a bit of extra fluid, which can help with constipation.

Adding more fruits and vegetables to your baby’s diet can also help. Prunes, pears, and peaches are frequently used to help soften stools, either as purees or a small amount of juice. If these changes don’t lead to softer stools, talk to your baby’s medical provider about other possible causes and treatments.

Diaper rash

All babies get a red or sore bottom from time to time, even with frequent diaper changes and careful cleaning. Diaper rash is such a common condition that it happens to nearly every baby at some point. You certainly aren’t a bad parent if your baby gets a diaper rash. Fortunately, diaper rash is usually easily treated and improves within a few days.

Diaper rash often results from prolonged contact with urine or stool. Mild cases can often be treated with over-the-counter products. Cases that are more severe may need to be treated with prescription medications.

Appearance Diaper rash is marked by red, puffy and tender-looking skin in the diaper area — buttocks, thighs and genitals. The skin may have rashes or just look red and irritated. Your baby may seem more uncomfortable than usual, especially during diaper changes.

Causes Causes of diaper rash include the following:

Irritation from stool Prolonged exposure to a soiled or damp diaper can irritate a baby’s sensitive skin. Your baby may be more prone to diaper rash if he or she has frequent bowel movements, because feces are more irritating than urine.

Irritation from a new product Disposable wipes, a new brand of disposable diaper, or a detergent, bleach or fabric softener used to launder cloth diapers can all irritate your baby’s delicate skin. Other substances that can add to the problem include ingredients found in some baby lotions, powders and oils.

Introduction of new foods As babies start to eat solid foods, the content of their stool changes, increasing the likelihood of diaper rash. Changes in your baby’s diet can also increase the frequency of stools, which can lead to diaper rash.

Bacterial or yeast (fungal) infection The area covered by a diaper — buttocks, thighs and genitals — is especially vulnerable because it’s warm and moist, making a perfect breeding ground for bacteria and yeast. These rashes generally start hidden within the creases of the skin, and there may be red dots scattered around the edges.

Chafing or rubbing Tightfitting diapers or clothing that rubs against the skin can lead to a rash.

Use of antibiotics Antibiotics kill bacteria — both bad and good ones. Without the right balance of good bacteria, yeast infections can occur. This can happen when babies take antibiotics or when mothers who are breast-feeding their infants take antibiotics. Because antibiotics often cause diarrhea, this can also lead to rashes.

• • • • •

Preventing rash: Cloth or disposable?

When it comes to preventing diaper rash, there’s no compelling evidence that cloth diapers are better than disposable diapers or vice versa, though disposables may keep baby’s skin slightly drier. Because there’s no one best diaper, use whatever works best for you and your baby. If one brand of disposable diaper irritates your baby’s skin, try another.

No matter whether it’s cloth or disposable, try to change your baby as soon as you can after he or she soils the diaper, to keep the bottom as clean and dry as possible.

• • • • •

Treatment The most important factor in treating diaper rash is to keep your baby’s skin as clean and dry as possible. This often means increasing “diaper-free” time and thoroughly but gently washing the area with water during each diaper change. Avoid washing the affected area with soaps and disposable, scented wipes. Alcohol and perfumes in these products can irritate your baby’s skin and aggravate or provoke the rash.

If the rash is severe, it might help to clean your baby’s bottom with warm water from a squirt bottle instead of using a moistened cloth or wipes, so you won’t have to rub the tender skin. It’s also important to allow baby’s bottom to air-dry completely before putting on a new diaper. If possible:

Let your child go without a diaper for longer periods of time.

Avoid using plastic pants or tight-fitting diaper covers.

Use larger sized diapers until the rash goes away.

In addition, use a mild ointment anytime pinkness appears in the diaper area. This can reduce friction and rubbing and block chemical irritants — from stools or from diaper materials — from contact with your baby’s skin.

Apply the cream in a thin layer to the irritated region several times throughout the day to soothe and protect the baby’s skin. You don’t have to completely remove the cream at every diaper change if the area is clean — rubbing will only irritate the skin further.

Many effective creams contain zinc oxide, which helps sooth the skin. Look for a cream that doesn’t contain fragrance, preservatives or other ingredients that could cause irritation or allergies, including neomycin. Some products are absorbed into the body through the skin. And some creams contain ingredients that can be harmful for your baby, including boric acid, camphor, phenol, benzocaine and salicylates.

Also avoid creams that have steroids, such as hydrocortisone, in them, unless your baby’s medical provider specifically recommends such a product. Creams containing steroids can be harmful, and they usually aren’t necessary. Also, don’t use talcum powder or cornstarch on a baby’s skin unless recommended by a your baby’s provider. An infant may inhale talcum powder, which can be very irritating to a baby’s lungs. Cornstarch can contribute to a bacterial infection.

When to seek medical treatment Contact your baby’s medical provider if:

The rash is accompanied by a fever.

The rash has blisters, boils, discharge or pus-filled sores.

The rash isn’t improving after two to three days of home treatment.

Your baby is taking antibiotics, and the rash is bright red with red spots around the edges. It could be a yeast infection, which needs additional treatment.

The rash is severe.

The rash is present on skin outside the diaper area.

Preventing diaper rash There are a variety of steps you can take to help prevent, or at least reduce the incidence of, diaper rash:

Change your baby’s diaper often so his or her skin is not in contact with urine or stools for very long.

Let your baby’s bottom air out once in a while by letting him go without a diaper for a brief period.

Avoid using superabsorbent disposable diapers, because they tend to be changed less frequently.

If you’re using cloth diapers, be sure to wash and rinse them thoroughly. Pre-soak heavily soiled diapers, and use hot water to wash them. Use a mild detergent with no fragrance, and skip fabric softeners and dryer sheets, which can contain fragrances that irritate your baby’s skin. Double-rinse the diapers.

If you use cloth diapers, select snap-on diaper covers, instead of those with elastic bindings, to help improve circulation.

After changing diapers, wash your hands well to prevent the spread of germs.

CHAPTER 6 Toilet training

Toilet training is a big milestone for kids and parents. Many parents look forward to the day when they no longer have to deal with soiled diapers and are free to leave the house without a diaper bag. Most don’t miss the expense either.

But it’s important to let your child lead the way. Learning to use the toilet is a natural part of growing up and not much different from learning to drink from a cup, walk, talk or any of the many other skills that infants and toddlers develop as they move toward independence. If left to learn how to use the toilet on their own, most children would probably toilet train themselves. As with learning to walk, it would occur in a long series of small successes, each next step occurring when the child is ready.

In fact, readiness is the key to successful toilet training. The single most common cause of toilet training problems is that the child isn’t ready. Being ready makes toilet training easier and quicker. Patience on the part of parents helps, too.

Recognizing readiness

Many children show signs of being ready for toilet training between ages 18 and 24 months. However, others might not be ready until they’re 3 years old. There’s no rush. Rather than relying solely on your child’s age — or when his or her peers are being toilet trained — look for your child to show key signs of being ready and interested in using the toilet.

Your child’s readiness depends on when he or she achieves certain physical, developmental and behavioral milestones. It doesn’t have anything to do with intelligence, will or character.

Physical readiness To use the toilet successfully, a child must have voluntary control over his or her pelvic muscles. This is something your child grows into with time. You don’t have much control over this aspect, and some kids take a little longer than others. Signs of voluntary control usually begin to appear by 18 months or so.

Signs of physical readiness include being able to recognize the urge to urinate or have a bowel movement and sense this urge in time to make it to the toilet or potty chair. Most children achieve this neurological function between 24 and 36 months.

Developmental readiness A number of motor, language and social skills are important to using the toilet. Your child may be developmentally ready if he or she is able to:

Walk to and sit on the potty

Stay dry for up to two hours

Pull bottom clothes down and back up again

Follow simple two-step instructions, such as, “Pick up the ball and put it in the toy basket”

Communicate the need to go potty

Behavioral readiness You can also look for key indications in your child’s behavior, such as:

Being able to imitate the behaviors of others, such as using the toilet

The ability to put things where they belong, which helps with understanding that pee and poop go in the toilet

The ability to say no, which shows a degree of independence from you

A desire to cooperate and less of a desire to engage in power struggles

An interest in using the potty on his or her own and in staying clean and dry

Parent readiness Your own readiness as a parent is important, too. Expect that toilet training will take some time and patience. It’s also likely to get a bit messy.

In general, let your child’s motivation, instead of your eagerness, lead the process. Avoid equating toilet training success or difficulty with your child’s intelligence or stubbornness.

Also, keep in mind that accidents are inevitable and punishment has no role in the process. Typically, punishment or criticism tends to make the process take longer. Plan toilet training for when you or another caregiver can devote the time and energy to be consistent on a daily basis for a few months.

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Setting the stage for success

There’s not much you can do as a parent to speed up your child’s physical readiness for using the toilet. However, as early as your child’s first birthday, there are some ways you can begin laying the groundwork for a successful psychological transition from diapers to the toilet.

There are several children’s picture books written specifically to interest children in this natural transition. You can read these books with your child. There are also videos and smartphone apps designed to help your toddler get acquainted with the benefits of using the toilet.

Another way to begin building for a successful transition at this early stage is to allow toddlers to watch parents and older brothers or sisters using the toilet. Thus, family members can be role models for a year or more before toilet training actually begins.

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Active training

When you think your child might be ready to start using the toilet, go ahead and swing into action. There’s no single best way to toilet train. But here are some general suggestions to keep in mind.

Pull out the equipment Consider purchasing a potty chair, available at most places that sell baby supplies, for the express purpose of toilet training. A potty chair is generally easier to learn on than an over-the-toilet seat and gives your child a more secure footing and better leverage to eliminate. In addition, your child can take ownership of the potty chair, decorating it or drawing on it to make it his or her own.

Place the potty chair in the bathroom or, initially, wherever your child is spending most of his or her time. If you have multiple levels in your home, you might want to put a potty chair on each level where your child spends time.

Encourage your child to sit on the potty chair in his or her clothes to start out. Make sure your child’s feet rest on the floor or a stool. If you have the potty chair in the bathroom, take the opportunity to have your child flush the toilet so that he or she becomes accustomed to the noise and motion of the water.

Share the purpose of the potty Use simple terms to explain what the toilet is for — to catch pee and poop, for example. Use terms consistently and positively. You might dump the contents of a dirty diaper into the potty chair or toilet to show its purpose. Or allow your child to watch you use the toilet.

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When to start and when to delay training

If possible, plan toilet training for a time that’s relatively stress-free and when schedules are fairly routine. For instance, if you live in a cold climate, you might plan for toilet training in the warmer months, when layers of clothing aren’t so much of an issue.

You may want to delay toilet training if you’re anticipating major changes in family life — such as a move to a new home or the arrival of a new sibling. Consider delaying training if the unexpected happens as well, such as a major illness or the death of a family member.

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Schedule potty breaks Have your child sit on the potty chair or toilet without a diaper for a few minutes at two-hour intervals, as well as first thing in the morning and right after naps.

Boys can learn to urinate sitting down, and then move to standing up after bowel training is complete.

Stay with your child and read a book together or give your child a toy to play with while he or she sits. Allow your child to get up if he or she wants. Even if your child simply sits there, offer praise for trying — and remind your child that he or she can try again later.

To maintain consistency, consider bringing the potty chair with you on vacation or when you’re away from home with your child.

Respond quickly to the ‘potty dance’ When you notice signs that your child might need to use the toilet — such as squirming, squatting or holding the genital area — respond quickly. Help your child become familiar with these signals, stop what he or she is doing, and head to the toilet. Praise your child profusely for telling you when he or she has to go. This will help reinforce the idea that having to go is a call to quick action.

To maximize the chances of success in getting onto the toilet in time, keep your child in loose, easy-to-remove clothing.

Encourage the feeling of comfort Some parents think that leaving a wet or soiled diaper on will help their children want to use the toilet. But this is generally counterproductive. You want your child to become accustomed to feeling clean and dry. You can help by encouraging your child to come to you when wet or soiled and changing diapers as soon as needed. At the same time, explain to your child the connection between being clean and dry and using the potty. You can say things such as, “If you go in the potty, your diaper (or pants) will stay nice and dry.”

Explain hygiene For girls, it’s important to wipe carefully from front to back to prevent bringing germs from the rectum to the vagina or bladder. Show your daughter how to spread her legs apart when wiping to make this task easier. Make sure both boys and girls wash their hands after using the toilet.

Ditch the diapers After a couple of weeks of successful potty breaks and remaining dry during the day, your child might be ready to trade diapers for training pants or underwear. Some experts recommend that children wear regular underwear as opposed to disposable training pants because they feel different from diapers. However, disposable training pants are convenient, especially in child care settings or when away from home. Celebrate your child’s transition toward “big-kid” clothes. If your child is unable to remain dry, it’s OK to return to diapers until he or she is ready to try again.

Praise and reward Reward your child for listening to body signals, heading toward the bathroom and sitting on the potty. Focus less on mistakes and more on your child’s efforts — even minor ones — at using the potty. Your happy voice, hugs and compliments for trying will help reinforce positive steps that build toward your child’s success. Consider finding some kind of reward — such as stickers or stars — to offer as additional positive reinforcement.

Nighttime training Nap time and nighttime training typically takes longer to achieve. Most children can stay dry at night between ages 5 and 7. In the meantime, use diapers or training pants and mattress covers when your child sleeps.

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Do’s and don’ts of toilet training

Things to do:

Make toilet training fun for your child.

Give lots of praise and encouragement.

Let your child feel in control.

Most important, relax.

Things not to do:

Don’t force your child to sit on the potty.

Don’t yell at or punish your child for accidents.

Most important, don’t rush the process.

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Troubleshooting

Your child will probably have numerous failures on the way to success. That’s OK — it’s the nature of learning. There’s no need to scold, discipline or shame your child for having an accident. Provide encouragement for behaviors your child can control, such as sitting on the potty, and don’t stress about those your child can’t control yet, such as voiding only in the potty.

Keep encouraging your child to repeat the learning steps you’ve already started — knowing when to stop playing and head to the toilet, undressing, sitting on the toilet, dressing and washing hands. Maintain a positive attitude and your child will follow suit. And don’t worry too much. Your child will get there eventually.

Accidents Accidents will happen, no doubt about it. Calmly help your child change clothing as soon as you can after an accident. Keep your tone sympathetic. You might say, “You forgot this time. Next time you’ll get to the bathroom sooner. You’ll get better at this.”

In the meantime, be prepared. Keep a change of underwear and clothing handy, especially in the car, on an extended outing or at child care.

In the beginning, many children will urinate or have a bowel movement right after getting off the toilet. This can be frustrating for parents. If this happens frequently, be patient. It takes a while to learn to relax bowel and bladder muscles on command. You might consider holding off on toilet training a bit longer if it leads to anxiety or tension between you and your child.

Lack of interest If your child isn’t interested in using the potty chair or toilet or isn’t getting the hang of it within a few weeks, take a break. Chances are he or she isn’t ready yet. Pushing your child when he or she isn’t ready can lead to a frustrating power struggle. Try again in a few months. Your child’s job is to ultimately learn to control his or her own bladder and bowel movements. Your job as a parent is to be patient and support your child’s efforts.

Regression Sometimes, a child will lose the willingness to use the toilet or forget certain steps after being toilet trained. Regression such as this isn’t uncommon, especially if there have been changes in the child’s routine. Usually, it’s just one more step on the way to successful toilet training. Consistent reminders and positive reinforcement while making necessary schedule adjustments are key to keeping your child on track.

Active resistance Some children are more independent and prefer to do things on their own. As they get older, they might resist “micromanaging” by a parent. They may hold back bowel movements or become constipated. They may even continue to wet and soil themselves.

If you’ve followed the steps described earlier for several months without success and your child is approaching 3 years of age, bring it up with your child’s medical provider. He or she can give you guidance and check to see if there’s an underlying problem. It may be time to try something new.

Sometimes with older children who enjoy being independent, it can help to step back and let them take responsibility for using the toilet.

Let your child know that he or she is in charge now and that you will no longer remind him or her to use the toilet. Tell your child — in the words you’ve chosen — that his or her body makes pee or poop every day and that these need to go in the potty. You can say, “I’m sorry I reminded you so much and made you sit on the potty. From now on you don’t need my help. You can do it by yourself.”

Stop all reminders about using the toilet. Let your child decide when to go to the bathroom. If your child has an accident, be gentle. Don’t punish, criticize or ask why or how it happened. Simply tell him or her to go clean up and change into dry clothes. If your child asks for assistance, it’s OK to help, but keep it simple and neutral.

When your child no longer gets attention for not going, he or she will eventually seek attention for using the toilet correctly. Give your child plenty of smiles, hugs and praise when he or she does use the toilet. Your child will soon embrace his or her newfound skills.

If you have questions about toilet training or your child is having difficulties, talk to your child’s medical provider. Also call if your child shows signs of constipation or pain or burning during urination. Treating these problems can help ensure successful toilet training.

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Coordinating toilet training and child care

Many kids go through toilet training while also attending child care. To keep the process of toilet training going smoothly, communicate closely with child care staff. Tell your child’s caregivers about your toilet training efforts so they can continue your efforts at child care or preschool. If you can use similar methods at home and at child care, your child is less likely to become confused and more likely to succeed.

Some advantages of toilet training at a child care center are that staff are often positioned to recognize signs of readiness and can help your child take steps to use the toilet. Being around other kids that use the toilet also may help motivate your child to do the same. Disadvantages may occur if the child care center is understaffed or there’s little communication between staff and parents.

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CHAPTER 7 Bathing and skin care

Bathing your baby can be a sweet and fun experience. Don’t worry if you feel a little awkward at first — it takes practice to get the hang of cleaning a slippery and squirmy baby. And don’t be surprised if, at first, your son or daughter doesn’t like being bathed. It’s a whole new experience for him or her — and for you, too!

The tips that follow will help make your bath-time routine safe and smooth. You’ll also learn how to identify and deal with skin conditions that are common in a baby’s first years. Sometimes people expect new babies to have flawless skin, but that’s rarely the case.

Bathing basics

As your child gets older, chances are he or she will enjoy taking a bath. Older babies and toddlers have fun splashing in the water and playing with bath toys. They’ll often jump at the chance to suds up. Newborns, however, don’t always enjoy the bath experience. They may not care for getting undressed or the cold feeling that comes with having no clothes on.

Fortunately, infants don’t need much bathing. It’s not until your child gets older and has more chances to get dirty that baths become more of a regular ritual.

How often? Generally, babies need only one to three baths a week in the first year, unless otherwise instructed by your baby’s medical provider.

During your newborn’s first couple of weeks, it’s OK to give your baby a bath even while the umbilical cord is still attached. Just avoid submersing your baby’s belly in water until the cord falls off. If the umbilical cord does get wet, dry the area thoroughly.

In between baths, check your baby’s folds — in the thighs, groin, armpits, fists and double chins — to see if they need occasional spot cleaning.

Once your baby starts crawling around and eating solid food, he or she might need up to three baths a week.

Sponge bath or full bath? You don’t have to start out with sponge baths, but they’re a gentle and easy way to introduce your new baby to bathing. It’s a fine alternative to a full bath for the first six weeks or so after your child is born.

A sponge bath basically involves using a warm washcloth to clean your baby instead of placing him or her in a tub of water. During a sponge bath, keep your baby warm by covering him or her with a dry towel. As you clean a part of baby’s body, move a piece of the towel aside in order to get at that area. Once finished, pat that area dry and cover it back up before moving on to another area. Don’t forget to moisturize your baby’s skin.

When’s the best time? Find a time for bathing your baby that’s convenient for both of you. Many people give their baby a bath before bedtime as a relaxing, sleep-promoting ritual. Others prefer a time when their baby is fully awake. You’ll enjoy this time more if you’re not in a hurry and aren’t likely to be interrupted.

You may also want to wait a bit after your baby eats or drinks to give a bath in order to allow his or her stomach to settle. Waiting briefly may also reduce the chances of your baby peeing or pooping during the bath.

Temperature For baby’s safety, you don’t want the water too hot — it could hurt or even burn your baby. And for his or her comfort, you also don’t want the water so cool that your baby gets chilled. Generally, a temperature between 95 and 100 F is ideal for a baby’s bath.

To start, make sure your home water heater is set at no higher than 120 F. This will prevent too-hot water temperatures. Before filling up the tub or basin, test the water temperature with your elbow or wrist. The water should feel warm but not hot. Once you fill the tub or basin, test the temperature again — water temperatures frequently change while the water is running. Never let the bath fill while your baby’s sitting in it. Instead, fill the tub or basin and then test the water again.

Once you’re confident the temperature is right, place your baby in the tub. If you’re not sure about the temperature, consider purchasing a bath thermometer to help guide you.

Attentiveness It’s important to give your baby your full and undivided attention during baths. If the phone rings or someone rings the doorbell, ignore it. Babies can drown in less than an inch of water in an instant, so you don’t want to be diverted from the task at hand. They can also roll and fall from high surfaces, or slip and hit their heads, even when they’re seated. During a bath, keep your eyes on your little one at all times. If you forgot something you need for the bath, take your baby out of the bath and take him or her with you, even if the item is just a step away.

Bathing, step by step

When you decide it’s time to try a full bath, you might start out using a baby bathtub, which you can set inside your regular tub or on the floor or next to the sink. The first few baths should be especially gentle and brief. If your baby doesn’t like it, you might stick with sponge baths for a while longer before trying a full bath again. Once your child gets older and is able to sit well on his or her own, placing him or her in a few inches of warm water right in the family bathtub works fine, too.

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Baby’s first bath

Breaking out the tub When you’re ready to give your baby a tub bath — whether you do so right from the start or you try sponge baths first — you’ll have plenty of choices. You can use a free-standing plastic tub specifically designed for newborns, a plain plastic basin or a small inflatable tub that fits inside the bathtub. Lined with a towel or rubber mat, the kitchen or bathroom sink might be another option.

Checking the water temperature You need only a few inches of warm water. To prevent scalding, set your water heater thermostat to below 120 F. A temperature between 95 and 100 F is ideal.

Use a secure hold A secure hold will help your baby feel comfortable and stay safe in the tub. Use one of your hands to support your baby’s head and the other to wash your baby’s body.

Washing baby’s back When you clean your baby’s back and buttocks, lean him or her forward on your arm. Continue to grasp your baby under the armpit.

Remember the creases Pay attention to creases under the arms, behind the ears, around the neck and in the diaper area. Wash between baby’s fingers and toes.

Rinsing baby’s hair You might want to try a football hold under the faucet for washing baby’s hair. Support your baby’s back with your arm, keeping a firm hold on your baby’s head while you rinse.

When baby cries If your baby cries in the tub, stay calm. Clean what you can and then wrap your baby in a towel. Wait a few days and then try again. In the meantime, use sponge baths where needed.

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Gather supplies Prepare the bath area with all the items you’ll need. Typically this involves:

A couple of clean, soft washcloths.

A mild fragrance-free baby soap or shampoo. This isn’t essential for newborns, as plain water will do just fine, but it becomes more important as baby gets older (and has more chances to get dirty).

A couple of soft, dry towels. Baby-sized ones are easy to manage.

Gentle, fragrance-free moisturizer.

A fresh diaper and pajamas or clothes.

Bath toys. These aren’t necessary early on but as your baby gets older, he or she will enjoy having a toy or two in the bath to play with. Make sure the toys stay clean and free of mildew.

Get baby ready Remove your baby’s clothes and diaper. Gently lower him or her into position. Support his or her head and torso to help him or her feel secure.

Keep hold Babies can be slippery and can become suddenly squirmy, so keep a good hold on your baby during bathtime. It may help to keep your dominant hand free for reaching and cleaning and use the other hand to keep your baby steady.

Eyes first Clean the delicate eye area first. Use a cloth dampened with water to wipe from the inside to the outside corner of your baby’s eye.

Start at the top Use a soft cloth to wash your baby’s face with water and then pat the face dry. Wash your baby’s head with water too, tipping his or her head back or cupping your hand over his or her forehead to keep any water or soap from running into baby’s eyes.

It’s not necessary to shampoo your baby’s hair with every bath — once or twice a week is plenty. If your baby seems agitated by a wet head, save the hair wash for last. You can use a soft washcloth, your fingertips or a baby scrubber to wash his or her hair and scalp.

Wash and check folds Wash the rest of your child’s body from the top down, including the inside folds of skin and the genital area. For a girl, gently spread the labia to carefully clean the area. For a boy, lift the scrotum to clean underneath. If your son is uncircumcised, don’t try to retract the foreskin of the penis. Let your baby lean forward on your arm while you clean his or her back and bottom, separating the buttocks to clean the anal area.

Pat dry Once your baby is clean and rinsed off, carefully pick him or her up and into a towel — remember, he or she will be slippery! One way to get your baby dry while holding him or her is to set a towel vertically over your body so that part of it hangs over your shoulder. Bring your baby to your chest and then bring the bottom of the towel up and around your baby. Another option is to spread a towel out on the floor. Place your baby on the towel and then wrap the towel around him or her.

Moisturize Gently pat your baby dry. Patting the skin instead of rubbing it dry will help keep your baby’s skin from getting irritated. After you’ve dried baby off, moisturize your baby’s skin all over with a gentle, fragrance-free moisturizer or petroleum jelly. You might find this easier to do on a changing table or bed than in the bathroom. Some studies show that daily moisturizing can help prevent eczema (atopic dermatitis) in babies, especially those who have a family history of the condition.

Finishing touches Place a fresh diaper on your baby, add clothes or pajamas to keep your child warm, and you are done! Enjoy the sweetness.

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Happy in the water

A bit of water near your baby’s eyes and ears is OK — babies can blink to protect their eyes from a little water. If you keep your baby from even the tiniest of splashes, you may end up with a baby who is fearful of water.

As your baby gets older, if he or she enjoys being in the bath water, give him or her some extra time to play and splash around after he or she is finished bathing. This will help him or her have positive feelings about water and may help reduce anxiety about water later.

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Umbilical cord care

After your newborn’s umbilical cord is cut, all that remains is a small stump. In most cases, the remaining cord will dry up and fall off one to three weeks after birth. Until then, you want to keep the belly area as clean and dry as possible.

Avoid swabbing the cord stump with rubbing alcohol or other antiseptic. Though this practice was recommended in the past, research indicates that doing so may prolong cord separation.

Exposing the cord to air and allowing it to dry at its base will hasten its separation. To prevent irritation and keep the navel area dry, fold the baby’s diaper below the stump. During baths, avoid submersing the belly area in water and dry the area thoroughly if it becomes wet. In warm weather, dress a newborn in just a diaper and T-shirt to let air circulate and help the drying process.

It’s normal to see a bit of crusted discharge or dried blood until the cord falls off. But if your baby’s navel looks red or has a foul-smelling discharge, call his or her medical provider. When the stump falls off, you may see a little blood, which is normal.

Umbilical cord problems, including infections, aren’t common. But have the area examined by your baby’s medical provider if you notice any of the following:

The navel continues to bleed.

The skin around the base of the cord is red.

There’s a foul-smelling, yellowish discharge from the cord.

Your baby cries when you touch the cord or the skin near the cord.

The cord hasn’t dried up or fallen off by the time the baby is 2 months old.

Umbilical granuloma In some cases, the umbilical cord forms a small red mass of scar tissue (granuloma) that remains on the bellybutton even after the cord has fallen off. The granuloma usually drains a light yellow fluid. If you notice these signs, contact your baby’s medical provider to discuss whether your baby needs to be examined. Typically, an umbilical granuloma resolves on its own after about a week, but if it doesn’t, your baby’s provider may need to remove the tissue.

Umbilical hernia If your baby’s umbilical cord area or bellybutton protrudes or bulges when he or she cries, strains or sits up, he or she may have an umbilical hernia. In this common condition, part of the abdomen pushes through a hole in the abdominal wall when there’s pressure on the area. Umbilical hernias typically resolve on their own and don’t need treatment. In rare cases, a baby may need surgery to close the hole. Taping the bulge down or taping a coin over the hernia is a potentially harmful practice and should be avoided.

Circumcision care

If your newborn boy was circumcised, the tip of his penis may seem raw for the first week after the procedure. Or a yellowish mucus or crust may form around the area. This is a normal part of healing. A small amount of bleeding also is common the first day or two.

Clean the area around the penis gently and apply a liberal amount of petroleum jelly to the end of the penis with each diaper change. This will keep the diaper from sticking while the penis heals. If there’s a bandage on the penis, change it with each diapering.

At some hospitals, a plastic ring is used instead of a bandage. The ring will remain on the end of the penis until the edge of the circumcision has healed, usually within a week. The ring will drop off on its own.

Problems after a circumcision are rare, but call your baby’s medical provider if you notice bleeding, redness or crusted sores containing fluid around the tip of the penis. Other signs to be aware of are swelling of the penis tip or a foul-smelling drainage coming from the penis tip.

Washing a circumcised penis It’s OK to gently wash the penis as it’s healing. And once it’s healed, the circumcised penis doesn’t need special care. Wash your baby’s penis with warm water and mild baby soap, just like you clean the rest of his bottom. Occasionally, a small piece of foreskin remains on the penis. If this occurs, gently pull back that skin to make sure the head of the penis is clean.

Caring for an uncircumcised penis During your baby’s first few months, clean his uncircumcised penis with water and a bit of mild baby wash, just like you would clean the rest of his bottom. You don’t need to use an antiseptic or cotton swabs. Don’t try to pull back or retract the foreskin. Doing so can cause tearing, pain and bleeding. The foreskin will retract on its own, a process that can take months to years.

It’s important to watch your uncircumcised baby urinate once in a while. If you notice his urine stream isn’t stronger than a trickle, or if he seems uncomfortable while he pees, contact your baby’s medical provider. It’s possible that the hole in the foreskin is too small to allow a normal flow of urine.

Because the foreskin separation can take several months or longer, check with your baby’s medical provider to find out when the separation is complete. Once it is, you can gently retract the foreskin to clean the head of the penis. Then pull the foreskin back over the penis when you’re finished.

Once your baby boy is older, it’s important to teach him how to properly wash his penis using these three steps:

Gently pull the foreskin back and away from the head of the penis.

Use warm water and soap to clean the head of the penis and the fold in the foreskin.

Pull the foreskin back to its original place over the head of the penis.

Nail care

Your baby’s nails are soft, but they’re sharp. A newborn can easily scratch his or her own face — or yours. To prevent your baby from accidentally scratching his or her face, you will want to trim or file the fingernails shortly after birth. Then continue to trim his or her nails a few times a week.

Sometimes you may be able to carefully peel off the ends with your fingers because baby nails are so soft. Don’t worry — you won’t rip the whole nail off. You can also use a baby nail clippers or a small scissors. Here are some tips to make nail trimming easier for you and your baby:

Trim the nails after a bath. They’ll be softer, making them easier to cut.

Wait until your baby is asleep.

Have another person hold your baby while you trim his or her nails.

Trim the nails straight across.

Don’t bite your baby’s nails as a method of keeping them trimmed — this can cause infection.

Your baby’s toenails will probably grow much more slowly than his or her fingernails. They may need a trim only once or twice a month. Toenails are also softer than fingernails, so they may appear to be ingrown, but unless the skin around the nail looks red and inflamed, they’re probably fine.

Two hints for making nail trimming easier: Wait until your baby is asleep and then work together, with one person holding the baby and the other person trimming the nails.

Common skin conditions

Many parents expect their newborn’s skin to be flawless. But most babies are born with some bruising, and skin blotches and blemishes are common. Young infants often have dry, peeling skin, especially on their hands and feet, for the first few weeks. Some blueness of the hands and feet is normal and may continue for a few weeks. Rashes also are common, even into the toddler years. Most rashes and skin conditions are treated easily or clear up on their own.

Milia Milia is the name for tiny white pimples or bumps that appear on the nose, chin and cheeks. Although they appear to be raised, they are nearly flat and smooth to the touch. If your baby has milia, you can wash his or her face once a day with warm water and a mild baby soap, but avoid using lotion, oils or other products. It’s also important to leave the skin alone — never scrub or pinch the bumps. Milia disappear in time, often within a few weeks, and they don’t require treatment.

Baby acne Baby acne (neonatal cephalic pustulosis) refers to small red and white bumps that are seen on the face, neck, upper chest and back of some newborns. The pimples are generally most noticeable within the first few weeks after birth.To care for baby acne, place a soft, clean receiving blanket under baby ‘s head and wash his or her face gently once a day with mild baby soap. Avoid lotions, oils and other treatments and never scrub, squeeze or pinch the affected skin. The condition typically disappears without treatment within the first couple of months, without scarring. If it doesn’t clear up after a few months, talk with your child’s medical provider.

Erythema toxicum Erythema toxicum is the medical term for a skin condition that’s typically present at birth or appears within the first few days after birth. It’s characterized by small white or yellowish bumps surrounded by pink or reddish skin. The condition causes no discomfort and isn’t infectious. Erythema toxicum disappears in several days, although sometimes it flares and subsides before completely clearing up. Treatment isn’t necessary.

Pustular melanosis These small spots look like yellowish-white sesame seeds that quickly dry and peel off. They may look similar to skin infections (pustules), but pustular melanosis isn’t an infection and disappears without treatment. The spots are commonly seen in the folds of the neck and on the shoulders and upper chest. They’re more common in babies with darker skin.

Cradle cap Cradle cap (infant seborrheic dermatitis) refers to a scaliness and redness that develops on a baby’s scalp. It results when oil-producing sebaceous glands produce too much oil. Cradle cap is common in infants, usually beginning in the first weeks of life and clearing up over a period of weeks or months. It may be mild, with flaky, dry skin that looks like dandruff, or more severe, with thick, oily, yellowish scaling or crusty patches.

Shampooing with a mild baby shampoo can help with cradle cap. Don’t be afraid to wash your baby’s hair frequently. This, along with soft brushing, will help remove the scales. If the scales don’t loosen easily, rub a few drops of mineral oil onto your baby’s scalp. Let it soak into the scales for a few minutes, and then brush and shampoo your baby’s hair. If you leave the oil in your baby’s hair, the scales may accumulate and worsen cradle cap.

If cradle cap persists or spreads to other parts of your child’s body, especially in the creases at the elbow or behind the ears, contact your baby’s medical provider, who may suggest a medicated shampoo or lotion.

Cradle cap isn’t usually uncomfortable or itchy for your baby, but sometimes a yeast infection can occur in the affected skin. In this case, the skin will become very red and itchy. If you notice this, mention it to your baby’s medical provider.

Eczema Eczema, also known as atopic dermatitis, is marked by dry, itchy, scaly red patches of skin that are often found around babies’ and toddlers’ elbows or knees. Sometimes the affected area is small and doesn’t bother a baby much, and treatment isn’t necessary. Many children outgrow eczema.

In other cases, eczema can cover a lot of skin and be extremely itchy and uncomfortable. In these cases, talk with your child’s medical provider about whether treatment is needed. You can also try the following methods to prevent eczema from recurring:

Use fragrance-free baby soaps to wash your child and laundry detergents that are free of fragrances, dye and deodorants. Even “mild” baby soaps may have a small amount of fragrance that can irritate sensitive skin.

Dress your little one in soft, cotton clothing, and avoid synthetic fabrics and wool.

Bathe your baby daily with a fragrance-free hypoallergenic bath oil. This can help moisturize your baby’s skin, in addition to helping prevent skin infections, which are more common in children with eczema.

Use a fragrance-free moisturizer or ointment such as petroleum jelly right after patting baby dry following a bath. This helps lock moisture from the bath into baby’s skin.

Keep your child away from environmental triggers for eczema, including heat and low humidity.

Check your child’s sleeping conditions and ensure that the area is free of dust and upholstery that may contain dust mites.

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Safe baby care products

Finding baby care products that are absolutely safe and gentle seems like it should be an easy task, but unfortunately, that’s not always the case. Baby products are generally marketed as safe, gentle, mild and natural, yet some of these products may contain ingredients that can be irritating to your baby.

Remember that whenever you put something on your baby’s skin, the ingredients in the product can be absorbed into your baby’s body through the skin. Here are some ways you can protect your baby from potentially harmful ingredients:

Limit the number of products you use on your baby.

Read labels to ensure you’re comfortable with all of the ingredients. This method has its limitations, however, since most people aren’t familiar with the many names and types of chemicals. In addition, in the United States, the Food and Drug Administration doesn’t require products to list the individual ingredients that are used to make a fragrance, and many products just list “fragrance” as the ingredient.

Go online or check government and health resources to learn more about the ingredients in products you’re using or are considering purchasing. One example is www.skinsafeproducts.com, developed in conjunction with Mayo Clinic.

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Contact dermatitis and ‘drool rash’ Contact dermatitis is a kind of skin inflammation that occurs when substances touching your skin cause irritation or an allergic reaction. The resulting red, itchy, dry or bumpy rash isn’t contagious or life-threatening, but it can be very uncomfortable. Culprits for young children could include soaps, laundry detergent, rough fabric or even your baby’s own drool (sometimes referred to as drool rash).

If you can identify the offending agent and eliminate contact between it and your child, the contact dermatitis should clear up. Often, using an absorbent bib and changing it frequently, as well as applying a barrier cream such as petroleum jelly to the area of irritation, can help prevent the rash from worsening. In the meantime, a wet compress may help comfort your baby. Contact your child’s medical provider if the rash is severe or gets worse or if your baby’s skin is oozing or extremely itchy.

Impetigo Impetigo is a highly contagious skin infection that mainly affects infants and children (see this discussion). It usually appears as red sores on the face, especially around a child’s nose and mouth. The sores may be covered with a yellow-brown scab or crust, or grow into blisters and pimples and ooze pus. Although impetigo commonly occurs when bacteria enter the skin through cuts or insect bites, it can also develop in healthy skin.

Because impetigo can sometimes lead to complications, your child’s medical provider may choose to treat impetigo with an antibiotic ointment or oral antibiotics.

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Skin conditions

Milia Many babies are born with tiny white bumps that appear on the nose, chin or cheeks. This condition, called milia, occurs when skin flakes become trapped near the surface of the baby’s skin.

Acne Acne typically appears as red or white bumps on a baby’s forehead or cheeks. The condition often develops as a result of exposure to maternal hormones during pregnancy.

Cradle cap Cradle cap appears as thick, yellow, crusty or greasy patches on a baby’s scalp. Cradle cap is common in newborns and usually appears within the first few weeks after birth.

Erythema toxicum The main symptom of this condition is a rash of small, yellow-to-white colored bumps (papules) surrounded by red skin. There may be a few or many papules.

Eczema Baby eczema is characterized by patches of red, scaly, itchy skin. Occasionally the patches ooze and crust over. Eczema often appears at the elbows and knees and on the cheeks.

Pustular melanosis This condition involves small blisters that resemble seeds that dry up and peel away. The blisters leave behind spots, or “freckle” marks, that disappear in weeks to months.

Impetigo Impetigo starts as a red sore that ruptures, oozes for a few days and then forms a honey-colored crust. Sores mainly occur around the nose and mouth and spread to other parts of the face.

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CHAPTER 8 Clothing your child

One of the things many new parents look forward to during pregnancy and after baby is born is shopping for baby clothes. While it may be hard to resist the sparkly dresses, designer jeans or miniature boots — they’re so cute! — you do want to be fairly practical in the clothes you buy. Between diaper blowouts, messy toddler meals, and playing in parks and puddles, your child will need plenty of outfit changes these first few years, and undressing and dressing may not be one of your child’s favorite activities. So there’s no need to make it more complicated than you have to. Not to despair though — tutus and dinosaur costumes and other such items are sure to become a fun part of your child’s wardrobe.

A few shopping tips

If you haven’t had a lot of experience in outfitting a baby, here are a few suggestions you may find helpful.

Size Almost all baby clothing is sized in three-month intervals. Sizes often begin with 0 to 3 months, followed by 3 to 6 months, 6 to 9 months and so forth. Some brands have a single number, which is typically the upper end of the size range. For example, a size 18 months is comparable to a sized 12 to 18 months in other brands.

But buying for baby often isn’t quite that simple — as many parents who’ve had to return clothing to the store can attest!

When you’re buying clothes for your newborn, don’t go strictly by what’s on the label. Look at the item and see if it appears to run small or about the right size for your child. You may find you want to choose a larger size, even if it means the item may be a little big to begin with.

Many babies fit into clothing long before what’s indicated on the label. A newborn may wear a size 3 to 6 months within a few weeks of birth. And it’s not uncommon for a 4-month-old to wear a size 6 to 9 months.

Many parents will tell you about waiting until their baby was 6 months old to wear the cute 6-to-9-month outfit, only to put it on and find out it was too small!

Manufacturers often include tags that list weight and height guidelines for each size. They may give you a better idea if the item will fit.

Fabric In general, look for soft, comfortable clothing that’s washable. Look for clothing that doesn’t irritate, bind, twist or rub your baby’s skin. Clothing made from 100% cotton is often recommended for children with sensitive skin — and that includes most infants.

Purchase machine-washable clothing that can be pretreated for stains. Also keep in mind that items made from cotton may shrink a bit.

Safety Keep it simple. Avoid clothes with buttons, which could be swallowed, and ribbons or strings, which could cause choking. Don’t buy garments with drawstrings around the neck, which could catch on objects and strangle a child.

Ease Because you may be changing your child’s clothing a few times a day — or at least changing diapers several times a day — make sure the outfits are uncomplicated and they open easily. Look for garments that snap or open down the front, have loosefitting sleeves, and are made of stretchy fabric. Be cautious dressing young children in clothing with zippers, which can catch skin accidentally.

Cost Since babies outgrow clothes so quickly, consider purchasing some clothes at thrift stores, garage sales or from other parents. If someone offers you hand-me-downs, don’t take it as an insult. Accepting hand-me-downs can save you money that you can use for other items you may want to purchase for your child.

Wardrobe essentials

Because babies and toddlers grow so fast, you don’t want to buy too much at once. You run the risk that your son or daughter will outgrow the clothes before he or she has a chance to wear them. It’s often best to purchase a few outfits at a time every few months.

In addition, if clothing is purchased too far in advance, the seasonality and comfort of the item may not be appropriate when your child is ready to wear it.

You’ll also find there are certain clothes babies seem to wear more than others — often because of ease, comfort or convenience.

As your child becomes more mobile, continue dressing him or her in clothes that are easy to move in and play in.

Bodysuits These shirts have bottom ends that extend between the legs, fit up over the crotch and snap in front. Bodysuits are especially nice for babies because the fabric doesn’t ride up to expose the belly. They come in short or long sleeves.

Bodysuits can be worn underneath clothing or, when temperatures are warm, by themselves. They provide an easy way to give your baby an extra layer of warmth, and they help keep your baby’s other clothing from rubbing up against his or her new and delicate skin. You’ll go through a lot of these. Buy enough to last between clothes washings.

One-piece outfits One-piece outfits go by a lot of names, including stretchies, sleepers or rompers. When your baby is young, you may find that one-piece outifts are quite practical. The outfits generally snap in front and at the crotch and are easy to get on and off. They may come with or without footies.

A gown resembles a stretchie or sleeper, but instead of having legs, it looks more like a sleeping bag at the bottom. A gown may have an open, elasticized bottom.

Again, because your baby may wear one-piece outfits a lot — especially in the first year — make sure you have enough to last between washings.

One-piece outfits are great for crawling children, as loosefitting pants can be difficult to keep in place. Stretchy cotton leggings or more-fitted pants are a popular choice, too.

As your toddler begins to walk and climb, look for clothing without loose strings or decorations. These can sometimes get caught on furniture or get pulled by other kids.

Pajamas Depending on the weather, infant pajamas may be of a lighter or heavier material. During hot summer months, a sleeper or gown may be all your baby needs while sleeping. During the colder winter months, you may want to put baby in a heavier blanket sleeper. Blanket sleepers keep a baby warm without the need for a comforter or blanket. You’ll likely want at least a couple of pajama sets for each season.

Don’t purchase oversized pajamas, regardless of how comfortable you think they might look. If the pajama top rides up on the neck and head or is too loose around the shoulders, the extra space between the material and baby’s skin may increase the risk of suffocation.

Some pajamas are made with chemically treated fabric that makes them flame resistant and can help prevent burn injuries in the case of a fire. If you’re concerned about these chemicals in your baby’s clothes, you can opt instead for snug-fitting pajamas — the kind that taper down from the shoulders to the ends of the sleeves and from the thighs to the hems of pant legs. Tight-fitting sleepwear is less likely to catch fire than the loosefitting kind. Most importantly, take appropriate fire prevention measures, such as installing smoke detectors in your home, not smoking and not leaving an open flame unattended.

Dress clothes For occasions when you‘ll be taking your child out and you want more dressy clothing, look for outfits that are comfortable and easy to get on and off.

Pairing a bodysuit with pants keeps the top from riding up. If the outfit has elastic at the waistline, legs or arms, make sure the elastic isn’t too tight. In the warm summer months, one-piece outfits with short sleeves and short pants are great daywear.

Socks As you probably well know, socks have a tendency to fall off! Look for those that are most likely to stay on, but also expect that you will lose some along the way. You don’t need to worry about purchasing socks with nonskid bottoms until your child starts walking.

Winter gear During the cooler winter months, you need a winter cap to cover your baby’s head. His or her hands should also be covered. When baby is young, you may find a bunting to be convenient. However, these sacklike outer garments aren’t recommended if your baby is in a car seat. The extra material could prevent baby from being strapped in securely. Instead, use a car seat cover or blanket to keep your child warm.

As your child becomes more mobile, he or she can continue to play outside and explore in all weather — with the right gear. A one-piece snowsuit prevents snow from getting in between layers when kids fall on uneven, snowy ground. Snow pants and a warm winter jacket are an alternative, especially as children become more steady. Outdoor winter gear isn’t recommended for use in a car seat, as it can prevent your child from being securely buckled.

Depending on where you live, your child may need warm winter boots, along with a winter hat and warm mittens. Toddlers will often refuse these items as they begin to assert their independence. Be persistent — it’s important to keep your child warm in cold weather!

Summer accessories To help protect your baby’s skin and provide a bit of shade, use a broad-brimmed hat or cap during warm, summer months. A hat or cap also helps keep the sun out of your baby’s eyes. Some toddlers get a thrill out of wearing sunglasses, which can also offer eye protection. If you purchase sun glasses for your child, make sure that they offer UV protection and will not shatter.

Try to avoid being outdoors during the hottest times of the day — typically between 10 a.m. and 4 p.m. Keep infants out of the sun. Babies older than 6 months can wear sunscreen that has an SPF of 30 or higher on (see this discussion).

Shoes Many babies don’t walk until after their first birthday, but a few young ones get their legs under them early. If your son or daughter begins walking early, you may need to purchase a pair of shoes.

There’s nothing wrong with your child walking in his or her bare feet — it’s actually a great way to learn. Shoes are needed at times, though, to protect your child’s feet from sharp objects and other unpleasant stuff, especially when outside.

When shopping for shoes, look for ones that are low-cut with flexible, nonskid soles. The upper part of the shoe should be made from material that’s breathable and lightweight. Err on the side of buying shoes that are too big rather than ones that will soon be too small. However, you don’t want shoes so big that your child has difficulty walking in them.

Once your toddler masters walking, he or she will definitely need shoes! Shoes and sandals with covered toes offer the best protection for the frequent falls that will occur as your child improves his or her walking and running skills.

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Dress for the weather

New parents sometimes overdress their infants. A good rule of thumb is to dress your baby in the same number of layers that you would feel comfortable wearing, and possibly one more light layer. For example, you might put baby in a diaper and undershirt, covered by a sleeper or gown, and wrapped in a receiving blanket.

In hot weather — over 75 F — a single layer of clothing is often appropriate. Babies don’t sweat easily and can become overheated. However, you may want an additional layer if the baby is in air conditioning or near drafts.

Remember that your baby’s skin will sunburn easily. If you’re going to be outside, keep baby out of the sun, and protect your baby’s skin with clothing and a hat or cap. For more on sun protection, see this discussion.

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Laundry tips

After your baby arrives, it can seem as if you do laundry all of the time. To make the process as easy as possible, purchase clothes that appear durable and that are likely to wash well. It’s also a good idea to wash all clothes before your child wears them to get rid of any potentially irritating substances that may have gotten on the clothing. Here are a few other tips.

Stains Stains are inevitable. Breast milk, formula, spit up, poop — these common offenders will more often than not wind up on your baby’s clothes, and probably on yours, too!. Later on, table food, dirt, paint and ink stains also are common.

If possible, blot or rinse off the substance while it’s still fresh and before it sets. You might soak stained clothes with a pre-soak before you wash them. At the very least, blast them with a good douse of stain remover before putting them in the washing machine. A mixture of equal parts white vinegar and water is often easy to keep in a spray bottle to apply to fresh stains.

Detergents Babies have sensitive skin, and some babies and young children develop skin irritation from standard laundry detergents. Even some detergents labeled for babies are scented and can be irritating to the skin. In general, wash your child’s clothes in unscented detergent. Several brands are available, usually with “free,” “free and clear” or “unscented” included in the name. Avoid fabric softeners for the same reason, though some unscented fabric softeners are available.

Some parents run baby’s clothes through an extra rinse cycle to ensure there’s no soap residue left on the clothing. This may not be necessary, but if you would like, you can try it to see if it helps.

CHAPTER 9 Sleep and sleep issues

Oh, baby! There’s nothing like getting a good night’s sleep. While newborns usually sleep up to 16 hours a day, it’s frequently for only one or two hours at a time. Your baby can thrive on that schedule, but you may find it exhausting. If you haven’t had a good night’s sleep since your baby was born, you’re not alone. Sleepless nights are a rite of passage for most new parents. But don’t despair; your baby will learn to sleep better at night. Honestly!

Sleep is vital to your child’s growth and development. From the time your baby is born, you can encourage him or her to adopt good sleep habits. By the end of the first year, your baby will likely do most of his or her sleeping at night, usually with a nap or two during the day, and these broad sleeping patterns will continue for the next few years.

In general, it’s easier to prevent sleep problems than to fix them later. No matter how old your child is, it takes calm, consistent effort and patience to help your child develop healthy sleep habits. This chapter offers tips on sleep schedules, reviews prevention strategies to reduce the risk of sudden infant death syndrome (SIDS) and crib accidents, and outlines steps you can use to help your toddler learn to sleep independently. Don’t beat yourself up if things don’t always go as planned. Do your best and eventually everyone will be sleeping through the night.

Newborn sleep schedule

It takes a while for newborns to get on any kind of schedule for sleeping. During the first month, they usually sleep and wake round-the-clock, with relatively equal periods of sleep between feedings.

In addition, newborns don’t know the difference between night and day. It takes time for them to develop circadian rhythms — the sleep-wake cycles and other patterns that revolve on a 24-hour cycle. As your baby’s nervous system gradually matures, so do his or her phases of sleep and wakefulness.

Fits and spurts Although newborns don’t usually sleep for more than a few hours at a stretch, altogether they typically sleep 12 to 16 hours a day. They may stay awake long enough to feed, or for up to about two hours, before falling asleep again. During the first few days home from the hospital, don’t be surprised if you feel exhausted. Remember, you just had a baby, and you’re now trying to get adjusted to what it’s like being up with a baby at night.

By the time your baby is 2 weeks old, you’ll likely notice that the periods of sleeping and wakefulness are lengthening. By age 3 to 4 months, some babies sleep at least five hours at a time and shift more of their sleep to nighttime, much to the relief of their parents! By age 6 months, nighttime stretches of nine to 12 hours are possible.

Many newborns nap frequently in one- to two-hour spurts. As baby gets older, nap times may lengthen and become more predictable. With some babies, though, napping remains random, and they never really fall into any type of pattern.

When baby is a few months old, you may find that he or she will fall into a three-naps-a-day schedule: a morning nap, an early afternoon nap and an early evening nap. However, this also varies considerably with each baby.

Syncing days and nights Some babies clearly have their days and nights reversed, and they sleep more in the daytime than at night. For parents who are sleep deprived, this can be a stressful time. Generally, though, within a few weeks to a couple of months, days and nights will become more predictable and regular.

One way to help speed up this transition is to limit daytime naps to no more than three or four hours each. In addition, during the day, have baby sleep in a more active area of the house with the lights on and where noises can be heard. In contrast, at night, keep the bedroom dark and quiet.

During nighttime feedings and diaper changes, avoid stimulation. Keep the lights low, use a soft voice, and don’t play or talk with your baby. This reinforces the message that nighttime is for sleeping.

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Noisy breathing

The familiar phrase “sleeping like a baby” conjures up images of a baby lying quietly and breathing ever so softly. But babies — especially newborns — often aren’t quiet when they sleep.

Newborns spend about half their time in an active phase of sleep, called rapid eye movement (REM) sleep. During REM sleep, babies may breathe irregularly, grunt, snort and twitch. During deeper sleep, called non-rapid eye movement (NREM) sleep, babies typically sleep more peacefully. As babies get older, they spend more time in NREM sleep and less time in active sleep. So they generally become less noisy.

In addition, newborns are dominantly nose breathers — they breathe through their noses, not their mouths. This is so they can breathe at the same time they nurse. The slightest congestion or mucus in baby’s tiny nasal passages as air flows in and out can make a lot of noise. If your baby’s breathing sounds a bit stuffy, it doesn’t necessarily mean that he or she has a cold or allergies.

Noisy breathing in infants can be very worrisome for parents. Most of the time, the noise is normal. However, if you’re concerned that something isn’t right, contact your child’s medical provider.

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Sleep safety

Sudden infant death syndrome (SIDS) is the unexplained death, usually during sleep, of a seemingly healthy baby. Although the exact cause is still unknown, it appears that sudden infant death syndrome may be associated with abnormalities in the portion of an infant’s brain that controls breathing and arousal from sleep. Other risk factors include sleeping on the stomach or side, on a soft surface, or with parents in the same sleep space.

SIDS is a scary thing to think about, but there are multiple ways to help reduce your baby’s risk of SIDS and put your baby safely to sleep.

‘Back’ to sleep Always place your baby on his or her back to sleep, even for naps. This is the safest sleep position for reducing the risk of SIDS.

Research shows that babies who are put to sleep on their stomachs are much more likely to die of SIDS than are babies placed on their backs. Infants who sleep on their sides also are at increased risk, probably because babies in this position can roll onto their stomachs. Since 1992, when the American Academy of Pediatrics (AAP) began recommending the back-sleeping position for infants, the incidence of SIDS in the United States has declined significantly.

The only exceptions to the back-sleeping rule are babies who have health problems that require them to sleep on their stomachs because the risk of death is greater if they sleep on their backs. If your baby was born with a birth defect, spits up often after eating, or has a breathing, lung or heart problem, talk to your baby’s medical provider about the best sleeping position for your child.

Make sure that everyone who takes care of your baby knows to place baby on his or her back for sleeping. That may include grandparents, child care providers, baby sitters, friends and others. Be firm in your instructions. Placing babies on their backs to sleep is based on evidence that doing so saves infant lives.

Some babies don’t like sleeping on their backs at first, but they get used to it quickly. Many parents worry that their baby will choke if he or she spits up or vomits while sleeping on his or her back, but researchers have found no increase in choking or similar problems.

A baby who sleeps on his or her back may develop a flat spot on the back of the head. For the most part, this will go away after the baby learns to sit up. You can help keep your baby’s head a normal shape by alternating the direction your baby lies in the crib — head toward one end of the crib for a few nights and then toward the other. This way, the baby won’t always sleep on the same side of his or her head.

Once your baby can successfully roll over from back to stomach and then back again — typically around age 6 months — you can let him or her sleep in the position he or she chooses. But until your baby becomes adept at moving around on his or her own, keep your baby’s bassinet or crib free of loose bedding or stuffed animals. This is to prevent your baby from rolling into them and being unable to roll out.

Share the room, not the bed Many new parents are tempted to take their baby into bed with them. This is often because they’re tired — understandably so! — and because having baby in bed seems more convenient. And for some parents, this is what their parents and grandparents did before them.

But the truth is that bed sharing can increase the risk of harm to your baby. Adult beds generally have softer mattresses than cribs and have lots of blankets and pillows. Though comfortable for adults, these factors can interfere with baby’s breathing or make a baby overly warm. In addition, there’s a risk of the adult inadvertently rolling over onto the baby during sleep or pushing the baby into bedding and causing suffocation. Falling asleep with your baby on a couch or chair can be even more dangerous because of the cramped quarters.

In addition, if your child learns to sleep well in your bed, it can make transitioning to his or her own bed later more difficult and traumatic. As your child gets older, it can be harder to break a bed-sharing habit.

Instead of bed sharing, the AAP recommends room sharing during your baby’s first year, or at least for the first six months. The rates of SIDS and other sleep-related deaths are highest during this time. Room sharing means your baby sleeps in your room with you but in a separate bassinet, crib or other structure designed for infants. Having your baby nearby can put your mind at rest and make it easier to monitor your baby. Evidence suggests that sharing a room with your baby, but not the bed, can decrease your baby’s risk of SIDS by as much as half.

A safe sleep space Make sure your baby is comfortable and safe. If you’ve made sure the crib and area around it are safe, you won’t immediately become concerned about your baby’s safety if you hear cries. Follow these safety guidelines.

Avoid old cribs or bassinets Even if an old crib is in good shape, safety standards have improved over the years, so it’s generally a good idea to buy a new crib if you can. If you do use a hand-me-down crib, make sure that it meets current safety standards. Older cribs with drop sides — the kind that have a side rail that moves up and down — are not considered safe. In addition, some older cribs may have been coated with lead paint, which is a health hazard. A crib should be the one place you feel comfortable leaving your child alone.

Check the slat spacing The crib’s slats should be no farther apart than 23/8 inches. This applies to bassinets, too. If you can fit a can of soda through the slats, the openings are too large. You’re more likely to find this problem in older cribs, but you can’t be too safe when it comes to your baby, so check any crib you put him or her in.

Get the right mattress The surface of your baby’s mattress should be firm, flat and smooth. Make sure the mattress fits snugly within the frame of the product it’s made for, so there’s no space for your baby to get trapped.

Remove extraneous items During the first year — or at least until your baby can easily move around the crib on his or her own — remove any extra bedding from the sleep space, such as bumper pads, pillows, cushions and comforters. This prevents your baby from rolling into a potentially suffocating situation. To keep your baby warm, try a sleep sack or other sleep clothing that doesn’t require additional covers. Save toys and stuffed animals for when your baby is awake and supervised.

Remove crib mobiles early Crib mobiles typically include string and small attached pieces. Make sure your little one cannot reach the mobile so that he or she can’t become entangled or pull anything off. When your baby is able to push up onto his or her hands and knees, the mobile should be removed from the crib.

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A safe sleep environment for your baby

To keep your baby safe during sleep, follow these recommendations from the American Academy of Pediatrics:

Place your baby on his or her back to sleep every time.

Use a firm sleep surface.

Breast-feed while you can.

Share your room with your baby using separate sleep surfaces.

Remove soft objects and loose bedding from your baby’s sleep area.

Consider using a pacifier during sleep time.

Avoid smoke exposure, alcohol and illicit drug use.

Avoid overheating.

Get your baby vaccinated on schedule.

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Safe swaddling Many young babies fall asleep and sleep better when swaddled. If you swaddle your baby, use a breathable 100% cotton blanket or a swaddling sleep sack. A blanket is breathable when you can hold one layer of the blanket up to your mouth and your breath can pass through the fabric. This is the best option for a baby because the baby can still breathe if the fabric slips and covers his or her face. Cotton also allows body heat to escape, which prevents overheating.

When swaddling your baby, make sure to allow room for the hips and legs to move freely. If you wrap your baby too tightly around the hips and legs, it can interfere with proper growth and joint development. Your baby’s legs should be able to bend up and out.

It’s time to stop swaddling when your baby first shows signs of rolling over, generally around 4 months. Ideally, a baby needs to be able to control his or her arms when rolling. But the baby can’t do that when he or she is swaddled.

Try a pacifier Sucking on a pacifier at nap time and bedtime may reduce the risk of SIDS. One caveat — if you’re breast-feeding, you may want to wait to offer a pacifier until breast-feeding is well established. For some babies, this can be 3 to 4 weeks of age. If your baby’s not interested in the pacifier, try again later. If the pacifier falls out of your baby’s mouth while he or she is sleeping, there’s no need to pop it back in.

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Make time for tummy time

Just because your baby should sleep on his or her back doesn’t mean baby should never spend any time on his or her tummy. Being on the tummy is good for babies. It prepares them for the time when they’ll be able to slide on their bellies and crawl by encouraging them to lift their heads and build strong head, neck and shoulder muscles. As babies grow older and stronger, they’ll need more time on their tummies to build their strength.

While baby is awake and being supervised, place him or her on the floor on his or her tummy. Place yourself or a toy on the floor for baby to look at or play with. Another option is to lay your baby tummy-down on your tummy or on your lap.

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Good sleep habits

A question that new parents often get from friends and family is, “Is your baby sleeping through the night yet?” But honestly, no one “sleeps through the night.” Everyone experiences nighttime arousals, but most of the time people go right back to sleep after these brief awakenings.

Babies experience the same nighttime arousals. In the first few months, a number of biological factors impact these awakenings. For example, new babies need to feed every few hours — including at nighttime — because although their stomachs are tiny, they’re growing fast and they need frequent feedings to sustain their growth and development.

As babies get older, they’re able to consume and retain larger amounts of calories during the day and require fewer feedings at night. At the same time, their biological rhythms are acclimating to day and night cycles. By 4 to 6 months, their sleep patterns are becoming more and more like those of adults.

During this process of getting used to the “real world,” babies are learning many things based on the repetition of patterns — such as making connections between the sound of your voice and loving attention, for example, or the smell of breast milk or a fresh bottle and the satisfaction of being fed. Likewise, your baby is also developing certain associations with falling asleep. Maybe every time you nurse your baby or give him or her a bottle, your baby falls asleep. Or you snuggle together in a chair until your baby falls asleep. Or you rock your baby to sleep.

There’s no denying that having your baby fall asleep on your chest can be deeply fulfilling. But if this happens every time your child falls asleep, it can become a condition your child needs in order to fall asleep. So, at 6 months, when your baby wakes at night, as any person would, he or she needs your chest to feel “right” about falling back to sleep. This is referred to as a sleep association.

You can help your baby develop positive sleep associations over time that allow him or her to fall asleep without your help. This is called self-soothing — a skill that can be especially useful in the middle of the night! Here are steps you can take that have proved to help babies and toddlers get a good night’s rest.

Develop a bedtime routine Bedtime routines, which can start in the early months, become very important to a child by age 1. A winding down of the day’s activities signals that it’s time for bed. Your routine could include soothing activities such as having a bath, reading or making up stories, and a good night hug or kiss. Avoid watching TV or using electronic devices with your baby before bed, as these activities can be overly stimulating. Finish the bedtime routine before your child falls asleep. The whole process might last 20 to 45 minutes.

Establish a consistent bedtime. The more consistent you can be with when you begin and end your bedtime routine — and all the steps in between — the easier it will be for you and your child. Children thrive on structure, so it’s OK to do the same thing every night.

Consider a rule — for yourself and your child — that your child should not leave the crib at night unless he or she needs to feed or have a diaper change. After age 2, a healthy child doesn’t need to leave his or her bedroom on a typical night except to go to the bathroom.

Allow self-soothing Drooping eyelids, rubbing the eyes and fussiness are the usual signs that a baby is tired. When you notice these signs, put your baby in his or her crib while he or she is drowsy but still awake. If your baby can fall asleep in bed without assistance when first laid down, it’s more likely that he or she will fall asleep on his or her own after waking in the middle of the night.

It’s common for babies to cry when put down for sleep, but if left alone for a few minutes, most will eventually quiet themselves. If you leave the room for a while, your baby will probably stop crying after a short time. If not, try comforting your baby and allow time for him or her to settle again.

During sleep, babies are often active, twitching their arms and legs, smiling, sucking, and generally appearing restless. And while sleeping, infants may cry and move about when entering different sleep cycles. Parents sometimes mistake a baby’s stirrings as a sign of waking up, and they begin unnecessary feeding. Instead, wait a few moments to see if your baby settles back to sleep.

Adopt a security object Once your child is a year old or more, he or she has likely developed enough motor skills to have a small blanket or stuffed animal nearby at night without the danger of suffocating in them. A favorite teddy bear or other safe object can help comfort and soothe your child when you’re not present. Offer a simple, breathable blanket. Choose soft toys without decorations, such as buttons or ribbons, that might come off and pose a choking hazard.

Pay attention to naps Naps are just as important to young children as a good night of sleep is. Napping helps your baby get the total amount of sleep he or she needs and helps prevent exhaustion before bedtime. At nap time, you can use some of the same steps you use for your bedtime routine. For example, read a story, tuck your child in, and leave the room. Allow a few minutes for your child to settle and fall asleep.

Some babies sleep for a long time, but they take fewer naps during the day. Other babies take more, short naps during the day. If your baby sleeps well at night, it’s fine to let him or her nap for as long as desired. If your baby isn’t sleeping at night as long as you wish, it may help to shorten the nap time. Or if baby takes three naps a day, try to change the habit to two naps a day. Most children between the ages of 12 and 18 months shift to taking one midday or afternoon nap a day. As early as age 3 years, many children drop naps entirely, and most do so by age 5.

Transition to separate bedrooms As babies grow into toddlers, parents and kids often find both parties sleep better if they’re in separate rooms. If you’ve had your child sleeping in your bedroom for the first six months to a year, you might be ready to transition your child to his or her own bedroom by about the first birthday. Here are some suggestions to make this change easier.

Start with naps. Place your child in his or her own bedroom at each nap time. Close the child’s bedroom door when you leave the room. This keeps most household noise out of the room so that your child can sleep better. Using a monitor can help you hear or see how your child is doing.

After a week or two of successful napping in the child’s own room, begin to put your child to bed at night in his or her bedroom. If your child is older than a year, make it a grand occasion. Tell the child, “Starting tonight, you get to stay in your own bed during the night. You’re old enough to do that now!” Kids are usually very happy to “grow up.” Invite your child to help you make the bed. Let him or her choose which blanket or stuffed animal to use on the bed.

Give a small reward if needed when a toddler or older child has stayed in his or her room overnight. Some examples are reading a new book together, going to the park, or doing a puzzle or game together. Try to avoid using sweets or extra treats as a reward. Be sure to tell your child why he or she is getting the reward.

Switch from crib to bed It’s time to switch from a crib to a bed as soon as your child learns how to climb out of a crib with the mattress at its lowest setting. This is usually around age 2 or 3. If you keep your child in the crib and the child falls as he or she tries to climb out, your child could get a serious injury.

Some parents choose to switch to a special toddler bed or a bed they think their child can grow into. For example, some toddler beds are designed to adjust in length or width as your child grows. But you also can put a mattress on the floor until you decide on a more permanent arrangement.

Troubleshooting

Establishing healthy sleeping habits for everyone in the family is often easier said than done. All babies sleep through the night eventually, but each one reaches this milestone on his or her own time. Try to be patient. In the meantime, expect some trial and error and nights of interrupted sleep because of teething, illness and other disruptions. There are no hard-and-fast rules for getting your child to sleep consistently through the night, but here are some suggestions that might help.

Phasing out nighttime feedings It’s normal for young babies to wake at night to feed. But by about 6 months of age, many babies can sleep five to eight hours or more without a feeding. By this age, babies should be able to get enough calories during the day so that they don’t need nighttime feedings.

If your child is 6 months old and cries one or more times a night to be fed, try these suggestions:

Try to dissociate nursing or bottle-feeding from falling asleep. You might feed your baby an hour or so before bedtime, and do it in a room separate from the bedroom. After feeding your baby, go through your regular bedtime routine, such as reading or singing, at your chosen bedtime. Do this even if it feels a little contrived. Put your baby to bed drowsy but still awake. If your baby needs to suck on something to help him or her go to sleep, offer a pacifier.

Increase the volume of feedings during the day and hopefully increase spacing of feeding during the day. If your baby consumes small volumes frequently throughout the day, he or she will be used to that feeding pattern. This may lead to your child waking up hungry during the night.

Reducing nighttime waking If your child is older than about 6 months and repeatedly wakes during the night crying for attention, you can help your child learn to self-soothe. But it does require patience and consistency. If your child is sick or going through a transition, such as attending a new child care center, it may not be a good time to teach self-soothing. When you’re ready, here’s what to do.

First, be sure your child’s basic needs have been met, such as feeding, appropriate clothing, and a dry diaper or trip to the toilet, before you put him or her to bed. Go through your usual bedtime routine.

If your child cries when you leave, wait a few minutes before you decide whether to go back into the room. Stay out of sight meanwhile.

If your child is still crying after several minutes, go into the room but don’t turn on the lights. Comfort your child with a soothing pat or two and a few loving words but avoid picking him or her up. Then say, “It’s time to go to sleep now” and leave the room. You should be in the room no more than a minute or two. Don’t be surprised if your child cries louder as you leave; this is to be expected.

Wait again, increasing the length of your wait by a few minutes before going back in. Repeat this process, increasing the wait each time. When your child falls asleep, make a note of the last time frame you waited before you entered the room — for example, 10 minutes.

The next night, if your child cries, repeat the entire process. Start with the last wait from the previous night — 10 minutes in the previous example — and go from there.

Over the next few days, repeat the process. It may take several nights, but your child will gradually learn to self-soothe — an important and positive development that will serve your child and your family well in years to come!

Staying in bed As your child moves into toddlerhood, he or she may have a hard time staying in bed even after going through your usual sleep routine — there are just so many interesting and exciting things to do and see! This can be especially true when your child has just learned a new skill or is at a developmental turning point. Some toddlers get upset when it’s time to sleep. They may even refuse to lie down. Generally, it’s best to ignore these protests, as well as any other questions or demands, and leave the room.

Stick to the rule that your child should stay in bed after being tucked in. Once your child starts potty training, you can make an exception for going to the bathroom, of course. If your child leaves the bedroom, calmly tell your child, “You need to go back to your own bed now.”

If your child won’t do as you directed, walk alongside the child with a hand placed gently on his or her shoulder. If your child refuses to go to the bedroom, carry the child back to the room without saying anything. Avoid showing frustration or anger. Place your child in his or her bed and walk away. Close the door to the bedroom.

If your child doesn’t know when it’s morning and gets up before you do, try using a “good morning light.” This is a night light with a timer. You can set the light to turn on or change colors when you want your child to wake. Tell your child that he or she can get out of bed when the light changes from red to green or when the light turns on.

If you follow these suggestions every time, after just a few days, your child soon will learn that delaying bedtime doesn’t lead to more “fun” or extra playtime.

Lastly, being consistent doesn’t mean being inflexible. If your child is sick, has had a nightmare or is truly afraid for some reason, spend some time with your child to make sure he or she feels secure.

CHAPTER 10 Comforting a crying baby

The dream: Your baby starts sleeping through the night just a few weeks after birth, gurgles happily while you run errands and only fusses when hunger strikes. The reality: Your baby’s favorite playtime is after a 2 a.m. feeding, and crankiness peaks whenever you’re out and about.

Babies cry. The average newborn cries one to four hours a day — and for lots of reasons. Babies cry because they’re tired, hungry, lonely, too hot, too cold or simply because it’s that time of day. All this crying can be particularly baffling for first-time parents, who often think they should know what their screaming bundle of joy is trying to tell them — and be able to do something, quickly! But it's not always easy to figure out why your baby is crying and what to do about it. It takes time and experience to learn to read your baby's cues.

Don’t take the tears personally. If your baby’s crying is causing you stress or anxiety, take a deep breath and try to relax. Ask for help if you feel you need it, and remember this stage won’t last forever. Crying usually peaks around six weeks or so and then gradually decreases. So hang in there!

Why babies cry

When your baby cries, it's true that he or she is generally trying to tell you something. Crying is a baby’s way of communicating that he or she is hungry, tired, uncomfortable, or simply has had too much stimulation for one day.

And in general, it’s best to respond quickly to your child’s cries — especially when your child is a newborn. Don’t be afraid that you’ll spoil your baby by giving him or her too much attention. Just the opposite: Studies indicate that being responsive to a child’s needs might help him or her cry less overall and show less aggressive behavior as a toddler.

Here are some of the more common reasons babies cry.

Hunger Most newborns eat every few hours round the clock and usually wake for feedings during the night. Quiet babies may squirm and root around or fuss gently when they’re hungry. More-active babies can become almost frantic when hunger strikes. They may get so worked up by the time feeding begins that they gulp air with the milk. This can cause spitting up, trapped gas and more crying. Some babies are intensely bothered by having air in their stomachs, while for others it isn’t as much of a problem.

Discomfort Just like adults, babies don’t like to feel uncomfortable. A common cause of baby discomfort is a wet or soiled diaper. Some babies don’t mind the warm, messy feeling they’ve created. Other babies can’t tolerate a soaked or dirty diaper, and they let you know right away that they’re unhappy. Tummy troubles also are a common source of discomfort. Gas or indigestion can cause babies to cry. If your baby fusses after being fed, he or she may be feeling some sort of tummy pain. Often, after a burp or the passing of gas, the crying will stop.Temperature can be another source of discomfort — if baby is too hot or too cold, it can trigger tears. So can tight, binding or itchy clothing. Make sure the waistband around baby’s stomach isn’t too tight, the collar doesn’t rub on baby’s face, and the legs or sleeves don’t pull when baby moves.

Loneliness, boredom or fear Sometimes, babies cry because they’re lonely or bored. Or because they're frightened. Your baby may calm down simply by seeing or hearing you, feeling your touch, or being cuddled. As you’ll find, babies like to be held. They like to see and hear their parents and listen to the sound of their parents’ heartbeats.

Overtiredness or overstimulation When a baby is overtired or overly stimulated, crying becomes a way to unwind or release tension. Tired babies generally fuss. And you may find that your baby needs more sleep than you think. Newborns often sleep for 16 hours a day. Too much noise, movement or visual stimulation also might drive your baby to tears. In addition, many babies have predictable periods of fussiness. They cry at certain periods of the day and often for no apparent reason.

Understanding baby’s cries

What many new parents find is that with time — as they get to know their child and the child’s developing personality — they come to understand what baby’s different cries mean. You'll likely find the same to be true for you. In the meantime, here are a few clues that may help you if you can’t figure out what your little one is trying to tell you.

A hungry cry might be short and low pitched.

A cry of pain might be a sudden, long, high-pitched shriek.

If your baby is making lip movements or rooting, hunger might be the problem.

If your baby is rubbing his or her eyes, he or she might be tired and in need of some sleep.

If your baby hears a loud noise and begins to cry, he or she may simply be startled.

Picking up on patterns can help you better respond to your baby. Getting to know your child’s crying triggers can also help you notice when your baby is experiencing unusual distress — crying for reasons he or she normally doesn’t.

Comforting strategies

OK. So your baby is crying. Now what do you do? Sometimes, the cause is obvious and you can quickly remedy the situation. In other cases, you may have to experiment with a couple of calming techniques until you find out what your baby likes — what brings comfort to him or her. It's often more art than science. What works for one baby doesn’t always work for another.

Check baby’s diaper Do a quick check of your baby’s diaper to make sure it’s clean and dry. A new diaper may be the answer to the problem.

See if baby is hungry If your baby is hungry, he or she will likely stop crying when you offer the breast or a bottle. Keep in mind, however, that crying is a late sign of hunger that can interfere with feeding. You might need to calm your baby before he or she can begin feeding. To avoid this situation, try to respond to early signs of hunger, such as lip smacking, rooting, facial grimaces or fussing. If your baby begins to gulp during the feeding, take a break. During and after each feeding, take time to burp your baby.

Look for signs of discomfort Feel your baby’s hands and feet. If baby seems too hot or too cold, add or remove a layer of clothing. You might also remove his or her clothing to see if tight elastic or irritating material might be the cause of the tears. If the culprit is air or gas, try to burp baby or gently massage baby's tummy. If your child remains warm, check his or her temperature to make sure he or she isn’t running a fever.

Caress baby A gentle massage or light pats on the back can often help soothe a crying baby. You might do this while lying baby tummy-down across your lap.

Keep baby movin’ Babies generally like movement. Sometimes, just that feeling of motion can help soothe your baby. You might rock baby or walk through the house. Keeping safety precautions in mind, try placing baby in an infant swing or vibrating infant seat, or experiment with an infant sling. If the weather permits, head outdoors with the stroller or a baby carrier. You might even want to buckle up baby in the car seat and go for a ride in the car.

Sing or play music White noise — such as a recording of ocean waves — or even the monotonous sound of an electric fan or vacuum cleaner in a nearby room sometimes can help a crying baby relax. Babies often like soothing, muffled sounds similar to the amniotic fluid waves or pulsing sounds they heard in the womb.

Let baby suck Offer a clean finger or pacifier. Sucking is a natural reflex. For many babies, it’s a comforting, soothing activity.

Seek quiet If your baby is overly tired or has had too much stimulation, provide some quiet time by moving to a calmer environment. At times, baby just needs to get away from the commotion.

Let baby cry If you’ve tried everything and your baby is still upset, consider just letting your baby cry while you hold him or her. If you need a break for yourself, put your baby in a safe place — such as the crib or bassinet. If you’ve fed, burped and changed your baby and he or she appears otherwise all right, it’s OK to let your baby cry for 10 or 15 minutes in the crib.

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The 5 S’s

Pediatrician Harvey Karp has combined five techniques for soothing a fussy baby into what he calls the “5 S’s.” Dr. Karp proposes that a baby’s first three months are more like a fourth trimester and that replicating womb-like conditions — warm, cozy and fairly noisy — can ease a baby’s transition to the big, open world. You can find detailed information in Dr. Karp’s book, The Happiest Baby on the Block, but here’s a quick run-down. One or two of these steps might do the trick, or you can try them all at once.

Swaddle Wrap your baby snugly in a blanket, with arms tucked in straight at the sides and legs left free to move and bend.

Side or stomach position If your baby is fussy, try holding him or her in a side or stomach position, or over your shoulder. Don’t use this position for sleeping, though. Always place your baby on his or her back to sleep.

Shush The womb is actually quite a noisy place, with the sound of blood pulsing through nearby blood vessels. Producing a loud shushing noise or white noise near the baby’s ear can help soothe fussiness.

Swing Replicate the motions inside the womb by gently jiggling your baby in fast, tiny motions. Keep your baby’s head and neck supported and your motions small. To avoid bodily harm, make sure not to shake your baby too hard.

Suck Sucking is a relaxing activity for most babies. Offer your baby a pacifier or a clean finger to suck on.

• • • • •

Colic

All babies cry, but some cry more than others. And for a few babies, no matter what you try to do to stop the crying, nothing seems to work. If your son or daughter fits this description, it’s possible he or she may have colic. Colic is the term for periods of intense, inconsolable crying that last for three hours or more, at least three days a week (sometimes every day) and for at least three weeks. The crying episodes typically start a few weeks after birth and generally begin to improve by age 3 months.

Causes The big question when it comes to colic is what is it that causes an otherwise healthy child to cry so much? And the answer is, experts really don’t know. There are a variety of theories, and not all doctors agree about what may be potential triggers. It’s possible the cause may be a combination of factors, and it may differ between infants.

Temperament. Some babies are naturally irritable or sensitive, which might contribute to colicky behavior.

Immature nervous system. If your baby has an immature nervous system, he or she might be unusually sensitive to stimulation. These babies become overloaded by all of the sights and sounds, and they aren’t able to console themselves. As a result, they cry and they may have difficulty sleeping. Premature babies may exhibit their sensitivity in the form of fussiness rather than crying.

Food sensitivities. If you breast-feed your baby, colic might be a sign that your baby is sensitive to certain foods in your diet. If you feed your baby formula, colic could be an indication that your baby is sensitive to milk protein in formula.

Underlying health problem. Rarely, colic might be a sign that your baby has a health problem, such as a hernia or an infection.

Many other theories about what makes a child more susceptible to colic have been proposed, but none have been proved. Gas was long thought to be a cause because many colicky babies have gas. However, colicky babies may develop gas as a result of swallowing too much air while crying. What doctors do know is that birth order doesn’t matter — colic doesn’t occur more often among firstborns than in later children. Girls and boys experience colic in similar numbers.

And there are no lasting effects or complications from the crying episodes. Babies with colic grow and develop normally, and they aren’t any more likely to cry when they become older infants or toddlers than are infants who didn’t have colic.

Common signs Some babies are fussy but they don’t have colic. Although the behavior can vary, a baby with colic generally exhibits the following signs:

Predictable crying episodes. A baby with colic often cries about the same time every day, often in the late afternoon or evening. The crying usually begins and ends for no clear reason.

Intense or inconsolable crying. Colic crying is intense and often high pitched. Your baby’s face might flush, and he or she is extremely difficult to comfort.

Posture changes. Among babies with colic, during crying episodes they tend to curl up their legs and clench their fists. You may also notice that the baby has tensed abdominal muscles.

Diagnosis If you think your baby may have colic, check in with your child’s medical provider, especially if your baby is inconsolable or you notice signs of illness, such as a fever, vomiting, or changes in eating or sleeping patterns, or other signs or symptoms that worry you. Your baby’s medical provider can help you tell the difference between normal tears and something more serious. Tell the provider when and how often the crying episodes occur, how long they last, and any observations you’ve made about your baby’s behavior before, during and after the episodes. The provider may ask about your efforts to soothe your baby, as well as your baby’s diet and feeding schedule.

Your baby’s medical provider may do a physical exam to identify any possible causes for your baby’s distress, but other tests generally aren’t necessary. If your baby is otherwise healthy, his or her doctor may identify the problem as colic.

• • • • •

Tummy hold

Some babies find comfort by being held on their tummies, a position sometimes referred to as the colic hold or colic carry. If your baby is fussy, you might try this position to see if it helps. Place baby facedown along your forearm with your arm firmly between his or her legs. Baby’s cheek should be resting on your palm. Hold your arm close to your body, using it to brace and steady your baby. Don’t let baby sleep in this position.

• • • • •

Managing colic

Caring for an infant who has colic can be exhausting, confusing and stressful — even for experienced parents. Colic isn’t a result of poor parenting skills, so don’t blame yourself for your baby’s colic. Instead, focus on ways to make this difficult stage a little more bearable. Remember, this too shall pass.

Unfortunately, there are few treatment options for colic. Over-the-counter drugs, such as simethicone (Mylicon Infants Gas Relief, Little Tummys Gas Relief, others), haven’t proved helpful for colic, and other medications can have serious side effects. Some studies suggest that treatment with probiotics — substances that help maintain the natural balance of “good” bacteria in the digestive tract — might soothe colic. However, more research is needed to determine the effects of probiotics on infants. Because of this, most Mayo Clinic pediatricians don’t recommend the use of probiotics in infants.

Some parents also report trying alternative therapies, such as herbal teas, herbal remedies or glucose. Alternative therapies for colic haven’t proved to be consistently helpful, and some might be dangerous. Before giving your baby any medication or substance to treat colic, consult your child’s medical provider.

While you might not be able to treat colic, there are things you can do to try to soothe your baby and reduce or lessen the severity of the crying episodes. Consider these suggestions:

Your feeding style Check that you're not overfeeding your baby. Try to wait at least two to two-and-a-half hours between feedings. During feedings, hold your baby as upright as possible and burp him or her often to reduce the chances of air swallowing.

If you feed your baby with a bottle, use a curved bottle. A bottle with a collapsible bag also might help. Some bottles are especially designed to minimize the amount of air your baby takes in while feeding. If bottle feedings typically take less than 15 to 20 minutes, consider using a nipple with a smaller hole.

If you use formula, you might consider giving your baby a hypoallergenic formula, such as whey hydrolysate formula, for one week. If your baby’s symptoms don’t improve, continue using the original formula. Avoid frequently switching your baby’s formula.

If you breast-feed, try to empty one breast completely before switching to the other breast. This will give your baby more hindmilk, the fattier and potentially more satisfying milk at the end of a feeding.

Your diet If you breast-feed and you suspect that a food or drink you consume may be making your baby fussier than usual, avoid it for several days to see if it makes a difference. Consider eliminating dairy products or other allergenic foods, which can cause allergic symptoms in breast-fed infants. Research suggests that in some special cases avoiding foods such as cow’s milk, eggs, peanuts, tree nuts, wheat, soy and fish for a week can reduce infant fussiness. Also, try to eliminate or reduce the amount of caffeine in your diet. Caffeine in your breast milk can keep your baby awake for prolonged periods or cause agitation. Some moms say avoiding gassy or spicy foods can help — but this hasn’t been proved.

Your lifestyle If you or your partner smoke, it's time to quit. Research suggests that exposure to cigarette smoke can increase your baby’s risk of colic, in addition to other health risks for you and your baby.

Calming techniques For most babies with colic, soothing techniques can often help calm the child and lessen the crying — at least for a while. The trick is finding out which techniques your son or daughter likes. Experiment with the comforting strategies here and here to see if they help. Also see “The 5 S’s” here.

Keep in mind that babies with colic often like motion. Anything you can do to keep baby moving may help. Sit with your baby in a rocking chair, carry baby around the house in a baby sling, or take a walk with your baby in a stroller . In addition, babies with colic often find certain sounds calming. A steady background of soft noise or “shushing” sounds may help. Turn on the kitchen or bathroom exhaust fan, run the vacuum in the next room, use a white noise machine or play music of environmental sounds, such as ocean waves or a gentle rain. Sometimes, the tick of a clock or metronome does the trick.

• • • • •

Always be gentle

When your crying baby can’t be calmed, you might be tempted to try just about anything to get the noise and the tears to stop. But remember the importance of treating your baby gently. Never yell at, hit or shake your baby.

Newborns have weak neck muscles and often struggle to support their heads. Shaking your baby out of sheer frustration can have devastating consequences — including brain damage that leads to seizures, learning disabilities or mental retardation. And severe shaking can be life-threatening, or even fatal.

If you’re worried about your ability to cope with a crying baby, contact your medical provider or your baby’s medical provider, a local crisis intervention service or a mental health help line for support. If you need to, take your baby somewhere where you know he or she will be safe and cared for.

• • • • •

Keeping your cool

Listening to a baby cry is stressful, especially when it seems to go on for hours on end. Even for the best of parents, coping with colic is tough. When you’re all tensed up over your baby’s crying, look for ways to calm yourself. Think about the happy moments you’ll spend with your baby and the milestones ahead. And while taking care of your baby, remember to also take care of yourself.

Take a break If your baby’s cries are getting to you, slow down. Take a deep breath and count to 10. Repeat a calm word or phrase, such as, “Take it easy.” Imagine yourself in a calm, relaxing place. Play soothing music in the background. In some cases, the best thing to do may be to put baby down in his or her crib for a period of time while you walk into another room and give yourself a break.

Get out of the house Put your baby in the stroller or a baby carrier and go for a walk together. The exertion might take your mind off the tears — and the movement or change of scenery might soothe your baby. You might even buckle the baby into his or her car seat and take a short drive, provided you feel that you can concentrate on your driving.

Ask for help Let a loved one take over for a while. Take advantage of baby-sitting offers from trusted friends, neighbors or other close contacts. Use the time to take a nap or do something you enjoy. Even an hour on your own can help renew your coping strength. Expressing yourself can help, too. When you’re getting frustrated, speak up. Saying the words out loud can help ease the tension. The more relaxed you are, the more able you’ll be to handle and cope with baby’s crying spells. It’s also good for baby. Babies can sense when you’re tense and stressed out.

Don’t judge yourself Most of all, don’t measure your success as a parent by how much your baby cries. Colic isn’t a result of poor parenting, and inconsolable crying isn’t a sign of your baby rejecting you. You and your baby will get through this phase. Colic typically goes away on its own by age 4 months.

CHAPTER 11 Building a relationship

Some days you gaze at your baby and feel a connection deeper than you ever thought possible. Other days, you stare at this little person crying inconsolably in your arms and have no idea what’s wrong. Then there’s the toddler stage. One moment you’re enjoying a book with your happy, cuddly tyke. The next he or she is staging an all-out war because it’s time for bed.

When your child was born, you embarked on one of the most rewarding, challenging and complex relationships you’ll ever experience. Like any relationship, your connection is a two-way street. Your child’s behavior, personality and moods affect you just as much as yours affect your child. There are good days and bad days. After all, no child or parent is perfect.

What matters is not perfection but a commitment to consistently engage with your child and do your best to respond to his or her needs with empathy and sensitivity. Whether that means comforting a crying baby or calming a frustrated toddler, your attention and affection help build the strong, secure and nurturing relationship your child needs to thrive.

Nurturing your bond

Your baby was born to bond with you. From the start, he or she has instinctively sought a connection with each cry, nuzzle or gaze into your eyes. As babies grow and become more interactive, they strengthen the parent-child relationship by smiling, cooing and imitating facial expressions. Even when your little one begins to scoot, crawl or walk, he or she will continually loop back to you, drawing comfort from the security of your special bond.

Each time you’re responsive to your baby’s instinctive connection-seeking behaviors, you’re building and deepening a stable, nurturing relationship with your child. Experts refer to this healthy child-parent bond as secure attachment. A securely attached child regularly seeks physical and emotional comfort from a parent and trusts that the parent will respond to his or her needs.

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Postpartum depression

Most new moms experience some form of “baby blues” in the first few days or weeks after childbirth. This commonly includes mood swings, crying spells, anxiety and difficulty sleeping. But some new moms experience a more severe, long-lasting form of depression known as postpartum depression.

Postpartum depression isn’t a character flaw or a weakness. Sometimes it’s simply a complication of giving birth. It’s possible to provide good care for a baby even with postpartum depression. But in some cases, postpartum depression can affect how closely a mother bonds with her baby.

If you’re feeling persistently sad after your baby’s birth, you may be reluctant or embarrassed to seek help from your doctor. But prompt treatment can help you manage your symptoms and continue to build a strong relationship with your baby.

It’s important to call your doctor as soon as possible if the signs and symptoms of depression have any of these features:

Don’t fade after two weeks

Are getting worse

Make it hard for you to care for your baby

Make it hard to complete everyday tasks

Include thoughts of harming yourself or your baby

Your doctor can help you find the treatment you need to get better. If needed, he or she may refer you to a counselor, psychiatrist or other mental health specialist.

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Benefits of a strong bond When babies feel secure in their relationship with a parent, they start to feel secure in their relationship with their world. This sense of security helps a child to thrive long after the first year of life. In fact, the positive impact of a baby’s connection with a parent can last well into adulthood. That’s why you can never spoil a baby with too much attention or affection.

Babies who have a secure, nurturing relationship with a parent in the first year of life may be more likely to:

Handle brief separations from parents more easily and with less distress

Explore their surroundings with greater confidence and experimentation

Adapt to new situations and people more easily

Tackle challenges with greater pleasure and persistence, leading to the mastering of new skills

Manage their emotions and stress more successfully in childhood and beyond

Show greater resilience in the face of obstacles

Gain a greater capacity to form close, lifelong relationships

Connecting with your baby Creating a secure attachment with your baby doesn’t require all-consuming sacrifice, but it does take conscious effort. If you strive to be a responsive, dependable and nurturing presence in your baby’s life, your bond will grow naturally. Your baby will feel safe, secure and loved knowing that he or she can count on you to offer comfort, fill a hungry tummy or change a soggy diaper.

Here are some things you can do to keep the connection between you and your baby strong:

Respond to your baby’s cries. Babies cry to communicate their needs, not to manipulate. There may be times when your baby needs to cry it out, but generally it’s best to respond quickly to his or her cries if possible. The reassuring comfort of your smell, touch and voice strengthens your baby’s attachment to you.

Spoil away. Don’t be afraid that you’ll be spoiling your son or daughter. Studies show that young babies who are consistently picked up and held in response to their cries tend to cry less by 1 year of age and show less aggressive behavior as toddlers. What’s more, soothing babies in this way can teach them to eventually soothe themselves. (For tips on how to soothe a crying baby, see this discussion.)

Tune in to your baby’s cues. Being attuned to your baby means paying close attention to the different facial expressions, sounds and movements that communicate his or her needs. Learning to understand these cues and responding to them with sensitivity helps your baby feel loved and secure.

Talk, sing and read frequently to your baby. Coo or chatter cheerfully to your little one while changing a diaper. When he or she coos back at you, respond in kind. Sing a silly song at bath time. Read a book together. These shared experiences will bring you closer and contribute to your baby’s brain development.

Make time for playtime. Playtime offers an opportunity to interact with your baby in a fun, joyful way. Delight your baby with a game of peekaboo or patty-cake. Dangle objects for him or her to observe, touch or grab. Get down on your child’s level to stack toys or roll a ball back and forth.

Give plenty of physical affection. Whether your child’s a newborn or a sturdy 1-year-old, he or she benefits from your touch. Hold, cuddle, rock and massage your baby — not only in times of distress but also in peaceful or playful moments. Let your little one know how special he or she is to you.

Offer gentle guidance. Your baby doesn’t understand the concepts of right or wrong, good or bad just yet. He or she depends on you to teach acceptable behavior. If your young baby yanks on a fistful of your hair, gently remove that little hand or distract your baby with an appealing toy. If your baby’s old enough to understand language, you can explain “That hurts.”

Be a dependable home base. Once babies are mobile, they want to explore their environment. This newfound freedom is both thrilling and overwhelming for your baby. He or she may periodically seek eye contact with you, call out to you, or return to your side for a quick hug or cuddle. When you’re responsive to these ways of reconnecting, you’re helping your child feel safe and secure. This allows your little one to continue exploring his or her world with confidence.

Be mindful of screen use. When interacting with your baby, try as much as possible to set aside your smartphone, turn off the TV and minimize other distractions. Your baby doesn’t require your single-minded attention every minute of the day. But if you’re making more eye contact with your phone than with your child, you’ll both be missing out on crucial parent-infant interactions that help your baby thrive.

Setting reasonable expectations Keep in mind that you won’t be able to meet every one of your baby’s needs perfectly or immediately, and that shouldn’t be your expectation. You aren’t harming your baby if you can’t hold her while she’s crying in her car seat on the drive to the playground. You won’t weaken your bond if it takes you a while to realize that he’s fussing because of a scratchy sweater instead of an empty tummy or wet diaper. As long as you’re generally responsive to your baby’s needs, your baby will flourish.

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Serve and return

Your baby babbles at you. You respond by looking into baby’s eyes and imitating the sounds. Your baby laughs with delight, causing you to giggle. Experts sometimes call this simple back-and-forth interaction serve and return, and it’s an important way that parents form close, nurturing relationships with their babies.

What’s more, serve and return interactions provide vital support for the rapidly developing connections in a young child’s brain. These interactions can also improve the ability to control impulses, regulate emotions and navigate social encounters later in childhood.

Here are some serve and return behaviors you can engage in every day:

Return your baby’s gaze or smile.

Mirror your baby’s expressions, vocalizations and actions.

Talk to your baby.

Describe to your baby what he or she is seeing, feeling or doing.

Play interactive games like peekaboo.

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Understanding temperament

To read your child’s cues and know how to best respond to his or her needs, it helps to gain a deeper understanding of your child. Many factors shape who your child is, including genetics, your home environment and your parenting style. Your child’s personality or temperament is another factor.

One way experts think about temperament is to break it down into nine observable traits. These traits are acquired before birth and have to do with how a child behaves. Temperament traits start to emerge within the first few months of life and will continue to influence your child’s behavior in the years to come.

Each trait functions as a continuum. A child may fall on either extreme or somewhere in the middle for any given trait. As you read through the different temperament traits below, think about where your son or daughter may fall on the scale of each one.

Activity. This is your baby’s usual level of physical motion throughout the day, his or her “idle speed.” It can range from low to high energy.

Regularity. This trait relates to the predictability of your child’s bodily rhythms, such as when he or she gets hungry or tired each day. Some children are as predictable as a clock, while others keep you guessing.

Approach or withdrawal. When encountering something new, some children are naturally curious, approaching a novel situation or person eagerly. Others are more cautious, waiting to see what will happen next before making their approach.

Adaptability. How easily does your baby adapt to change and transition? Some children adjust easily, while others are less adaptable and need more time to shift gears.

Sensitivity. Some babies are highly perceptive of their environments and respond readily to external sources of stimulation, such as lights, sounds, tastes or even the way clothing feels on their skin. Others don’t display such strong sensitivities — or they may be more sensitive to certain factors than others.

Intensity. Intensity refers to the energy level of your child’s response to different situations, whether positive or negative. An intense baby will squeal, laugh, scream, wail and flail. Less intense babies might smile, whimper or just turn away when they’ve had enough.

Mood. As with adults, children can have various emotions throughout the day. But children tend to have an overall disposition, ranging from sunny to more serious or grave.

Distractibility. Some children remain focused on an activity for some time, despite potential distractions. Other children are more easily distracted, flitting from one thing to another as they investigate their environment.

Persistence or attention span. Certain children persist in the face of obstacles, whereas others give up more easily when confronted with frustration. For example, does your toddler persist in trying to fit the peg in the hole or does he or she cry for help after a few unsuccessful tries?

Trait clusters Researchers have observed that certain temperament traits tend to cluster together to form general temperament styles. For example, some kids are naturally easygoing. They quickly develop regular sleeping and eating schedules, fuss infrequently, smile easily, and adapt well to new situations. Caring for these children can be smooth sailing oftentimes.

Other kids are naturally more shy or slow to warm up. These little ones may be less active and not too intense, approach new things slowly and with caution, and have a harder time transitioning from one activity or person to another. These children tend to be more serious.

Then there are children who keep you on your toes. They display fierce emotion, may have tons of energy, and approach things and people with either avid curiosity or determined caution. They become easily frustrated and have difficulty making changes. Caring for these feisty children is naturally more challenging than for more even-tempered ones.

Many children have mixed traits. Overall, their temperament may be moderate to easy to live with, but they may score high on intensity, activity or persistence, for instance.

Blending temperaments As a parent, you might find a particular temperament trait in your child to be pleasing, challenging or somewhere in between. A highly active child might be a blast on an outing but nonetheless a handful for a busy parent juggling multiple responsibilities. By keeping an open mind and staying flexible, you can engage positively with your child in ways that meet both of your needs.

Do you have an extremely focused or persistent son or daughter? Consider working together on a fun challenge, like building a colorful block tower or completing an age-appropriate puzzle. For a curious child who’s always on the move, visit a place you personally love, such as a scenic park. Play a simple game of hide-and-seek or I spy. Everyone has different talents and abilities. If your partner or another caregiver naturally fits better with some aspects of your child’s temperament, work as a team to help your child develop.

Getting to know your baby’s temperament better can also help to alleviate some worries you may have about your parenting. Is your baby high on the intensity and sensitivity scale? Those long bouts of crying might be a reflection of his or her temperament rather than anything you feel you’ve done or failed to do. Do you have more difficulty redirecting your son’s or daughter’s attention than other parents seem to? It might just be a sign of a powerful persistence on your baby’s part. Learning the ins and outs of your baby will help to guide you in his or her first year of life, and in the years to come.

You and your toddler

The foundation of love, security and trust that you’ve built for your baby takes on new importance as you enter the toddler stage. Parenting children this age is a balancing act. Toddlers crave both a close connection with a parent and greater independence. They’re realizing that they are their own person, with their own wants and needs — and they’re ready to take charge of their world. This eagerness to strike out on their own is tempered by their limitations and the dawning awareness that life doesn’t always go their way.

Toddlers can’t always move as swiftly and skillfully as they’d like, or clearly express their feelings or needs in words. They also are learning to deal with limits, compromise and disappointment. This can naturally lead to intense emotions, tantrums and misbehavior.

Children at this age benefit from a parent who understands and honors their natural desire for autonomy while also helping them learn how to cope with negative emotions, listen to directions and accept limits. By continuing to provide a secure relationship based on love, stability and consistency, you can help your toddler manage the ups and downs of this stage of life.

Little person, big emotions Your toddler’s putting together a puzzle but can’t seem to fit in the last piece. With each failed attempt to jam it into place, frustration mounts. Like an incoming tsunami, big emotions such as anger and frustration threaten to sweep in.

Toddlers want to do so much — and they want to do it all by themselves, right now. This is what they see you do every day. But they don’t yet know how to do it themselves. They also don’t know how to handle intense emotions and control their impulses.

That’s where you come in. You can teach your child how to accomplish tasks and how to remain calm by word and by example. A caring, compassionate parent can be an anchor in stormy seas. When your child is overcome with strong feelings, your calm presence can help to bring down the intensity level and teach your child how to understand and cope with his or her emotions.

To support and soothe your child in moments of frustration, sadness or disappointment, try these techniques:

Get close. Calmly and slowly move closer to your child so that he or she knows you’re there. Being nearby reassures your child that you’re present and available. You can also say something encouraging, such as “I’m here to help.”

Validate emotions. Let your child know that you’re listening and understanding what he or she is feeling. Label your toddler’s emotions. “You seem frustrated that the puzzle piece won’t fit.” You’re not only validating your child’s feelings but teaching how to identify strong emotions.

Soothe with a calming touch. Try rubbing your child’s back, patting his or her head, or offering a hug. A parent’s touch can be extremely comforting.

Offer guidance. If your child is frustrated with a specific task, gently intervene by providing some assistance. Avoid solving the problem for your child right away. A bit of guidance may be all that’s needed for him or her to complete the task. Or you can offer to work on the problem together.

When emotions explode into tantrums Sometimes, your child’s emotions are just too big for either of you to contain. Despite your best efforts to understand and soothe your child, there are times when a tantrum seems as unstoppable as a bullet train. What’s a parent to do?

First, it’s important to understand that temper tantrums are a normal way toddlers express frustration with the challenges of the moment. Your toddler might be upset about taking turns at the playground or having to share a toy. He or she could be struggling to transition from playtime to bedtime. Or perhaps the culprit is hunger, tiredness or jealousy. These everyday obstacles can be hard for a toddler to deal with, at times sparking a full-blown meltdown.

Experts recommend that parents avoid punishing a toddler’s tantrum. Instead, try these strategies to manage a child’s meltdown:

Keep your cool. If you react with anger or frustration, you’ll likely escalate the current level of stress you and your toddler are experiencing. Take some deep breaths to calm yourself. If that doesn’t work and you’re at home, leave the room for a minute to gather yourself. By staying calm, you’re modeling self-control in the face of powerful emotions. In time, your child will learn from your example and gain more control over his or her emotions too.

Try distraction. You may be able to redirect your child’s negative behavior with a positive distraction, especially with young toddlers. Try moving your toddler to another room or a different part of the playground. Offer a book or toy, or ask your child to join you in a different game or activity.

Give your child space. Sometimes a child needs time to calm down. If your toddler can’t stop crying, screaming or stomping, don’t continue to react to the behavior. Doing so may only increase the intensity of the tantrum. Instead ignore the behavior. If possible, place your child in a safe, quiet place. Having quiet alone time will help your toddler cool off and learn to soothe himself or herself. Check back with your child after several minutes or after he or she has calmed down.

Know when to step in. If your child starts hitting, kicking or throwing things at others, stop the harmful behavior. Move your toddler away from the situation. Calmly acknowledge his or her feelings but explain that the behavior is unacceptable. “It’s OK to be mad, but it’s not OK to hit.”

Stand firm. Avoid giving in to your toddler during a temper tantrum. Stick to the limit or rule you have set. If your refusal to buy your child ice cream set off the tantrum, don’t appease your child by buying the ice cream. Giving in sends the message that negative behavior works. You’ll also make it harder to enforce the rule or limit next time.

Reconnect. Once your child’s flood of emotion has passed, see if he or she is willing to accept some comfort. A kind word and some physical affection can help your child move on.

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Can tantrums be prevented?

There might be no foolproof way to prevent tantrums, but there’s plenty you can do to encourage good behavior in your toddler.

Be consistent. Establish a daily routine so that your child knows what to expect. Stick to the routine as much as possible, including nap time and bedtime. Set reasonable limits and follow them consistently.

Plan ahead. Run errands when your child isn’t likely to be hungry or tired. If you’re expecting to wait in line, pack a small toy or snack to occupy your child.

Pick your battles. If you say no to everything, your child is likely to get frustrated. Look for times when it’s OK to say yes.

Offer choices, when possible. Encourage your child’s independence by letting him or her pick out a pair of pajamas or a bedtime story. Offer a choice between two options. “Do you want strawberries or blueberries?”

Praise good behavior. Provide extra attention when your child behaves well. Give your child a hug or tell your child how proud you are when he or she follows directions or does something positive. “Great job coming right away.” “I love how you’re sharing with your brother.”

Avoid situations likely to trigger tantrums. Don’t give your child toys that are too advanced for him or her. If your child begs for toys or treats when you shop, steer clear of tempting areas. If your toddler acts up in restaurants, pack a picnic or eat at home. Save restaurants for date night.

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Setting limits

Walking, running and climbing toddlers can have a lot of fun exploring their world, but they can also get into a lot of trouble. Just because they can open cabinets, jump on beds and race down sidewalks doesn’t mean they know how to stay safe. Your toddler needs clear limits to keep out of danger and learn what behavior is and isn’t acceptable.

Now is a good time to establish family rules. Start with two or three core rules related to safety, such as “no hitting” or “no jumping on furniture.” Agree on these limits with your partner ahead of time and communicate them to other caregivers. That way, you’ll be on the same page and can enforce the rules consistently. If you’re co-parenting and your child has more than one home, it’s helpful to have consistent core rules at both homes.

You’ll also need to clearly express these expectations to your child so that he or she can successfully understand them. Be prepared to repeat the rules regularly to help your child remember and act on them. As your toddler begins to master a rule, you can add a new one to the list.

Rules that are age-appropriate, consistently enforced, and balanced with warmth and affection will help your child navigate life within your family and beyond the walls of your home.

Encouraging good behavior Part of a toddler’s job is to test the limits, including breaking rules or ignoring directions. But don’t assume that your child is being deliberately defiant when he or she disobeys you. Toddlers aren’t known for their spectacular listening skills. They’re still learning how to understand language, pay attention to what’s being said and think about their effect on others.

Positive behavior doesn’t happen overnight. It’s developed through hundreds of small exchanges with your child. These daily interactions teach him or her how to exert emotional self-control, make good choices and behave appropriately, even when you’re not around.

Whether you’re reinforcing a no-hitting rule or asking your child to put away a toy, try these positive techniques to communicate your expectations and encourage good behavior:

Get close. Whenever possible, get down on your child’s level and make eye contact. A gentle hand on the back or head can set a positive, caring tone.

Speak calmly. Get your child’s attention by using his or her name or a term of affection. Keep your voice neutral when reminding your child of a rule or asking your child to do something.

Keep it simple. Use simple, clear language and short sentences, such as “Please sit down” or “It’s time to get your coat.” Try to avoid negative statements such as “Don’t get out of your chair.”

Be patient. It might take your toddler a moment to focus on you and process what you’re saying. Give your child time to figure it out and transition to the new behavior.

Model the behavior. If your toddler doesn’t respond to a request or reminder, try modeling the behavior. Repeat your request, “Time to put away your toys.” Then put away one of the toys yourself and say, “Your turn.” Another technique is to say, “I’ll show you.” Then physically guide your child in the task or expected action.

Reward with praise. If your child does as you ask, offer warm praise. Let your child know how much you appreciate his or her efforts.

Playing with your toddler

Teaching your child how to manage emotions and follow rules is a lot easier when you’re doing it in the context of a secure, loving relationship. One way to keep your connection going strong is to spend one-on-one time with your son or daughter. After all, you are your toddler’s favorite playmate. The chance to hang out with Mommy or Daddy is the absolute best.

Aim for five to 15 minutes of uninterrupted, one-on-one playtime with your toddler each day. You may find it works best to schedule the playtime into your daily routine. But be flexible. Your time together will go better when your child’s rested and fed and you have the energy to devote to him or her.

Playtime with a parent has many important benefits for children. It serves a vital role in their social, emotional and cognitive development. It also improves their self-control and helps them form close relationships with other children and adults in their lives. Consider these suggestions for making the most out of playtime:

Put away devices. Spend this special time with your child without distractions or interruptions. Silence your phone, turn off the television, and set aside any other devices that could compete for your attention.

Let your child take the lead. This is a time when you can focus on what your child wants to do. Let your child set the agenda while gently discouraging activities that are aggressive, competitive, frustrating or destructive. Do things that allow you to be together in a relaxed and happy manner.

Show that you’re fully engaged. If your child picks up a doll and says “doll,” repeat the word and build on the conversation. “Doll. You’re hugging the doll.” You can also describe your child’s actions out loud as he or she plays next to you. “You’re stacking red and blue blocks. Now you’re knocking them down.”

Mirror your child. Another way to connect with your child is to imitate what your child is doing. If your child is moving a train on the tracks and making tooting sounds, grab a train and do the same. If he or she gets up to dance to some music, mimic his or her movements.

Describe emotions. Label the emotions you’re observing with phrases like “You look happy.” You can label your feelings too. “I’m excited to play this game.” These statements can help your toddler learn to identify and express feelings.

Enjoy yourself. Take time to notice and think about how amazing your child is. Show your enjoyment with positive words, an enthusiastic voice and animated facial expressions. Take time for a hug and a kiss. Savor these special moments together.

Part 2 Health and safety

CHAPTER 12 Finding the right medical provider

During your baby’s first year, you and your baby will likely spend a lot of time with his or her medical provider. Beyond the recommended checkups every couple of months, it’s likely that your son or daughter will get his or her first illness at some point this year. In addition, you may have questions about newborn care or your baby’s health and development.

In the second and third years, you’ll see your baby’s medical provider less often than in the first year. But there’ll still be plenty of occasions to visit between scheduled vaccinations and well-child checkups, and the ever-present colds and other viruses children so often get.

While finding a medical provider for your baby might sound simple, it’s worth the effort to find an individual who can best meet your baby’s and family’s needs. Determining what you’re looking for in a provider for your child can help you find a pediatric care professional whom you feel comfortable with and whom you can build a good relationship with as your child grows and matures.

Getting started

If you haven’t already chosen a medical provider for your baby, now is the time to do so. If possible, you want to choose your baby’s medical provider before your baby is born — such as during your third trimester. Settling on a provider before your baby is born will make it easier for you to arrange your newborn’s first checkup in the hectic first few days after his or her arrival. Visiting with your baby’s provider before your baby is born will also give you a chance to ask questions, talk about any problems during your pregnancy, discuss the practice’s policies and fill out any necessary insurance forms without the distraction of having your new baby with you. It’s also comforting to know that you already have a trusted source you can call with any questions you might have regarding newborn care — and most first-time parents have lots of questions!

In addition, if you choose your baby’s medical provider before your son or daughter is born and you deliver your baby at a hospital where the provider works, you might be able to have the provider examine your baby at the hospital. Don’t worry, though, if that’s not possible. Your baby will still be seen at the hospital by qualified staff.

If you don’t have a specific medical provider in mind, start by asking for recommendations from trusted family members, friends or co-workers who have children. Your own medical provider might be a good referral source, too. You may also be able to find information about pediatric providers by calling a nearby hospital or other community health resources.

Keep in mind that your health insurance company may require you to choose from its approved network of medical providers. Check to see if the company provides information about the providers in the network to help you make your decision.

Whatever you do, don’t put off finding a medical provider for your baby. Even if you’re about to move or change insurance providers, do your best to find a medical provider as soon as possible. Waiting until your baby becomes sick can be stressful for you and might delay your baby’s care. Establishing a relationship with a provider for your baby will also make it easier for you to schedule regular visits and keep your child’s vaccinations up to date.

Medical provider options

When it comes to choosing a medical provider for your baby, you have options. Many types of medical personnel treat babies and children, including:

Pediatricians Many parents choose a pediatrician to be the medical provider for their children because pediatricians specialize in the care of children from infancy through adolescence. After medical school, pediatricians go through a three-year residency program. Some pediatricians receive further training in subspecialties such as the care of sick and premature newborns (neonatology), children’s heart conditions (pediatric cardiology) or children’s skin issues (pediatric dermatology). If your baby ever needs to be treated by a subspecialist, his or her regular provider can provide a referral.

Family physicians Family physicians provide health care to people of all ages, including babies. They’re trained in adult and pediatric medicine. A family physician can see your child from infancy all the way through adulthood. Family physicians take care of most medical problems. Also, if the rest of your family sees the same provider, he or she will gain an overall health perspective of your family. If you already have a family doctor you trust, ask whether he or she sees infants.

Midlevel providers Midlevel providers include nurse practitioners and physician assistants.

Nurse practitioners are registered nurses who have advanced training in a specialized area of medicine, such as pediatrics or family health. After nursing school, a nurse practitioner must go through a formal education program in his or her specialty field. A pediatric nurse practitioner focuses on caring for infants, children and teens. Family nurse practitioners often see all family members, including children.

Physician assistants are medical professionals who are trained and licensed to diagnose illness, develop and manage treatment plans, and prescribe medications. Physician assistants work in all areas of medicine, including pediatrics and family medicine.

Nurse practitioners and physician assistants often work with or under the supervision of a doctor but may practice independently, depending on state guidelines, and may serve as your primary medical provider.

Factors to consider

Before you choose a medical provider for your child, think about what you’re looking for in a provider. For example:

Your needs and preferences Would you prefer your child to see the same medical provider who takes care of the rest of your family’s health or a provider who specializes in pediatrics? Would you like a provider who is older and may have more experience or an individual who is younger and also may have young children at home? For parents who have children with complex care needs, a provider with the relevant experience and training may be the best fit.

Cost Do you need to find a medical provider from among your insurance company’s list of approved providers?

Location, accessibility and hours Is the medical provider’s office in a convenient location for you? Would you prefer an office that has extended hours? Is it important for you to be able to contact the provider at night or on the weekends or by email? Would you like your child’s provider to have privileges at a particular hospital? Would you prefer that he or she have an office that has separate waiting rooms for children who are well and those who are sick?

Evaluating your options

Once you’ve thought about what you’re looking for and compiled the names of some possible medical providers, call each provider’s office to confirm that he or she is accepting new patients. If necessary, double-check that he or she works with your insurance company. This information may also be available on the provider’s website.

Next, call to schedule an appointment with the provider. Try to schedule the visit at a time when both you and your partner can attend, so you can both ask questions. If you’re given a recommendation by friends or family, you may be able to get some basic information from them before talking to the medical provider. For example, you might ask about:

Bedside manner. Does the provider interact well with both adults and children? Does the child of your friend or relative like the provider?

Office atmosphere. Is the office staff helpful? How do staff members manage phone calls, particularly when it comes to emergencies? Is it difficult to make an appointment when a child is sick? Is there generally a long office wait before seeing the provider?

Issues to consider During your visit with a new medical provider, bring a list of questions or just have an informal chat with the provider. Don’t feel embarrassed about asking questions that might help you get to know the person and make the right decision for your family.

Training and style How long has the individual been caring for children? At what hospitals does the medical provider have privileges? Does he or she have any particular area of expertise or interest? Does the provider listen to your questions and answer them? Does he or she appear interested in your concerns?

Knowledge Does the medical provider seem to know about medical advances, and does he or she offer helpful advice?

Accessibility and referrals How does the medical provider handle emergencies, including those that occur after hours? Does the office have guidelines for what kind of questions can be resolved with a phone call or email and what requires a visit? Is the provider part of a group practice? If so, will you be able to request an appointment with a specific provider? If you choose a provider who is part of a group practice, make sure you feel comfortable with other members of the practice who might treat your baby.

Ask the medical provider about his or her referral process for specialists. Some providers may be limited to referring your child to someone who is practicing in the same health care network or at certain medical institutions.

Making your decision After meeting with a medical provider, consider his or her overall approach to health care and your interactions with the staff. Most important, would you trust this person to provide care for your child? Trust your instincts. If you don’t feel comfortable, consider another provider.

Once you’ve selected your child’s medical provider, you may have a number of issues to discuss. You may want to get the provider’s input on topics such as breast-feeding, circumcision or child care. If you feel it would be helpful, schedule an appointment to discuss these issues.

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Keep medical information handy

Write down key information about your child’s medical provider, such as his or her contact information, the office’s hours and location, and any policies for making appointments. Keep this information in a place that will be easy for you and anyone caring for your child to access. Also, create a file or notebook or an electronic record for your child’s medical information. Include information such as his or her vaccination record, measurements, and any prescriptions or lab test results.

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A team approach

If you’re ever unhappy with the care your child receives, talk to the medical provider about your concerns. Chances are, once the issue is discussed, you can come to a resolution that is mutually agreeable. If you can’t resolve the problem, you might consider seeking another provider for your child.

In the coming months, your child’s medical provider will play an important role. His or her guidance can help you make healthy choices for your baby, as well as determine what to do if your son or daughter has a health problem. While you may have certain viewpoints, don’t forget that your provider is trained in infant care and likely has considerable experience. It’s important that the two of you work together as a team to stay on top of your child’s health.

CHAPTER 13 Checkups

Frequent checkups with a medical provider are an important part of your baby’s first few years. These checkups — often called well-child visits — are a way for you and your child’s medical provider to keep tabs on your child’s health and development, as well as spot any potential problems. Well-child visits also give you a chance to discuss any questions or concerns you might have and get advice from a trusted source on how to provide the best possible care for your child.

At first, well-child visits aren’t always easy on you or your baby. Your baby might not like getting undressed and measured — and then there are vaccinations. Rest assured, however, that visiting the medical provider will soon become a part of your and your baby’s routine and, with time, the visits will become less stressful and more enjoyable as your baby becomes familiar with exploring the office’s toy selection, and you look forward to finding out just how big your baby is getting. You’ll also find the provider’s guidance invaluable in the months and years ahead.

Checkup schedule

Most newborns have their first checkups within 48 to 72 hours of being discharged from the hospital. This timeline is particularly important for breast-fed babies, who need to have their feeding, weight gain and skin color — in case of jaundice — evaluated. During your baby’s first two years of life, he or she should see a medical provider at ages:

2 months

4 months

6 months

9 months

12 months

15 months

18 months

24 months

After age 2, most children move to a yearly exam schedule. Some children need more-frequent visits. Plus, you can make an appointment for your child to see a medical provider any time your child is sick or you’re concerned about his or her health and development.

If possible, both parents should try to attend baby’s first few checkups together. This will give you and your partner a chance to get to know the medical provider and ask basic questions. If it’s just you, ask a family member or friend to help you navigate these early visits. Remembering your questions and listening to your provider’s advice can be difficult when you’re also trying to undress or calm a fussy baby. An extra set of hands may also prove useful during your first few outings.

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Tips for scheduling appointments

When scheduling appointments, consider avoiding the medical provider’s busiest times. You might have the best chance of getting in and out of the provider’s office quickly if you ask for the first appointment of the day or choose a time right after lunch. On the other hand, if you think you’d like to have extra time to speak with your child’s provider, you might ask for an appointment at the end of the day. Also, consider avoiding appointments on Mondays and Fridays, as well as on holidays when the provider’s office is open. These days tend to be busier than others. The end of summer vacation also tends to be a busy time for medical providers, since many children are required to have physicals before the start of the new school year.

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What to expect at a well-child visit

Early on, the medical provider is likely to pay extra attention to taking measurements of height, weight and head circumference and doing a thorough physical exam. Over time, as the provider gets to know you and your child, things will likely go a little faster and exams may become a little more routine. The benefit of seeing your child’s provider regularly is that each visit adds critical information to your child’s health history. Over time, you and the provider will get a good idea of your child’s overall health and development.

In general, the provider will be more attentive to your child’s pattern of growth over time, rather than to specific one-time measurements. Typically what you’ll see is a smooth curve that arcs upward as the years go by. Regularly reviewing your child’s growth chart can also alert you and the provider to unexpected delays in growth or changes in weight that may suggest the need for additional monitoring. You can see examples of growth charts here and here.

Each medical provider does things a bit differently, but here’s what’s generally on the agenda during a well-child exam.

Body measurements Checkups usually begin with measurements. During first-year visits, a nurse or your baby’s medical provider will measure and record your baby’s length, head circumference and weight. Once your child is upright and walking, height measurements generally replace length measurements. Starting at age 2, head circumference measurements are no longer routine but your child’s provider may start measuring your child’s body mass index (BMI). This is a screening tool based on population averages that uses weight in relation to height to estimate whether body size falls into categories of underweight, overweight or obese. BMI for children is expressed in percentiles, also called BMI-for-age percentiles.

Your child’s measurements will be plotted on his or her growth chart. This will help you and the provider see how your child’s size compares with that of other children the same age. Try not to fixate on the percentages too much, though. All kids grow and develop at different rates. In addition, babies who take breast milk gain weight at a different rate than do babies who are formula-fed.

Keep in mind that a child who’s in the 95th percentile for height and weight isn’t necessarily healthier than a child who’s in the fifth percentile. What’s most important is steady growth from one visit to the next. If you have questions or concerns about your child’s growth rate, discuss them with your child’s provider.

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Premature babies

If your baby was born prematurely, his or her growth and development will be measured using his or her corrected age — your baby’s age in weeks minus the number of weeks he or she was premature. For example, if your baby was born eight weeks early, at age 6 months, or 24 weeks, your baby’s corrected age is 4 months, or 16 weeks. This adjustment will be necessary until your baby reaches age 2 or so. Vaccinations, however, will be given to your baby according to his or her chronological age.

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Physical exam Your child’s medical provider will give your child a thorough physical exam and check his or her reflexes and muscle tone. Be sure to mention any concerns you have or specific areas you want the doctor to check out. The more information you can provide about your child’s health, the better. Here are the basics of what providers commonly check for during an exam:

Head In the beginning, your child’s medical provider will likely check the soft spots (fontanels) on your baby’s head. These gaps between the skull bones give your baby’s brain plenty of room to grow in the coming months. They’re safe to touch and typically disappear within two years, when the skull bones fuse together.

The medical provider may also check baby’s head for flat spots. A baby’s skull is soft and made up of several movable plates. If his or her head is left in the same position for long periods of time, the skull plates might move in a way that creates a flat spot. If flat spots are a concern, continue to place your baby on his or her back to sleep. However, your baby’s provider may recommend alternating the direction your baby’s head faces in the crib, giving your baby more tummy time while he or she is awake, and limiting the amount of time your baby spends in a car seat outside of the car. If these types of changes are made, the flattening typically improves in two to three months. Occasionally, babies need to wear a positioning helmet to improve head shape.

Ears Using an instrument called an otoscope, the medical provider can see in your child’s ears to check for fluid or infection in the ears. The medical provider may observe your child’s response to various sounds, including your voice. Be sure to tell the provider if you have any concerns about your son’s or daughter’s ability to hear or if there’s a history of childhood deafness in your family. Unless there’s cause for concern, a formal hearing evaluation isn’t usually needed at a well-child exam.

Eyes Your child’s medical provider may use a flashlight to catch your child’s attention and then track his or her eye movements. The provider may also check for blocked tear ducts and eye discharge and look inside your child’s eyes with a lighted instrument called an ophthalmoscope. Be sure to tell the provider if you’ve noticed that your child is having any unusual eye movements, especially if they continue beyond the first few months of life.

Mouth A look inside your baby’s mouth may reveal signs of oral thrush, a common, and easily treated, yeast infection. The medical provider might also check your baby’s mouth for signs of tongue-tie (ankyloglossia), a condition that affects the tongue’s range of motion and can interfere with a baby’s oral development as well as his or her ability to breast-feed.

As your baby gets older, the medical provider may ask whether your child has started to drool more than usual, become fussy or irritable, or lost his or her appetite. These are often the first signs of teething. Your child’s provider will check for emerging teeth. After teeth erupt, the provider will likely discuss with you the importance of regularly cleaning your baby’s new teeth to prevent decay. Your provider may also recommend making an appointment for your baby with a pediatric or family dentist.

Skin Various skin conditions may be identified during the exam, including birthmarks, rashes, and jaundice, a yellowish discoloration of the skin and eyes. Mild jaundice that develops soon after birth often disappears on its own within a week or two. Cases that are more severe may need treatment (see this discussion).

Heart and lungs Using a stethoscope, your child’s medical provider can listen to your child’s heart and lungs to check for abnormal heart sounds or rhythms or breathing difficulties.

Abdomen, hips and legs By gently pressing a child’s abdomen, a medical provider can detect tenderness, enlarged organs, or an umbilical hernia, which occurs when a bit of intestine or fatty tissue near the navel breaks through the muscular wall of the abdomen. Most umbilical hernias heal by the toddler years without intervention. The provider may also move your child’s legs to check for dislocation or other problems with the hip joints, such as dysplasia of the hip joint.

Genitalia Your child’s medical provider will likely inspect your son’s or daughter’s genitalia for tenderness, lumps or other signs of infection. The provider may also check for an inguinal hernia, which results from a weakness in the abdominal wall. For girls, the doctor may ask about vaginal discharge. For boys, the provider will make sure a circumcised penis is healing well during early visits. The provider may also check to see that both testes have descended into the scrotum and that there’s no fluid-filled sac around the testes, a condition called hydrocele.

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Failure to thrive

Failure to thrive is a term — not a disease — that’s used to describe a baby or toddler who isn’t growing or developing at an appropriate rate. The term might be used when a child’s weight or height appears below the fifth percentile on a growth chart or if a child’s growth rate is lower than expected. Failure to thrive can be caused by multiple issues, such as an underlying health problem or environmental problems. If your child’s medical provider is concerned about your baby’s growth and development, he or she may ask you questions about your pregnancy and delivery, your baby’s medical and dietary history, and your family history. With early intervention, many children respond well and catch up in their growth and development.

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Nutrition Your child’s medical provider will likely ask you about your child’s eating habits. If you’re breastfeeding, the provider may want to know how often you’re feeding your baby during the day and night and whether you’re having any problems. If you’re pumping, the provider may offer suggestions for managing pumping frequency and storing breast milk. If you’re formula-feeding, the provider will likely want to know how often you feed and how many ounces of formula your baby takes at each feeding. In addition, the provider may discuss with you your baby’s need for vitamin D and iron supplements.

Although breast milk or formula will be the main part of your baby’s diet throughout the first year, eventually you’ll want to discuss introducing your baby to solid foods. A medical provider can offer advice on the best foods to start with, the importance of making healthy choices and how to feed your baby. Once your baby starts eating solid foods, the provider may check to see if you’re having any problems feeding your child or if your child has had any allergic reactions.

As your son or daughter gets older, discussion topics may include drinking from a sippy cup and when it’s OK for your child to start to use utensils to feed himself or herself. You might also discuss weaning your baby from the bottle by age 1, when and how to start giving your baby whole cow’s milk, and any concerns about picky eating in your toddler (see Chapter 3 and Chapter 4).

Bowel and bladder function In the first few visits, your child’s medical provider will likely also ask how many wet diapers and bowel movements your baby produces on a daily basis. This information offers clues as to whether your baby is getting enough to eat.

As your child gets older and you move closer to toilet training, usually between ages 2 and 3 years, your child’s provider can offer advice on when might be the best time for your child to start. The provider may also have some tips to help you and your child transition successfully from diapers to toilet (see Chapter 6).

A well-child visit is also an opportunity to discuss any concerns you might have about your child’s bowel functions and any irregularities, such as frequent loose stool or constipation.

Sleeping status Your child’s medical provider may ask you questions about your child’s sleep habits, such as your regular bedtime routine and how many hours your child is sleeping during the day and night. Don’t hesitate to discuss any concerns you may have about your child’s sleep, such as getting your baby to sleep through the night, when it’s OK to drop naps, switching your toddler from a crib to a bed or getting your child to stay in bed (see Chapter 9). Your child’s provider may also help you figure out how to find rest for yourself, especially in the early baby months.

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Developmental delays

If your child doesn’t reach a specific milestone by an expected age, he or she may have a developmental delay. Delays can occur in one or several areas of development. Your child’s medical provider might recommend certain tests to check for underlying problems. You may also meet with a specialist, such as a developmental pediatrician. If your baby or toddler has a developmental delay, the provider can recommend a type of developmental therapy that may help your child make progress. Most children are eligible to receive a wide range of therapies in their homes, often at no cost. Early identification of a developmental delay is important because it will enable you to get your child the help he or she needs as soon as possible. For more information on developmental delays, see Chapter 44.

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Development Your child’s development is important, too. The medical provider will monitor your child’s development in the following five main areas. (For a list of developmental milestones by age, see chapters in Part 3 of this book.)

Gross motor skills These skills, such as sitting, walking and climbing, involve the movement of large muscles. Your child’s medical provider may ask you how well your baby can control his or her head. Is your baby attempting to roll over? Is your baby trying to sit on his or her own? Is your child starting to walk or throw a ball? Can your toddler walk up and down steps?

Fine motor skills These skills involve the use of small muscles in the hand. Does your baby reach for objects and bring them to his or her mouth? Is your baby using individual fingers to pick up small objects? Does your child use a cup? Can your toddler draw a straight line?

Personal and social skills These skills enable a child to interact and respond to his or her surroundings. Your child’s medical provider may ask if your baby is smiling. Does your baby relate to you with joy and enthusiasm? Does he or she play peekaboo? Is your toddler starting to explore on his or her own or show signs of independence?

Language skills These skills include hearing, understanding and use of language. The medical provider may ask if your baby turns his or her head toward voices or other sounds. Does your baby laugh? Is he or she responding to his or her name? Is your toddler starting to say no or point to named objects in a book?

Cognitive skills These skills allow a child to think, reason, solve problems and understand his or her surroundings. Your child’s medical provider might ask if your baby can bang together two cubes or search for a toy after seeing you hide it. Can your child point to a body part or follow simple one-step instructions?

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Keep a record

Consider starting a file, notebook or electronic medical record for your child’s medical information, such as his or her vaccination record, measurements, and any prescriptions or lab test results. Taking time to organize your child’s health history will give you a chance to review any information the medical provider gives you. It’s also a good habit to start early because when your child enters preschool or kindergarten, you’ll likely be required to provide certain medical details. Plus, your notes about your baby’s growth make for a cherished keepsake.

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Behavior Your child’s medical provider may ask you questions about your child’s behavior or whether your child has started throwing tantrums or misbehaving. Explain what you’ve noticed so far and anything that seems out of the ordinary to you or is causing you concern. Your child’s provider can help reassure you about what’s normal and how to handle your child’s budding sense of autonomy.

As your baby gets older and begins exploring everything in sight, you may find yourself setting greater limits. Your toddler also might get frustrated as his or her growing desire for independence conflicts with his or her limited vocabulary and physical abilities. Your child’s provider might discuss the importance of creating a safe home environment and predictable routine, as well as how to handle your toddler’s meltdowns without having one yourself (see Chapter 11).

Vaccinations Your baby will need a number of vaccinations during his or her first years. The medical provider or a nurse will explain to you how to hold your baby as he or she is given each shot. Be prepared for possible tears. Keep in mind, however, that the pain caused by a shot is typically short-lived but the benefits are long lasting. Keeping up with vaccines, including flu shots every year, is important throughout your child’s life. Chapter 14 provides more detailed information on the vaccinations your son or daughter will receive during the first 36 months.

Safety Your child’s medical provider may talk to you about safety issues, such as the importance of placing your baby to sleep on his or her back and using a rear-facing infant car seat as long as possible. As your child becomes more mobile, the provider may give you tips for baby-proofing your home. He or she may discuss how to prevent falls, the importance of water safety and how to prevent infections by washing hands.

Questions and concerns

During your son’s or daughter’s checkups, it’s likely that you’ll have questions, too. Ask away! Nothing is too trivial when it comes to caring for your baby or toddler. Write down questions as they arise between appointments so that you’ll be less likely to forget them when you’re at your child’s checkup. Feel free to ask your child’s medical provider for advice on topics that aren’t medically related, too. For example, if you’re looking for child care, ask the provider if he or she has any advice.

Also, don’t forget your own health. If you’re feeling depressed, stressed-out, run-down or overwhelmed, describe what’s happening. Your child’s provider is there to help you, too.

Before you leave the medical provider’s office, make sure you know when to schedule your child’s next appointment. If possible, set the next appointment before you leave the provider’s office. If you don’t already know, ask how to reach your child’s provider in between appointments. You might also ask if the provider has a 24-hour nurse information service. Knowing that help is available when you need it can offer peace of mind.

CHAPTER 14 Vaccinations

Before you met your baby, did you think about his or her health? Chances are, you did. Think back to your pregnancy — the things you did to keep yourself healthy and to prevent problems from occurring, so the baby inside you could grow and develop.

Prevention is crucial to good health. It’s far better to prevent a disease than to treat it. And one of the best ways to protect your family from many diseases is to get vaccinated. Immunization is the best line of defense against diseases such as tetanus, hepatitis, influenza and many other infections.

Thanks to vaccines, many infectious diseases that were once common in the United States are now rare or nonexistent. As a parent, you no longer have to fear that your child will die of or become disabled by smallpox or tetanus. And you no longer have to keep your children away from water fountains and swimming pools to avoid getting polio.

Truth be told, vaccinations aren’t exactly fun — for children or parents. It’s hard to see your little one cry after receiving a series of shots. But as much as you want to shield your child from discomfort and tears, keep in mind that the discomfort is temporary and very minor compared with the potential discomfort and harm of a serious illness.

Vaccinations prevent millions of deaths worldwide each year. However, despite the availability of vaccines, many people remain underimmunized. One reason is that some people have concerns about the safety and risks of vaccines. In addition, some people feel it’s dangerous to give more than one vaccine at a time, and others feel certain vaccines are no longer needed. These concerns are often the result of incorrect information.

How vaccines work

Every day, the human body is exposed to bacteria, viruses and other germs. When a disease-causing microorganism enters your (or your child’s) body, your immune system mounts a defense, producing proteins called antibodies to fight off the harmful germ. The goal of your immune system is to neutralize or destroy the germ, rendering it harmless and preventing you from getting sick.

One way the body’s immune system fights off harmful germs is through what’s called post-exposure immunity. After you’ve been infected with a certain organism, your immune system puts into play a complex array of defenses to prevent you from getting sick again from that type of virus or bacterium.

Another way to get the immune system to fight bad germs is through vaccines. With this method, a person becomes immune without getting sick. A vaccine contains just enough of a killed or weakened form or derivative of the infectious germ to trigger your immune system’s infection-fighting ability but without the harmful effects of a fullblown infection. When given to you before you get infected, the vaccine makes your body think that it’s being invaded by a specific organism. Your immune system begins building defenses against that organism.

If you’re exposed to a disease for which you’ve been vaccinated, the invading germs are met by antibodies prepared to defeat them. And vaccines can be given without the risk of the serious effects of disease.

Sometimes it takes several doses of a vaccine for a full immune response — this is the case for many childhood vaccines. Some people fail to build immunity to the first doses of a vaccine, but they often respond to later doses. In addition, the immunity provided by some vaccines, such as tetanus and pertussis, isn’t lifelong. Because the immune response may decrease over time, you may need another dose of a vaccine (booster) to restore or increase your immunity. And for some diseases, the organism evolves, and a new vaccine is needed against the new form. This is the case with the annual flu (influenza) shot.

Why get vaccinated?

Because many vaccine-preventable diseases are now uncommon in the United States, some people feel less urgency about getting themselves or their children immunized. If you wonder if it’s necessary to vaccinate your family and to keep everyone up to date with vaccinations, the answer is yes. Many infectious diseases that have virtually disappeared in the United States can reappear quickly. The germs that cause the diseases still exist and can be acquired and spread by people who aren’t protected by immunization.

As travelers unknowingly carry disease from one country to another, a new outbreak may be only a plane trip away. From a single entry point, an infectious disease can spread quickly among unprotected individuals. Outbreaks of mumps and measles have repeatedly occurred in just this way in the United States in the past few years.

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Well-child vaccination schedule

The following chart lists the recommended routine childhood vaccinations. Vaccine guidelines for children change fairly often as new vaccines are developed, recommendations on timing and dosages are revised, and more combination vaccines are created. Check with your child’s medical provider to make sure that your child is up to date on his or her vaccinations. You can also view current vaccination schedules on the website for the Centers for Disease Control and Prevention (CDC).

Health insurance usually covers most of the cost of vaccinations. A federal program called Vaccines for Children provides free vaccines to children who lack health insurance coverage and to other specific groups of children. Ask your medical provider about it.

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Vaccine safety

As a new parent, you might have some misgivings about giving your child vaccines. You don’t want to do anything to harm your child. And while you know that vaccinations are important, you’ve also heard that they could be harmful, too — possibly causing side effects. You may worry after hearing or seeing reports about a severe “reaction” that occurs shortly after a child’s vaccination visit that’s said to be a side effect or complication of the vaccine. Unfounded stories such as these frequently circulate on the internet.

The fact is, vaccines are extremely safe. Before they can be used, they must meet strict safety standards set by the Food and Drug Administration (FDA). Meeting these standards requires a lengthy development process lasting 10 to 14 years, from exploratory work in laboratories through years of testing in humans, all before being licensed. These studies, unlike drug studies, involve tens of thousands of individuals.

Once vaccines are licensed and made available to the general public, the FDA and the Centers for Disease Control and Prevention (CDC) continue to monitor their safety. Furthermore, vaccines are subject to ongoing research, review and refinement by doctors, scientists and public health officials. Those who provide vaccines, such as medical providers and nurses, must report any side effects they observe to the FDA and CDC.

The bottom line is, your child’s chances of being harmed by an infectious illness are far greater than his or her chances of being harmed by a vaccine used to prevent that disease.

Vaccine additives In addition to the killed or weakened microorganisms that make up vaccines, small amounts of other substances may be added to a vaccine to enhance the immune response, prevent contamination, and stabilize the vaccine against temperature variations and other conditions. Vaccines may also contain small amounts of materials used in the manufacturing process, such as gelatin.

One additive that has received much attention is a preservative called thimerosal, which is a derivative of mercury. Thimerosal has been used in medical products since the 1930s and in small amounts in some vaccines to prevent bacterial contamination. No evidence shows that children have been harmed by its use in vaccines. Nonetheless, childhood vaccines are now made without thimerosal or with only trace amounts.

Vaccines and autism Many parents have heard claims that vaccines cause autism. The most common and specific claims are that autism stems from the measles, mumps and rubella (MMR) vaccine or from vaccines that contain the preservative thimerosal. Studies conducted around the world have shown without a doubt that the MMR vaccine doesn’t cause autism. In the meantime, researchers have learned a great deal about autism itself. For example, it’s now known that the signs of autism appear well before the timing of the MMR vaccine. And several causes of autism have been identified — some are genetic in nature; others act early on in pregnancy. Unfortunately, the claims about autism and the MMR vaccine persist, and they’ve led some parents to refuse to vaccinate their children.

Some people also worry that receiving too many vaccines early in life can overwhelm a baby’s immune system and that this might somehow harm the baby. Such reasoning doesn’t fit with what we know about the remarkable capacity of the immune system. From the moment a child is born, his or her immune system begins battling microorganisms in the form of bacteria, viruses and fungi on a daily basis. A system that effectively copes with exposure to countless everyday bacteria can easily withstand exposure to the antigens in vaccines.

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Alternative vaccine schedules

Some people tout what they call alternative vaccine schedules that delay shots or space them further apart. For parents who may be skittish about giving their children so many shots, the idea of the alternative schedule is to separate out the vaccines and give them over a longer period of time.

But health experts, including those at Mayo Clinic, say that these approaches leave too many kids unprotected for too long, and they aren’t backed up by science. Alternative schedules are unstudied, and they can be dangerous because of the increased risks they pose. Skipping or spacing out vaccines dramatically increases a child’s risk of illness.

If you’re concerned, the best advice is to talk with your child’s medical provider to make sure that you’re getting the correct information.

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Childhood vaccinations

Fortunately, many of the most familiar diseases of childhood — chickenpox, measles and mumps — can be prevented through vaccination (see vaccination schedule here).

Chickenpox Chickenpox (varicella) is a common childhood disease. It can also affect adults who aren’t immune. Furthermore, chickenpox can lead to recurrences of viral inflammation later in life called shingles (herpes zoster).

The chickenpox virus is spread by breathing in infected droplets from the air or by direct contact with fluid from the rash, which is the best-known sign of the disease. The rash begins as superficial spots on the face, chest, back and other areas of the body. The spots quickly fill with a clear fluid, rupture and turn crusty.

Recommendation Children should receive one dose of the chickenpox (varicella) vaccine between 12 and 15 months of age and a second dose between 4 and 6 years of age.

Diphtheria Diphtheria is a bacterial infection that spreads from person to person through airborne droplets. It causes a thick covering (membrane) to develop in the back of the throat and can lead to severe breathing problems, paralysis, heart failure and death. The disease is now rare in the United States.

Recommendation The diphtheria vaccine typically is given in combination with the tetanus and pertussis vaccines (a DTaP shot). Vaccination should begin when a child reaches 2 months of age. A child should receive five shots in the first six years of life, a booster shot of tetanus, diphtheria and pertussis (Tdap) at age 11 or 12, and then a tetanus and diphtheria (Td) booster every 10 years after.

German measles German measles (rubella) is a contagious disease that spreads through the air from people sick with the infection. It’s typically a mild infection that causes a rash and slight fever. However, women who develop rubella during pregnancy may have miscarriages, or the babies could be born with birth defects.

Recommendation Two doses of the combination measles, mumps and rubella (MMR) vaccine are given, the first at ages 12 to 15 months and the second at 4 to 6 years.

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Comforting baby during and after vaccination

It can be difficult to see your baby cry or be uncomfortable as a result of a vaccination. Try to keep in mind that protecting your baby against serious disease is worth the short-term discomfort.

During each injection, hold your baby close. Offer a pacifier, blanket or other comfort object. Your calm presence can help your baby feel secure.

Your baby may experience mild side effects from the vaccines, such as redness, pain or swelling at the injection site. Ask the doctor what to expect. If your baby develops discomfort from fever or soreness at the injection site, you may give your baby acetaminophen (Tylenol, others). If your child is 6 months or older, you can use ibuprofen (Advil, Motrin, others). Follow the label instructions for the correct dose (see dosage charts here).

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Hib disease Haemophilus influenzae type b (Hib) disease is primarily a childhood illness, but it can also affect some adults. It’s caused by bacteria that spread from person to person through the air. This infection can cause serious and potentially fatal problems, including meningitis, sepsis, severe swelling in the throat, and infections of the blood, joints, bones and membranes around the heart (pericarditis).

Recommendation The Hib vaccine is given to children at ages 2 months, 4 months, 6 months, and 12 to 15 months.

Hepatitis A Hepatitis A is a highly contagious liver disease caused by the hepatitis A virus. The virus is found in an infected person’s stool. It’s usually spread by eating or drinking contaminated food or water or by close personal contact.

Recommendation The two-dose series of hepatitis A vaccine is recommended for all children in the U.S. The first dose is generally given at 12 to 23 months and the second dose six to 18 months later.

Hepatitis B The hepatitis B virus can cause a short-term (acute) illness marked by loss of appetite, fatigue, diarrhea, vomiting, jaundice, and pain in muscles, joints and the abdomen. More rarely it can lead to long-term (chronic) liver damage (cirrhosis) or liver cancer.

The virus is spread through contact with the blood or other body fluids of an infected person. This can happen by sharing personal items, such as toothbrushes or razors, or having unprotected sex. It can also happen during birth, when the virus passes from an infected mother to her baby.

Recommendation The hepatitis B vaccine is given to children in three doses — at birth, at least one month later (1 to 2 months of age) and then at 6 to 18 months. Most people who are vaccinated with hepatitis B vaccine are immune for life.

Flu (influenza) Influenza is a viral infection that sickens millions of people each year and can cause serious complications, especially in children and older adults. Flu vaccines are designed to protect against strains of flu virus expected to be in circulation during the fall and winter of that year. Flu season varies across the U.S. It’s best to get vaccinated by the end of October, so that you and your child receive protection before the start of the flu season.

Recommendation The influenza vaccine is recommended yearly for infants and children, beginning at age 6 months. Children require two doses of the flu vaccine the first time they receive it. That’s because they don’t develop an adequate antibody level the first time they get the vaccine. Antibodies help fight the virus if it enters your child’s system.

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Missing a vaccination

If your baby falls behind on his or her vaccinations, catch-up vaccination schedules can address the problem. Make an appointment with your child’s medical provider to determine the vaccinations your baby needs and when he or she should receive them.

An interruption in the schedule doesn’t require a child to start a series over or redo any doses. But until your child receives the entire vaccine series, he or she won’t have maximum possible protection against diseases.

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Measles Measles (rubeola) is primarily a childhood illness, although adults also are susceptible. It’s the most contagious human virus known. The measles virus is transmitted through the air in droplets, such as from a sneeze.

Signs and symptoms include rash, fever, cough, sneezing, runny nose, eye irritation and a sore throat. Measles can lead to an ear infection, pneumonia, seizures, brain damage and even death.

Recommendation Typically, two doses of a combined measles, mumps and rubella (MMR) vaccine are given, beginning at ages 12 to 15 months and then again at 4 to 6 years.

Mumps Mumps is a childhood disease that can also occur in adults. Mumps is caused by a virus that’s acquired by inhaling infected droplets. The disease causes fever, headache, fatigue and swollen, painful salivary glands. It can lead to deafness, meningitis, and inflammation of the testicles or ovaries, with the possibility of sterility.

Recommendation Two doses of a combined measles, mumps and rubella (MMR) vaccine are given, usually beginning at ages 12 to 15 months and then again at 4 to 6 years. Use of this vaccine has markedly decreased the incidence of mumps in the United States.

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Why so many so soon?

Newborns need multiple vaccines because infectious diseases can cause more-serious problems in infants than in older children.

While a mother’s antibodies help protect newborns from many diseases, this immunity may begin to disappear as quickly as one month after birth. In addition, children don’t receive maternal immunity from certain diseases, such as whooping cough. If a child isn’t vaccinated quickly and is exposed to a disease, he or she may become sick and spread the illness.

Research shows that it’s safe for infants and young children to receive multiple vaccines at the same time, as recommended by the Centers for Disease Control and Prevention. In addition, giving several vaccinations at once means fewer office visits, which saves time and money for parents and may be less traumatic for the child.

Remember, newborns and young children can be exposed to diseases from family members, child care providers and other close contacts, as well as during routine outings — such as trips to the grocery store. Vaccines can often be given even if your child has a mild illness, such as a cold, earache or mild fever. It’s important to keep your child’s vaccination status up to date.

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Pneumococcal disease Pneumococcal disease is the leading cause of bacterial meningitis and ear infections among children younger than 5 years old. It can also cause blood infections and pneumonia. Children below the age of 2 are at greatest risk of the most serious complications of this disease.

Pneumococcal disease is caused by Streptococcus pneumoniae bacteria. The bacteria spread from person to person through physical contact or by inhaling droplets released into the air when a person with the infection coughs or sneezes. Because many strains of the bacterium have become resistant to antibiotics, the disease can be difficult to treat.

Recommendation Pneumococcal conjugate vaccine (PCV) can help prevent serious pneumococcal disease. It can also prevent one cause of ear infections. The vaccine is given in four doses between ages 2 and 15 months.

Polio Polio is caused by a virus (poliovirus) that enters the body through the mouth. Polio affects the brain and spinal cord, and can result in paralysis or death. Polio vaccination began in the U.S. in 1955. No polio cases have been reported in this country for many years, but the disease still occurs in some parts of the world. Because the virus could be brought to the U.S. through travelers, getting vaccinated against polio continues to be critical.The vaccine, called inactivated poliovirus vaccine (IPV), contains the chemically killed virus. IPV is given by multiple injections.

Recommendation IPV is given in four doses, at ages 2 months, 4 months, 6 to 18 months and at 4 to 6 years. This last vaccination is a booster dose. Contrary to the fears of some people, the shots can’t cause polio.

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Vaccinations for preterm babies

If your baby was born early or with a low birth weight, you might be concerned about having your baby vaccinated at the standard schedule. However, it’s recommended that even premature babies should be given the routinely recommended vaccinations at the normal times.

Keep in mind that premature babies have a greater chance of having disease-related problems, putting them at particular risk if they acquire a preventable infection. All of the vaccines that are currently available are safe for premature babies and those with low birth weight and pose the same risk of side effects.

There is only one exception to this: the hepatitis B vaccine that is given soon after birth. For an infant that weighs less than 2.2 pounds at birth, your medical provider may need to give your baby a fourth dose in the first six months or, depending on your prenatal testing, delay the first dose for one month or until hospital discharge.

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Rotavirus Rotavirus is a common cause of severe diarrhea among infants and children. Almost all children are infected with rotavirus before their fifth birthday. The infection is often accompanied by vomiting and fever. It can cause severe dehydration, especially in infants and toddlers.

Recommendation Rotavirus vaccine is a swallowed (oral) vaccine medication, not a shot. The vaccine is very good at preventing diarrhea and vomiting caused by rotavirus. Since the vaccine was introduced, it has significantly decreased the number of rotavirus infections in young children. It won’t prevent diarrhea or vomiting caused by other germs, however.

There are two brands of rotavirus vaccine. A baby should get either two or three doses, depending on which brand is used. The first dose is given at 2 months, the second at 4 months and the third dose, if needed, at 6 months.

Tetanus Tetanus causes painful tightening of the muscles, usually all over the body. It can be difficult to open your mouth (lockjaw) or swallow. Tetanus isn’t a contagious disease. The tetanus bacteria enter the body through deep or dirty cuts or wounds.

Recommendation The tetanus vaccine typically is given in combination with those for diphtheria and pertussis (DTaP vaccine). Immunization is acquired through a series of five shots beginning when the infant is 2 months old and continuing to between ages 4 and 6. Starting at age 11, people should boost their immunization every 10 years with the adult form of the vaccine.

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Signs of a severe reaction

After vaccination, watch for any unusual conditions, such as a serious allergic reaction, very high fever (104.8 F) or unusual behavior. Signs and symptoms of a serious allergic reaction include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat, dizziness, and swelling of the throat. Severe reactions are rare, but if you think that your baby may be experiencing one, call your child’s medical provider or go to an emergency department immediately.

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Whooping cough Whooping cough (pertussis) is a disease that causes severe coughing spells, making it hard for infants and toddlers to eat, drink or even breathe. The word pertussis is from the Latin word for “cough.” These coughing spells can last for weeks and can lead to pneumonia, seizures, brain damage and death. Severe whooping cough primarily occurs in children younger than 2 years and is contracted by inhaling infected droplets, often coughed into the air from an adult with a mild case of the disease.

Recommendation The DTaP vaccination combines vaccines for diphtheria, tetanus and pertussis. It’s given as a series of five shots beginning when the infant is 2 months old and continuing to between ages 4 and 6. The DTaP vaccine is a better tolerated version of an older vaccine called DTP. The “a” in DTaP stands for acellular, meaning that only specific parts of the pertussis bacteria are used in the vaccine.

An adult form of the vaccine, called Tdap, is recommended starting at age 11.

Side effects of vaccines

Although vaccines are considered very safe, like all medications they aren’t completely free of side effects. Most side effects are minor and temporary. Your child might experience soreness or swelling at the injection site or a mild fever. Serious reactions, such as a seizure or high fever, are very rare.

According to the Centers for Disease Control and Prevention (CDC), serious side effects occur on the order of 1 per thousand to 1 per million of doses. The risk of death from a vaccine is so slight that it can’t be accurately determined. When any serious reactions are reported, they undergo careful review by the Food and Drug Administration and the CDC.

Some vaccines are blamed for chronic illnesses, such as autism or diabetes. (See this discussion for more on autism and vaccines.) However, decades of vaccine use in the United States show no credible evidence that vaccines cause these illnesses. Researchers have, on occasion, reported a link between vaccine use and chronic illness. But when other researchers have tried to duplicate those results — a test of good scientific research — they haven’t been able to produce the same findings.

When to avoid vaccination In a few circumstances, vaccination should be postponed or avoided. Talk to your child’s medical provider if you question whether your baby should be vaccinated.

Vaccination may be inappropriate if a child has:

Had a serious or life-threatening reaction to a previous dose of that vaccine

A known, significant allergy to a vaccine component, such as gelatin

A medical condition, such as AIDS or cancer, that has compromised the child’s immune system and could allow a live virus vaccine to cause illness

Immunization may need to be delayed if a child has:

A moderate to severe illness

Taken steroid medications in the last three months

Received a transfusion of blood or plasma or been given blood products within the past year

Vaccination shouldn’t be delayed because your baby has a minor illness, such as a common cold, an ear infection or mild diarrhea. The vaccine will still be effective, and it won’t make your child sicker.

Weighing the risks and benefits

The consequences of acquiring a disease that can be prevented by vaccination are far greater than the extremely rare risk of a serious side effect resulting from vaccine use. For example, if your child gets mumps, the risk of him or her developing encephalitis is 1 in 300. For measles, the risk is 1 in 2,000. Encephalitis is a brain inflammation that can cause permanent, serious brain damage. In contrast, the risk of contracting encephalitis from the mumps and measles vaccines is virtually nonexistent.

If a child gets serious Hib disease, the chances of death are 1 in 20. The vaccine for Hib disease, meanwhile, hasn’t been associated with any serious adverse reactions and is highly effective.

Most childhood vaccines are effective in 85 to 99 percent or more of children who receive them. For example, a full series of measles vaccine protects 99 out of 100 children from measles, and a polio vaccine series protects 99 out of 100 children from polio.

CHAPTER 15 Child care

When you first bring your baby home from the hospital, it might be hard to imagine trusting anyone else to take care of him or her. You might have a difficult time feeling comfortable taking your baby with you as you run errands, let alone picturing yourself dropping him or her off at a child care center. But for many families, child care is a necessity at some point — whether in the form of the occasional baby sitter, full-time nanny, child care center or other option. So how do you find child care that will promote your baby’s health, safety and development but won’t completely empty your bank account?

To begin, determine how much you can afford to spend on child care, and identify your needs and expectations — what’s important to your family when it comes to child care. Then begin looking around at the available options in your area, usually the sooner the better. To make the most of your visits, make sure you know how to identify quality child care providers.

Getting started

Whether you need full-time child care after your baby is born or just need some help a few days a week, it’s never too early to start thinking about child care arrangements. Even if you’re not sure about your plans, begin exploring and researching your options early.

Start by asking your friends, co-workers or your child’s medical provider for recommendations. Your local child care resource and referral agency can be a great source of information, too. It can provide resources about licensing requirements, and also assess whether your family may qualify for financial assistance. See the additional resources here.

You might want to visit multiple child care centers to find the right one for your child — and many child care centers have long waiting lists. If you’re looking for in-home care, you might need time to find a child care agency, interview caregivers, and set up health insurance or workers’ compensation for your child’s caregiver.

Before you return to work, you might want to have your child spend time at a child care center or with a child care provider to see how he or she handles the situation and whether the arrangement works for your family.

Child care options

There are a variety of child care options. Generally, they tend to include the following arrangements.

In-home care Under this arrangement, a caregiver comes to your home to provide child care. The person might live with you or come to your home each day, depending on the agreement you have worked out. Some examples of in-home caregivers include baby sitters, nannies and au pairs. Au pairs are typically people who come to the United States on a student visa and provide child care in exchange for room and board and a small salary.

Pros One of the big advantages of this type of arrangement is that your baby can stay at home. You don’t have to be bundling up your baby early in the morning to drop him or her off on your way to work. In addition, you set your own standards, and you might have more flexibility with your work hours.

Other advantages of an in-home arrangement are that your child will receive individual attention and he or she won’t be exposed to other children’s illnesses or poor behaviors. Plus, you likely won’t need backup care if your baby becomes ill. You won’t need to worry about transportation for your baby unless you want your child care provider to take your baby somewhere. An in-home caregiver also might be able to help with light housework or preparing meals during your baby’s naps.

If you use an agency to find a child care provider, you may have the comfort of knowing that someone has already checked the backgrounds and references of potential candidates. If you have more than one child, the cost of in-home care might not be significantly more expensive than other care options.

Cons This type of care isn’t well regulated and is typically more expensive than other options. If you use an agency to find a child care provider, you’ll likely have to pay a hefty fee. Your caregiver might have minimal training in child development, first aid or CPR. As an employer of a child care provider, you might also have certain legal and financial obligations, such as meeting minimum wage and tax-reporting requirements or providing health insurance. Some people also feel uncomfortable having a caregiver spending time in or living in their homes.

There might not be as much opportunity for your baby to socialize with other children, which becomes increasingly important as your baby develops into a toddler. You may need to provide your child’s caregiver with an allowance for gas and activities you’d like your child to be involved in. And when your child care provider becomes sick or goes on vacation, you’ll need to find backup care.

Family child care Many people provide child care in their homes for small groups of children, sometimes in addition to caring for their own children. Typically, family child care centers provide care for children of mixed ages. Small programs provide care for up to six children at one time, while large programs are for seven to 12 children.

Pros One of the main attractions of family child care is that it allows your baby to be in a homelike setting with other children. In addition, family child care is often less expensive than care provided by an in-home caregiver or a child care center. Homes that offer child care usually have to meet state or local safety and cleanliness standards. Some places might be able to cater to your baby’s and family’s specific needs, providing care for children with special needs or extended hours.

Cons The quality can vary widely. While many family child care providers undergo background checks and participate in ongoing training, not all may be required to do so. Family homes may not have the same facility resources as larger child care centers. You may have to drop off and pick up your baby at the home at specified times.

Child care centers Child care centers — also called day care centers, child development centers, or sometimes preschool or pre-kindergarten programs — are organized facilities with staff members who are trained to care for groups of children. In these settings, care typically is provided in a building — rather than a home — with separate classrooms for children of different ages. Programs can be large or small, based on their maximum capacity. A child care center can be part of a chain, independent for profit, nonprofit, state funded or part of a federal program, such as Head Start. Some child care programs also have religious affiliations or income eligibility requirements.

Pros Child care centers offer many advantages. They’re generally required to meet state or local standards. Many have structured programs designed to meet the needs of children at different age levels. Child care centers often have high education requirements for staff. And because most centers have several caregivers, you likely won’t need backup care if a child care provider becomes sick. In addition, child care centers provide opportunities for socialization with other children. Some centers might provide extended hours or allow you to enroll your baby for less than a full week if you work part time. Some child care centers also allow you to check in on your baby during the day via secure online video systems.

Cons A drawback of larger facilities is that they might have long waiting lists for admission. Also, spending time with other children can increase your baby’s risk of getting sick. Because of this, some child care centers might not let you bring your child to the center if he or she is mildly ill. Child care centers can also be expensive, depending on the services offered. Regulations also vary. If the program is large or the ratio of care providers to children is low, your child might not receive a lot of individual attention. You may have to drop off and pick up your baby at the child care center at specified times. Some centers charge fees if you don’t pick up your baby on time.

Relative or friend Many people rely on relatives or friends to provide part-time or full-time care for their children. While having someone you know and trust take care of your child is comforting, there are advantages and disadvantages to this type of arrangement, too.

Pros Chances are your baby will receive plenty of individual attention. You might even be able to have your relative or friend care for your baby in your own home so you don’t need to worry about transportation. Your baby won’t be exposed to other children’s illnesses or misbehaviors, and you may not need backup care if your baby becomes ill. This type of arrangement might also give you some flexibility with your work hours. It’s also possible, depending on the agreement you work out, that you might not need to pay your friend or relative for child care services, or you can pay at a discounted rate.

Cons Your friend or relative might not have any training in CPR or other emergency care. If you pay your friend or relative and they provide care in your home, you’ll want to check out your local employment laws to make sure you meet requirements for matters such as tax withholding, health insurance and workers’ compensation.

Sometimes, the main drawback of having a family member or a friend provide care is that it can cause tension. You might not feel comfortable talking to your relative or friend if you have differing opinions about how he or she cares for your child. Your relative or friend might also offer unwanted parenting advice.

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Care for children with special needs

If your child has a developmental disability or chronic illness, finding quality child care may require additional considerations. The best programs encourage regular activities and also meet each child’s special needs. To find a child care program for your son or daughter, ask your child’s medical provider or your state’s department of health or education. Your child’s provider can also help you determine what kind of care will best address your child’s needs. Look for a program that meets the basic requirements you’d want in a child care program. In addition, look for:

Specialized staffing and equipment Has the program’s staff been trained to meet your child’s specific needs and recognize when your child might need medical attention? Does the program have a medical consultant who is involved in the program’s development? What kind of specialized equipment does the program provide, and is it in working condition? Has the staff been trained to use it? Does the program tailor emergency plans to the needs of its children?

Confidence-building activities What kinds of activities will your child be able to participate in? Does the program include children who don’t have special needs? Programs that care for children who have different levels of ability can help encourage social confidence and sensitivity.

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Factors to consider

Before you begin looking at facilities or interviewing care providers, take some time to think about what kind of child care might work best for your family. Knowing your priorities will help you in the process.

Expectations Think about your family’s needs and what’s most important to you in a child care provider. Here are some questions to ask yourself: How many days and hours a week do you expect your child to need care? How do you want your child care provider to approach misbehavior in your child? If you’re considering hiring a nanny, do you want him or her to be able to drive and do light housework? If you’re considering out-of-home care, how far away from your home or place of work would you like your child to be? How will you handle transportation to and from the child care center or access to transportation your caregiver and child might need during the day? What kind of backup arrangements can you make if your child or care provider becomes sick? Do you want your child to be exposed to a specific language? How much free playtime will your child have? How much time outdoors?

Budget Think about how much money you can afford to spend on child care and how different types of child care will affect your budget. Are you eligible for any state subsidies or assistance from your employer, such as employee discounts or dependent care spending accounts? If you’re considering in-home care, are you prepared to pay any necessary state taxes and the cost of backup care during your child care provider’s vacation and sick days? If you’re concerned about the expense of child care, could you or your partner adjust work hours or schedules to reduce your need for child care?

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Sick care

When your child becomes ill and you need backup care, you might have options beyond staying home to care for him or her. Some child care centers or family child care programs offer care for sick children in a segregated area. Your community also might have child care centers or family child care programs that specialize in providing care only for sick children. Some employers also provide sick care for their employees’ children. Investigate your options before your child becomes ill. When looking for this type of care, ask about how much individual care your child will receive, how the facility and equipment are cleaned, and whether the facility has a medical provider on call.

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Evaluating your options

Once you’ve thought about what kind of child care will work best for your family, compile a list of potential caregivers or facilities in your area. Next, call, interview or visit the caregivers or facilities. During your visit, pay special attention to the way staff members treat the children. After a tour, be prepared with a list of questions. If you’re evaluating several different settings or child care providers, consider taking notes.

In-home care When looking for someone to come into your home to care for your baby, checking references is crucial — especially if vetting by an agency hasn’t already occurred. Talk to several of the child care provider’s previous employers and ask questions about his or her strengths and weaknesses, as well as any problems or concerns the employer might have had. Do a background check. Search for information about the person online via a search engine or social networking sites. Ask about the care provider’s approach to child care. What will the care provider do if your baby won’t stop crying? How will the care provider manage tantrums? What kind of hours can he or she work? What kind of salary does the child care provider expect? Does he or she need health insurance? Does he or she have CPR and first-aid training?

Family child care Look for a facility that’s certified and licensed and provides a safe environment for children. Ask about how many child care providers are on staff and if they have undergone background checks. Request references. Ask about the provider’s training, how many children are enrolled and the facility’s hours. Discuss the facility’s approach to child rearing. How many child care providers are currently certified in CPR and have first-aid training? Who lives in and visits the home? What are their backgrounds, and how might they interact with your child? How does the staff plan to deal with emergencies? What safety measures are in place? Are there daily activities for the children? Find out what happens if the care provider becomes ill and if he or she goes on vacation. How much does the program cost?

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Handling the separation

Babies up to age 7 months often adjust well to being taken care of by a new child care provider. Older babies and toddlers, however, might have a harder time with the transition. Between ages 7 and 12 months, babies begin to develop stranger anxiety. They might need extra time and help getting used to a new child care provider and setting. If possible, arrange for an in-home care provider to spend time with your child while you’re at home. Or take your child to visit the family child care or child care center before he or she begins attending it. Stay nearby while your child plays, and steadily increase the length of your visits. When you begin dropping your child off at the program, create a goodbye ritual, and let him or her bring a reminder of home, such as a stuffed animal or picture of you, to the program. Always say goodbye to your child before leaving. If your child shows persistent fear about being left alone with a caregiver, talk to your child’s care provider.

Separation is sometimes harder for the parents than the child. Checking in regularly with your child care provider to see how your child is doing might help reassure you. The care provider may be able to send you pictures and updates throughout the day. Talk to friends and family who’ve been through it before.

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Child care center When evaluating child care centers, find out about each program’s practices. Many child care centers provide pamphlets or have websites that will answer your questions. You can also speak to the program’s director. Consider asking about:

Credentials and staff qualifications Make sure the program is licensed and has a recent inspection certificate. Programs that are accredited have met voluntary standards for child care that go beyond most state licensing requirements. The National Association for the Education of Young Children and the National Association for Family Child Care are the two largest organizations that accredit child care programs. Staff should have training in early child development, CPR and first aid. References should be available upon request. Ask if there are frequent staff changes, since high staff turnover might be a sign of a problem and changing care providers can be hard on a child. If possible, talk to at least one parent whose child was in the program in the past year.

Adult-to-child ratios Ask about the ratio of adults to children. The fewer the children for each adult, the better the child care experience may be for your son or daughter. For infants, look for an adult-to-child ratio of 1-to-3 or 1-to-4. Also, look for a group size that’s no larger than six to eight infants or six to 12 young toddlers. Keep in mind that infants and young toddlers do better in smaller groups.

Health and sanitation practices Ask whether the program requires children and staff to have standard vaccinations and regular checkups. Is the staff prohibited from smoking inside and outside of the building? What happens if your baby becomes ill during the day? Are parents notified when a child or staff member contracts a communicable disease, such as chickenpox? When should you keep your sick child home? How are medications and first aid administered? How often are a baby’s diapers changed? Are diapering areas and toys cleaned and sanitized on a regular basis? Do staff members regularly wash their hands? How are babies put to sleep? How regularly is bedding cleaned?

Safety and security Ask what kind of security system the facility has to ensure that strangers don’t enter the building. What happens if a child becomes injured or lost? Are outdoor play areas secured? Do outdoor play areas have sturdy structures and safe surfaces? What kind of security measures are taken during field trips? How are children transported? What is the program’s emergency evacuation plan? How are other emergencies handled?

Daily activities Ask what your child’s daily routine would be like. Is there a mix of group play and individual attention? Is there a balance between physical activity and quiet time? Is there time for free play? Are there activities appropriate for different age levels? Do care providers read to the children? Are meals and snacks provided? If so, what kinds? What are the program’s overall goals? Is parental involvement expected or encouraged?

Additional details What is the program’s admissions policy? What kind of information will you need to provide? If the program has a waiting list, how long is it and how does it work? What are the program’s hours of operation and cost? Can you pay in installments? Will you need to pay if your child is absent for a vacation? What is the policy for withdrawing a child from the program? How are parents notified of weather cancellations? Do parents need to provide any supplies? Can you drop in and visit your child during the day?

Preschool Some preschools begin enrollment at 2 years, while others require children to be at least 3. Think about whether this is something that might be a good fit for your child. This will depend on your child’s personality and needs, as well as the resources in your community. At this age, preschool curriculums are almost entirely play based. But ideally, preschool teachers encourage expanded thinking and language skills through frequent conversation with your child, reading and use of new words to expand vocabulary.

Contact information

Whenever you leave your child with a child care provider or a sitter, make sure you’ve provided a list of important contact information, including your phone number and how to reach you at all times. Also, provide the phone numbers of any other close family members or friends who can be contacted in the event of a problem. Explain what you want your child’s care provider to do in the case of an emergency.

If you’re leaving your child with a care provider in your home, show the care provider the locations of all exits, the smoke detector, the fire extinguisher and the poison control hotline number. Make sure that anyone who provides care for your baby understands the importance of putting your baby to sleep on his or her back. If the care provider will be driving your child anywhere, make sure he or she knows how to properly use car seats.

It’s also a good idea to write down your address and your child’s full name and birth date in the event of an accident. The stress of an emergency may make it difficult for a child care provider or sitter to remember those details.

Working together

In the coming weeks, monitor the performance of the child care provider you hire or the child care providers at the center your child attends. Pay close attention to your child, his or her adjustment, and the way he or she interacts with the care provider or providers. Establishing a good relationship with your child’s care provider benefits everyone involved. You may worry that your child will come to love a care provider as much as your child loves you or more. Remember, no one can replace you in your child’s heart.

Showing your child’s care provider warmth and courtesy will make him or her, as well as your child, comfortable. This will also make it easier for you and your child’s care provider to communicate. Be sure to set aside a few extra minutes to discuss any relevant issues when you leave your child with the care provider and when you return. If your child didn’t sleep much the previous night, is teething or has another issue that might affect his or her behavior that day, let your child’s care provider know. If your child is taking any medications, explain what the medication is for and provide written instructions detailing how it needs to be stored and administered and what side effects might occur. If there are certain activities you’d like your child’s care provider to do with your child, or not do — such as watch TV — talk with the care provider.

When you return, you’ll want to find out what happened with your child that day. How much did he or she drink and eat and at what times? How many diapers did he or she wet and soil? What activities did he or she do? How many naps did he or she have, and how long were they? Did your child achieve any new milestones or display any behavior that’s of concern? Are any necessary baby supplies running low? Going over these topics regularly will help ensure consistency in your child’s care and might help eliminate some confusion.

For instance, if you’re unaware that your child skipped his or her afternoon snack, you might be bewildered when he or she has a total meltdown due to hunger just before dinner. Some child care centers provide daily logs with this information. You can also ask your child’s care provider to create a daily log for you.

Beyond going over your child’s daily activities, make time occasionally to have longer talks about your child’s changing needs and how to meet them. This will also give you and your child’s care provider a chance to discuss any other issues or concerns. Be sure to listen to your child care provider’s thoughts on each topic and, if possible, work together to come up with solutions. If you’re happy with your child’s care, don’t forget to mention it, too. Showing appreciation for your child’s caregiver can help strengthen your relationship.

Finding good child care can be a stressful process. By considering your family’s needs at the outset and thoroughly researching your options, you’ll save time and energy. Carefully reviewing each candidate’s background and evaluating different child care settings will help you feel more comfortable with your decision and ease your concerns about spending time apart from your child.

CHAPTER 16 Traveling with a little one

Whether you’re bringing your baby home from the hospital, taking your child for a stroll around the block, or going on your first family flight together — you and your child are likely to do some traveling in the months and years ahead.

As you might have guessed, traveling anywhere with a child takes some planning. Your child may never have a leaky diaper, spit up all over, or stray from mealtime when you’re at home, but it always seems to happen when you’re out and about. Add in toilet training days, and you’re bound to need supplies on the go.

It’s a good idea to be prepared for anything when you’re traveling with your child. In addition to knowing what to bring with you to meet your child’s needs while you’re away from home, you’ll have to figure out which modes of transportation work best and how to use them safely. You probably have more options than you might realize.

Before you hit the road, find out what you need to know about traveling with a baby or a toddler, and then have fun!

Heading out

You and your baby are both likely to benefit from getting out of your home. While you may feel nervous at first about leaving the comfort of your home as you learn to care for your baby, fresh air and a change of scenery may lift your spirits. Taking small trips to uncrowded places with your baby now will also help you gain confidence and help you prepare for bigger adventures later on.

But at the same time, if you’ve been up all night with your baby, your baby is having a fussy day, you can’t face figuring out how to work the stroller yet or you’re just plain tired, that outing you planned can always wait until tomorrow. There’s no gold medal for the new parent who gets out of the house first. Take your time and head out with your baby when you feel ready. To help ensure a successful outing, consider the following tips.

Limit contact When you first take your newborn out, consider avoiding places where he or she will come into close contact with a lot of people and, as a result, germs. Or head to a destination when it’s least likely to be crowded.

Dress for the weather Young babies have trouble regulating their body temperatures when exposed to extreme heat or cold. As a rule, dress your baby in one more layer than you’re wearing. Infants should wear hats when it’s cold because they can lose a large amount of heat from their exposed heads.

If you’re unsure about your baby’s temperature, check his or her hands, feet and the skin on the chest while you’re out. Your baby’s chest should feel warm, while the hands and feet should feel slightly cooler than the body. If your baby feels cold, remove the outer clothing layer and hold him or her close to your body. Feeding your baby something warm also might help. Dressing your baby in layers and bringing extra layers will help you adapt if the weather changes. See Chapter 8 for more on clothing your child.

Provide sun protection Babies have sensitive skin. If your baby is younger than 6 months, avoid exposing him or her to direct sun for long periods of time. Protect your child from sun exposure by dressing him or her in lightweight, light-colored protective clothing and a hat with a brim. Apply sunscreen on exposed areas of your child’s skin, remembering to reapply as needed. For more information on young children and sunscreen, see this discussion.

Keep child equipment cool Avoid letting your child’s car seat or stroller sit uncovered in the sun for long periods of time before using them. Plastic and metal parts may become hot enough to burn your child or yourself.

Be prepared Take along diaper supplies, a change of clothes for your child (and maybe even yourself) and food for your baby — just in case. Bring a water bottle for yourself and for a child old enough to drink water, especially in warm weather. If you’re nervous, ask a family member or friend to go with you on your first few outings. As your child gets older, a favorite toy or book in the diaper bag often comes in handy.

Baby carriers

One of the most convenient and intimate ways to carry your baby around is in a baby carrier. These carriers can be used around the house, on a hike or about town. If you’re considering purchasing a baby carrier, you’ve got options, including:

Backpack or front pack. This device allows you to carry your baby in an upright position on your back or against your chest.

Baby sling. This is a baby carrier made of soft fabric that you wrap around your body, often over your shoulders or around your torso.

Choosing a baby carrier Not all baby carriers are created equal. Some carriers aren’t appropriate for certain babies. Others are quickly outgrown. When looking for a carrier:

Find the appropriate size for your baby. The carrier’s leg holes should be small enough so that your baby can’t fall through them. Some carriers can be adjusted to fit as your child gets older.

Check the weight minimum and maximum. Different models have different weight limits. Keep in mind that some models aren’t appropriate for newborns. Also, consider how long you’d like to use it.

Look at the construction. Will the carrier provide adequate support for your baby’s head and neck? Is the material sturdy? If you’re looking for a hiking backpack with an aluminum frame, is it padded to protect your baby if he or she bumps against it?

Try it out. Is the carrier comfortable for you and your baby? If you plan to use the carrier for a while, consider how the straps will feel when your baby grows, gains weight and becomes more restless.

Baby carrier risks When used incorrectly, a baby sling can pose a suffocation hazard to an infant younger than 4 months. Babies have weak neck muscles and can’t control their heads during the first few months after birth. If the fabric of the baby sling presses against a baby’s nose and mouth, he or she may not be able to breathe. This can quickly lead to suffocation. In addition, a baby sling can keep a baby in a curled position — bending the chin to the chest. This position can restrict the baby’s airways and limit his or her oxygen supply. In turn, this can prevent a baby from being able to cry for help. If your baby was born prematurely or has respiratory problems, don’t use an upright positioning device until you talk to your baby’s medical provider.

Safety tips When using any baby carrier, take the following precautions:

Be careful when bending. Bend at the knees, rather than at the waist, when picking something up. This will help keep your baby settled securely in the carrier and protect your back.

Keep up with maintenance. Keep an eye out for wear and tear. Repair any rips or tears in the carrier’s seams and fasteners. Also, check the Consumer Product Safety Commission’s website to make sure the carrier hasn’t been recalled (see “Additional Resources” here).

Keep your baby’s airway clear. If you use a baby sling, make sure your baby’s face isn’t covered by the sling and is visible to you at all times. Check your baby frequently to make sure he or she is in a safe position. If you breast-feed your baby in a baby sling, make sure you change your baby’s position afterward so his or her head is facing up and is clear of the baby sling and your body.

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Shopping cart safety

Grocery shopping with a baby or toddler can be an adventure, to say the least. While your baby is young, it may be less stressful to shop online. But a quick run on the way home from work and child care is bound to happen. Be sure to take proper precautions with shopping carts. They can easily tip over when a child is in the shopping cart seat or basket. A child could also fall out of the shopping cart seat if he or she isn’t properly buckled in. If possible, look for an alternative to placing your child in the shopping cart. Avoid placing an infant carrier on top of the cart. Consider using a front pack carrier instead. If you must place your child in the cart, make sure he or she is buckled into the seat. Look for carts that have kid seats closer to the ground, such as the model car carts. Don’t allow your child to ride in the basket or ride on the outside of the cart.

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Strollers

If you’re like most parents, you’ll want to get at least one stroller for your child. But what’s the best stroller for your baby, family and lifestyle? When looking for a stroller for your baby, consider the following:

Where and how will you use it? If you live in or near a city, you’ll need to be able to maneuver your stroller along crowded sidewalks and down narrow store aisles. You also might need to be able to collapse your stroller in a pinch to get on a bus or down stairs to the subway. Suburban parents, on the other hand, might want to look for a stroller that fits into their car trunks. If you have twins or an older child, you might consider getting a double stroller or a stroller with an attachment that allows your older child to stand or sit in the rear. Frequent travelers might also want a collapsible umbrella stroller — either in addition to or as the primary stroller. Plan to take your baby along on your runs? You might look for a jogging stroller, too.

Is it appropriate for a newborn? If you plan to use a stroller while your baby is a newborn, you’ll need to make sure that the stroller offers enough of a recline — since newborns can’t sit up or hold up their heads. Some strollers fully recline or come with bassinet attachments. Strollers that can be used in combination with an infant-only car seat are also a good choice. However, most umbrella strollers typically don’t provide adequate head and back support for young babies. In addition, most jogging strollers aren’t appropriate for a baby until age 5 to 6 months.

Do you need a travel system? If so, you might look for a stroller that can hold your baby’s car seat. Some car seats and strollers come in matching sets, while others require you to buy separate attachments that allow the strollers to be used with certain car seats. Once you strap your baby into his or her car seat, these kinds of strollers will allow you to easily move your baby between the stroller and the car. This type of stroller can also be helpful in an airport if you plan to take your baby’s car seat on the plane.

What kinds of accessories are available? You might consider whether you’ll want features or accessories for your stroller, such as a basket, a rain cover, a stroller blanket, a sun shade or parasol, or a cup holder. Some accessories aren’t available for certain strollers.

Other features Strollers with wide bases are less likely to tip over. Look for a stroller with practical brakes that you can lock easily when the stroller is stationary. Avoid strollers with hinges or latches that might readily pinch or damage a child’s fingers. Always read the stroller manufacturer’s weight guidelines, especially when looking for a stroller with an area for an older child to sit or stand.

Safety tips Once you find the right stroller, follow these safety tips, and remember to never leave your child unattended in his or her stroller:

Take caution when folding. Always make sure the stroller is locked open before you put your child in it.

Buckle up. Always buckle your child’s safety harness when taking him or her for a stroller ride. Make sure your child can’t unfasten the safety harness or slide out from underneath it. Most stroller-related injuries occur when a child falls out of the stroller.

Be careful with toys. If you hang toys from a stroller bumper bar to keep your baby entertained, make sure that the toys are securely fastened.

Properly store belongings. Don’t hang a bag from the stroller’s handle bar, which can make a stroller tip over. Place items in the stroller basket.

Car seats

Whenever you travel by car with your baby, a car seat is a must. Not only are car seats required by law in every state, but they’re essential for your child’s safety. Traveling with your baby in your lap could put him or her at risk of serious injury in case of an accident.

The best time to get a car seat for your baby is during your pregnancy, so you’ll be able to install the car seat in your car — which might be a more complicated process than you realize — and have it ready for your baby’s trip home from the hospital.

A good fit When choosing a car seat, you’ll have lots of options. Don’t assume that the pricier models are best. Instead, look for a car seat that will keep your baby safe and best serve your family’s needs. Keep these important points in mind:

Maintain the right fit. Make sure the car seat fits your child’s current size and age. Also, make sure the car seat fits your vehicle. You’ll want the car seat installed and used correctly every time.

Follow height and weight limits. Carefully adhere to your car seat manufacturer’s guidelines on height and weight limits. Follow your vehicle’s owner manual on installing the car seat using the seat belt or lower anchors and a tether, if available.

Maximize safety. The American Academy of Pediatrics (AAP) and National Highway Traffic Safety Administration (NHTSA) recommend that all infants and toddlers ride in a rear-facing car seat as long as possible, until they’ve reached the maximum height or weight limit allowed by the specific car seat manufacturer. In a car crash, a rear-facing seat helps cradle and protect your child’s delicate neck and spinal cord. Once your child outgrows the rear-facing limits, switch him or her to a forward-facing car seat with a harness for as long as possible, up to the manufacturer’s allowed height and weight limits.

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Is your car seat too old?

Yes, car seats do expire — typically after six years. The expiration date is usually stamped in the plastic on the bottom of the seat. With time, pieces of the car seat may become worn, jeopardizing the seat’s ability to keep your baby safe in a crash. As technology improves, safety recommendations may also change, but for now, the six-year time frame does matter.

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Types of car seats Several types of car seats can accommodate the needs of babies and toddlers:

Infant-only car seat An infant-only car seats is made specifically for newborns and small babies. It comes with a five-point harness and can only be used in the rear-facing position. It typically has a handle and can be snapped in and out of a base in your car. This allows you to carry the car seat with you wherever you go; just lock the car seat in place when in the car. Some models also snap into a stroller base. When your baby reaches the maximum weight or height allowed for an infant-only car seat, you’ll need to move your child to a rear-facing convertible or all-in-one car seat.

Infant-only seat

Convertible car seat A convertible seat can be used rear facing or forward facing and typically has a higher rear-facing weight and height limit than an infant-only seat. This type of car seat also has a five-point harness.

Convertible seat

When your child reaches the rear-facing weight or height limit recommended by the manufacturer of the convertible seat, you can begin to face the seat forward.

All-in-one car seat This seat can be used rear facing, forward facing or as a booster seat. As such, you can use it through preschool and beyond. Just be sure not to switch positions too early, before your child has reached the maximum height and weight limits.

Other considerations If you have two cars, you might consider buying two car seats or for an infant-only car seat, two bases. Otherwise, be sure to always move the car seat to the car in which your child will be traveling. Also, look for a model with a cover that’s easy to clean — in case your child spits up, vomits or spills food in the car seat at some point. No matter what kind of car seat you choose, make sure the label says that it meets all federal safety standards. Register your car seat online or by filling out the manufacturer’s product registration card so that you can be notified of any recalls.

Used car seats If you’re considering borrowing or buying a used car seat, make sure the car seat is safe. Look for a car seat that:

Comes with instructions and a label showing the manufacture date and model number

Hasn’t been recalled

Isn’t expired or more than six years old (the expiration date is usually stamped in the plastic on the bottom of the seat)

Has no visible damage or missing parts

Has never been in a moderate or severe crash

If you don’t know the car seat’s history, don’t use it. If the car seat has been recalled, be sure to find and follow instructions for how to fix it or get the necessary new parts.

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Sleeping in a car seat

A car seat is designed to protect your child during travel. It’s not for use as a replacement crib in your home. Limited research suggests that sitting upright in a car seat might compress a newborn’s chest and lead to lower oxygen levels. Even mild airway obstruction can impair a child’s development.

Sitting or sleeping in a car seat for lengthy periods can also contribute to the development of a flat spot on the back of your baby’s head and worsen reflux, a condition that causes a baby to spit up. In addition, a child can easily be injured by falling out of an improperly used car seat or while sitting in a car seat that falls from an elevated surface, such as a table or counter.

While it’s essential that your child be in a car seat during car travel, don’t let your child sleep or relax in the car seat for long periods of time out of the car.

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Safe car seat use

Choosing the correct car seat is important. But it’s equally important to install and use car seats appropriately. Here are some tips to getting it right.

Back seat is best The safest place for your child’s car seat is the back seat, away from active air bags. If the car seat is placed in the front seat and an air bag inflates, it could hit the back of a rear-facing car seat — right where your child’s head is — and cause a serious or fatal injury. A child who rides in a forward-facing car seat could also be harmed by an air bag.

If it’s necessary for a child to travel in a vehicle with only one row of seats, deactivate the front air bags or have a power switch installed to prevent air bag deployment during a crash. Otherwise, air bag power switches should only be used if your child has certain health problems, and his or her medical provider recommends it.

If you’re placing only one car seat in the back seat, install it in the center of the seat — if possible — rather than next to a door to minimize the risk of injury in case of a crash.

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Rentals, taxis, trains and more

Follow the same car safety rules, whether you’re traveling in your own car, a rental car, a ride share, taxi, train or any other vehicle. Plan to bring your baby’s car seat with you on any trip in which you might be riding in a vehicle or renting a car from a rental car company. If you’re using an infant-only car seat that has a base, determine if you’re going to bring the base with you. If not, make sure you know how to install the car seat in a vehicle without the base.

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Installing and buckling Properly installing a car seat and correctly buckling your child into it before the start of every car ride is crucial. Before you install the car seat, read the manufacturer’s instructions and the section on car seats in your vehicle’s owner manual. Make sure the seat is tightly secured — allowing no more than 1 inch of movement from side to side or front to back when grasped at the bottom near the attachment points — and facing the correct direction.

Rear facing If you’re using an infant-only seat or a convertible seat in the rear-facing position, keep these tips in mind:

Use the harness slots described in the car seat’s instruction manual, usually those at or below the child’s shoulders. Place the harness straps over your child’s shoulders.

Buckle the harness straps and chest clip, with the chest clip even with your child’s armpits. Make sure the straps and clip lie flat against your child’s chest and over his or her hips with no slack. Most car seats include head positioning accessories to prevent slouching.

In the rear-facing position, recline the car seat based on the manufacturer’s instructions so that your child’s head doesn’t flop forward. Babies must ride semireclined to keep their airways open. Many seats include angle indicators or adjusters to guide you. Keep in mind that as your child grows, you might need to adjust the angle.

Forward facing Resist the urge to place your child’s car seat in the forward-facing position just so that you can see his or her face in your rearview mirror. Although it’s natural to want to interact with your child during a trip, remember that your child’s safety is of ultimate importance. Riding rear facing is recommended until a child reaches the highest weight or height allowed by the car seat manufacturer.

When your child reaches the weight or height limit of the convertible seat, you can face the seat forward. When you make the switch:

Install the car seat in the back seat according to the manufacturer’s instructions, using either the seat belt or Lower Anchors and Tethers for Children (LATCH) system.

Use the tether strap — a strap that hooks to the top of the seat and attaches to an anchor in the vehicle — for extra stability.

Adjust the harness straps so that they’re at or above your child’s shoulders and fit snugly.

After you install the car seat, consider having a certified child passenger safety technician check your handiwork at a local car seat clinic or inspection event. Before each trip you take, check that the car seat is installed tightly.

The NHTSA’s website is an excellent resource for help choosing an appropriate car seat. It also offers information on finding a car seat inspection station and other car seat safety information, including video demonstrations.

Remove heavy outerwear Bulky coats and blankets can prevent harness straps from snugly securing your child. Buckle the harness, then place a coat or blanket over the harness to keep your child warm.

Stay together Remember, never leave a child alone in a car. Children can quickly become overheated, cold or frightened. Even though it might be hard to imagine forgetting your child and leaving him or her in the back of the car, it can happen. To remind yourself of your precious cargo, place your cellphone or bag in the back whenever your child rides in the car with you so that you’ll have an extra reason to check the back seat before leaving the car.

Be a force of nature As your child gets older, he or she may protest riding in a car seat. Don’t be afraid to draw the line when it comes to your child’s safety. Help your child understand that riding in a car seat is non-negotiable and that even grown-ups must wear seat belts to stay safe. To keep your child entertained during travel, bring a favorite toy or book along. You can also talk, play music or sing songs together.

Preemies and small babies

If your baby is born prematurely or at a low birth weight, he or she might need to be monitored while sitting in a car seat before being discharged from the hospital. This is because sitting semireclined in a car seat can increase the risk of breathing problems or a slow heartbeat. To make sure your baby is safe in a car seat, you’ll need to bring your baby’s car seat to the hospital prior to discharge. Your baby will be placed in the seat and have his or her vital signs recorded for a certain period of time.

If your baby has a health problem that requires him or her to lie flat, a vehicle bed may be recommended. Look for a vehicle bed that’s been crash tested. Position the bed lengthwise in the back seat so that your baby’s head will be in the center of the car. Always use the buckle and harness to secure your baby in the bed.

When you have the OK to use a car seat, you may need an infant-only car seat to accommodate your small baby. Use it only during travel, and don’t let your child sleep in it outside of the car.

If your baby needs to travel with devices such as an oxygen tank, secure them in the vehicle so that they don’t become flying objects in case of a sudden stop or accident.

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Is it safe for your baby to fly?

Generally, age doesn’t affect an infant’s ability to handle air travel. While it’s always a good idea to avoid enclosed, crowded spaces when you have a newborn, most healthy term babies are OK to fly at age 1 week to 2 weeks. If your baby was born prematurely or has a history of lung disease, however, talk to your baby’s medical provider before flying with your baby. Because your baby’s lungs might be sensitive to the effects of the changes in altitude, the provider might recommend postponing air travel until later. If your baby has an underlying respiratory condition, his or her provider might recommend supplemental oxygen.

Ear infections and ear tubes aren’t thought to pose problems during air travel. However, if your baby is ill, you might want to consider postponing the flight.

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Air travel

Your first flight with your child will likely be a lot different from your previous flights. Instead of worrying about whether you have enough reading material, you may now be worried about entertaining your baby or toddler. While there’s no telling how your baby will react to his or her first time on an airplane, careful planning can go a long way toward calming you and your child’s nerves.

Identification For domestic travel, consider bringing a copy of your child’s birth certificate with you. If leaving the country, your child will need a passport. If you know you’ll be traveling outside of the country with your child in the future, consider applying as soon as possible. The application process can typically be expedited for a fee.

Seat safety Although airlines typically allow infants to ride on a caregiver’s lap during flight, the Federal Aviation Administration recommends that infants ride in properly secured safety seats. Most infant car seats are certified for air travel. In order for your little one to travel in a car seat on the plane, your child will need his or her own seat. Though airlines typically will let you use an empty seat if available, the only way to guarantee a seat for your child is to purchase a ticket.

When booking your flights, check if there are any discounts for infant children. Keep in mind that car seats must be secured in a window seat so other passengers will be able to exit the row.

If you don’t bring a car seat for your child on the plane, ask the flight attendant for instructions on how to hold your child during takeoff and landing. If you sit in an aisle seat with your child, be sure to protect your child’s head, hands and feet from getting bumped by service carts or other passengers.

Many traveling families seek out the bulkhead of the plane, which offers extra space. Others prefer the back of the plane, which is typically noisy enough to drown out crying and may even lull a baby to sleep. Do what makes the most sense to you.

Getting through the airport If you plan to bring a car seat on the plane, a stroller that allows you to attach the car seat to it is a smart investment. You’ll be able to wheel your child in his or her car seat until you board the plane, at which point you can collapse the stroller base and check it at the gate. You will, however, have to take your child out of a car seat and carry him or her through security while the stroller is screened. While the Transportation Security Administration limits the amount of fluids you can bring on a plane, exceptions are made for baby-related items, such as medications, formula, baby food and breast milk. Be sure to notify security officials about what you’re carrying and expect it to be inspected. Also, let security officials know if your child is using or has any special medical devices.

Boarding Many airlines offer families priority boarding. However, some families prefer to board last to minimize the amount of time spent on the plane.

Keeping baby happy Dress your child in comfortable, easy-to-remove layers. This will help you keep him or her warm or cool enough and make diaper and clothing changes easy. Nursing or sucking on a pacifier or bottle might ease discomfort during takeoff and landing, since babies can’t intentionally “pop” their ears by swallowing or yawning to relieve ear pain caused by air pressure changes. A sippy cup of water can help a toddler with the same issue.

If your child is restless, consider taking an occasional break to walk up and down the aisle — as long as the crew approves moving throughout the cabin. Although parents often joke about giving a child a sedating over-the-counter medication to induce sleep during the flight, this isn’t recommended. In some cases, the medication could end up producing the opposite effect and make your child agitated.

If your child does cry during the flight, do your best to figure out what’s wrong — just as you would at home — and try to stay calm. Chances are that many passengers on the plane have been in your situation before and likely sympathize.

Plan for success

Taking your child on a trip — particularly those involving flights, overnight stays and different time zones — requires some planning ahead. When you schedule your trip, think about your child’s normal routine and what you can do during your travels to accommodate his or her daily needs.

Minding your child’s internal clock If your child is an early riser, consider booking an early morning flight and scheduling morning activities during your trip. Think about what times your child typically naps and eats and how you’ll be able to keep his or her schedule intact while away. Keep in mind that if you cross time zones during your trip, it might take your child a few days to adjust to new sleeping and eating schedules.

Gathering essentials If your child is still in diapers, start by packing your diaper bag because you’ll need it with you at all times. Fill it with diapers, wipes, diaper ointment and a changing pad. If you feed your baby with a bottle, make sure you have bottles, nipples and formula or properly stored breast milk. Bring enough to cover your travel time and well beyond, just in case you encounter delays. If you’re breast-feeding, a blanket or nursing cover might come in handy. If your baby uses a pacifier, bring at least one. Bring all medications onboard with you.

For older toddlers, bring easy snacks and a sippy cup that you can fill with water. Small toys, books, crayons and paper, or a tablet loaded with a few select games or videos can help you entertain your child while at the airport and onboard.

It’s always smart to pack an extra change of clothes — or two — for your baby and yourself in your carry-on, just in case. You might also bring hand sanitizer and disposable bags for dirty clothes.

For your stay When packing your child’s clothes for the trip, think about the weather you’re likely to encounter, how many outfit changes your child typically needs in a day, and whether you’ll have access to a washer and dryer. You might bring along a few familiar items, such as small toys, books or a white noise machine, to help your child feel comfortable in the new environment. If you’ll be staying at a hotel, call ahead and see if you can reserve a crib for your room. Otherwise, you’ll need to bring a collapsible crib with you or arrange to rent or borrow one during your stay. In addition to the bottle supplies you bring with you on the plane, consider what kind of sterilizing or pumping equipment you might need to bring for the rest of your trip.

Traveling with a little one takes some thought and — often — a lot of luggage. Think about what your child might need, and do your best to prepare for the worst. And don’t forget to enjoy your trip!

CHAPTER 17 Home and outdoor safety

As your baby becomes more mobile, exploration will become the name of the game. Rocking, rolling and sitting will give way to crawling, climbing and cruising along the furniture. And then, walking and running. Your child’s budding curiosity and inexperience, however, can prove to be a dangerous mix. Power cords, dresser drawers, kitchen cabinets, dish soap and the toilet are just a few household items that your child might touch, grab or try to climb onto in the coming months. Small toys, hot drinks, slippery surfaces and furniture with sharp edges also can pose hazards for your little explorer. While trying to prevent injuries, you can take lots of steps to safeguard your home and keep your child safe outdoors.

To get started childproofing your home, consider your family’s lifestyle and the layout of your home. Think about which rooms your child will spend time in and what dangers each room poses. Sit on the floor in each room to get an idea of what might catch your child’s attention or be within your child’s reach. If you don’t childproof every room in your home, you’ll need to take extra vigilance to keep your child away from those areas. As your child gets older, reassess each room and your childproofing measures to make sure they still meet your needs.

Nursery safety

Your son or daughter will spend a lot of time in the nursery. To help keep him or her safe while in the room, here are some helpful tips:

Use safety straps Always use the safety strap on your baby’s changing table and never leave a baby alone on the changing table. Even at young ages babies can move suddenly and flip over the edge of a high surface. Look for a changing table with a guardrail and keep diapering supplies within your reach but beyond your child’s reach.

Safely store disposable diapers If you use disposable diapers, keep them out of your child’s reach and cover them with clothing when he or she is wearing them. A child can suffocate if he or she tears off pieces of the plastic liner and eats them.

Avoid powders Powders, such as talcum powder or corn starch, contain fine particles that can damage your child’s lungs if they’re inhaled.

Take crib precautions It’s important to keep your baby’s crib free of loose items, especially during the first year or at least until your baby can move easily around the crib. This helps avoid a risk of suffocation. Put your baby to sleep on his or her back on a firm mattress and not on a soft comforter or pillow. Don’t allow your baby to sleep with loose blankets. For more on crib safety, see this discussion.

Watch toy box lids If you use a toy box, look for one with no top, a lightweight lid, or sliding doors or panels. If you have a toy box with a hinged lid, make sure it has lid support for any angle to which it’s opened. In addition, look for a toy box with ventilation holes, in case your child gets trapped inside it. Don’t block ventilation holes by storing the toy box against the wall. Rounded edges are also a plus.

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Safe toys

Babies and toddlers love to play with toys, but you want to make sure the toys around them don’t pose any hazards.

Choose toys carefully Don’t let your baby play with balloons, marbles, coins, toys that contain small parts or other small items. Balloons, in particular, pose a major choking hazard when uninflated and broken. Avoid projectile toys, extremely loud toys, and toys with cords, long strings and small magnets. Remove plastic wrapping and stickers from new toys, and make sure any decorations or small parts — such as eyes, wheels or buttons — are tightly fastened to the toy. Regularly check your child’s toys for small parts that could come loose, sharp edges, and mechanical parts that could trap a child’s finger, hair or clothes.

Safely store toys with small pieces If you have an older child, you likely have toys in your home with small pieces that your baby could easily choke on or swallow. Gather up games and toys that have small parts, and do your best to keep them out of your baby’s reach. When your older child wants to play with these kinds of toys, make sure he or she plays with them in a designated area and picks up all of the pieces afterward.

Take care with electronic toys Don’t allow small children to play with toys that need to be plugged into electrical outlets. Make sure battery covers are securely fastened. If the toy contains a button battery, make sure your child cannot access the battery.

Avoid baby walkers A young child may fall out of the walker or fall down the stairs while using a walker. The American Academy of Pediatrics has called for a ban on the manufacture and sale of baby walkers with wheels.

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Kitchen safety

The kitchen is often the center of the home. Most parents spend a good amount of time there and it can be a fun place to do activities with your child. But the kitchen also can pose a number of hazards. Take these steps to prevent accidents.

Find a safe spot for your child When you need to spend time in the kitchen, consider placing your baby in a high chair with a few toys on the tray. For a toddler, fill a low kitchen cabinet with safe items to play with — such as plastic bowls and cups. You might place your child in a playpen in an adjoining room where you can see him or her.

Reduce water temperature Set the thermostat on your water heater to below 120 F. If you bathe your baby in the kitchen sink, never run the dishwasher at the same time — in case hot water from the dishwasher backs up into the sink. Don’t run the faucet while your baby is in the sink.

Safely store hazardous items Keep sharp instruments in a drawer with a latch or a locked cabinet. Make sure appliances are unplugged and out of your child’s reach. Don’t allow electrical cords to dangle where your child could tug on them. Keep hazardous substances out of sight, out of reach and — whenever possible — in a high cabinet that locks automatically every time you close it. Hazardous substances in the kitchen might include dishwasher soap, cleaning products, vitamins and alcohol.

Avoid hot spills Don’t cook, drink or carry hot beverages or soup while holding a child. Know where your child is when you’re walking with a hot liquid so that you don’t trip over him or her. Keep hot foods and liquids away from table and counter edges. Don’t use tablecloths, place mats or runners, which young children can pull down. When you’re using the stove, use the back burners and turn the handles of your pots and pans inward. Don’t leave food cooking on the stove unattended.

Safeguard your oven Try to block access to the oven. Place tape on the floor around the oven and call it a “no-kid” zone. Never leave the oven door open. If you have a gas stove, turn each dial to the off position and — if possible — remove the dials when you’re not cooking. Otherwise, use knob covers.

Look around Watch out for other situations that could be hazardous.

Put away small refrigerator magnets. A young child could choke on or swallow them.

Address slippery or uneven surfaces and clean spills quickly.

Keep a fire extinguisher handy.

Feeding safety

Feeding your child is often a messy experience, but you don’t want it to be a dangerous one. If you use a high chair during feedings, always use the chair’s safety straps to buckle your child in. And before you feed your child, always check the temperature of the food. Never warm your baby’s formula or milk in the microwave. Food or liquids warmed in a microwave may heat unevenly. For more information about feeding your child, see Chapter 3 and Chapter 4.

Choking prevention Choking is a common cause of injury and death among young children, primarily because their small airways are easily obstructed. It takes time to master the ability to chew and swallow food, and babies and even toddlers may not be able to cough forcefully enough to dislodge an airway obstruction.

Sometimes health conditions increase the risk of choking as well. Children who have swallowing disorders, neuromuscular disorders, developmental delays or a traumatic brain injury, for example, have a higher risk of choking than do other children. To prevent choking:

Don’t introduce solids too soon. Giving your baby solid foods before he or she has the motor skills to swallow them may lead to infant choking. Wait until your baby is at least 4 months old, preferably 6 months old, to introduce pureed solid foods.

Stay away from high-risk foods. Don’t give babies or young children small, slippery foods, such as whole grapes and hot dogs; dry foods that are hard to chew, such as popcorn and raw carrots; or sticky or tough foods, such as peanut butter, marshmallows and chunks of steak.

Supervise mealtime. Don’t allow your child to play, walk, run or lie down while eating.

Keep in mind that as young children explore their environments, they also commonly put objects into their mouths — which can easily lead to choking. For information about how to respond if your child chokes, see this discussion.

Bathroom safety

The easiest way to avoid bathroom injuries is to make sure your child can’t access bathrooms in your home without an adult. Consider these precautions around the bathroom.

Keep the bathroom door closed Bathrooms can be dangerous for many reasons. The best way to avoid accidents is to keep young children out. Install a safety latch or doorknob cover on the outside of the door. Keep the toilet seat down after use. It’s also a good idea to install childproof locks on toilet lids.

Reduce water temperature Make sure the thermostat on your water heater is set below 120 F. Don’t run the faucet while your child is in the tub. Instead, fill it and test the water temperature with your wrist or elbow before placing your child in the water. Consider installing anti-scald devices on bathtub faucets and shower heads.

Supervise bath time Never leave a child alone or in the care of another child in the bathtub. A child can drown in just a few inches of water. Drain water from the tub immediately after use. Remember, infant bath seats or supporting rings aren’t a substitute for adult supervision.

Safely store hazardous objects and substances Make sure electrical appliances, such as hair dryers, are unplugged and out of your child’s reach. Don’t allow electrical cords to dangle where your child could tug on them. Keep substances in a cabinet that locks automatically every time you close it. Hazardous substances in the bathroom might include nail polish remover, mouthwash, medications and bathroom cleaners. Dispose of unused, unneeded or expired medicines.

Address slippery surfaces Use a rubber pad or slip resistant stickers in the bathtub to help prevent slipping. Place a bathmat with a nonskid bottom on the bathroom floor. Clean spills quickly.

Garage and basement safety

Accidents and injuries can also happen in areas where kids don’t spend a lot of time. Don’t forget to childproof areas of the house such as the garage and basement.

Safely store hazardous objects and substances Keep them in a cabinet that locks automatically every time you close it. Hazardous substances in the garage or basement might include cleaning products, windshield washer fluid, paint and paint thinner. Always unplug and store tools after using them. If you have an unused refrigerator or freezer, remove the door so that a child can’t become trapped inside.

Don’t allow your child to play near the garage It might be difficult for a driver to see a small child. Automatic garage doors can pose a danger for children. Always keep the garage opener out of reach.

Carefully store ladders Put ladders away after each use, and anything else that a young child could climb on. Always store a ladder on its side.

Front yard and backyard safety

To protect children from outdoor hazards:

Set boundaries. If your backyard doesn’t have a fence, make sure you keep your child within a safe area. Don’t let your child play unattended.

Check for dangerous plants. If you’re not sure about the plants in your yard, contact your regional poison control center for advice. If you have poisonous plants in your yard, remove them.

Be cautious with pesticides and herbicides. Wait at least 48 hours before allowing your child to play in an area that’s been treated.

Keep children away from power mowers. Mowers may throw yard debris with enough force to injure a child. Keep your child away when mowing. Also don’t allow your child to ride on a riding mower.

Safeguard grills and fire pits. Don’t allow children to play near these potential hazards. If you have a grill, screen it so your child can’t touch it. Make sure charcoal is cold before you dump it.

General safety tips

To reduce the risk of injury in other areas in and outside of your home, consider the following suggestions. Keep in mind that, especially as toddlers grow, barriers aren’t a replacement for adequate supervision.

Use furniture bumpers Cover sharp furniture and fireplace corners with corner or edge bumpers, just in case your child falls. Consider removing items with sharp edges from high-traffic areas while your child is learning to walk.

Secure furniture Pieces of furniture can tip over and crush a young child. Injuries typically occur when a child tries to climb onto, falls against or uses the furniture to stand up. Be sure to anchor TV stands, shelves, bookcases, dressers, desks, chests and ranges to the floor or attach them to a wall. Free-standing stoves or ranges can be installed with anti-tip devices. Move floor lamps behind other furniture.

Use doorknob covers, locks and stops Doorknob covers and door locks can help prevent your child from entering a room where he or she might encounter hazards. Look for a doorknob cover that’s sturdy but can be used easily by adults, in case of an emergency. Make sure any locks you use on a door can be unlocked from the outside. Consider temporarily removing swinging doors and folding doors or keep your child away from them.

Keep hazardous objects out of reach Common household items that may pose a choking hazard include safety pins, coins, pen or marker caps, buttons, small batteries, baby powder and bottle tops. Always safely store all potentially poisonous substances in a high, locked cabinet. Always keep products in the original containers, which might contain important safety information. Don’t allow your child to play with plastic bags or to play around recycling bins. Consider placing your trash can in a locked cabinet or getting a childproof lock for it, in case you throw out potentially hazardous items.

Address outlets and electrical cords Insert plastic plugs — make sure they don’t become choking hazards — into electrical outlets, or cover them with plates. Keep electrical cords, including cellphone chargers and other electronic cables, out of the way so that children don’t chew on them or grab them.

Keep cords out of reach Keep electronic device, lamp and window-blind cords secured and inaccessible — especially near your baby’s crib. Safety tassels and inner cord stops for window blinds and draperies can help prevent strangulation. When buying new window coverings, be sure to ask about safety features.

Watch out for liquid containers Keep your child away from fish tanks and coolers. Empty buckets and other containers immediately after use. Don’t leave them outside, where they may accumulate water and create a drowning hazard.

Avoid certain houseplants Some plants — poinsettias, English ivy and peace lilies, for example — can be hazardous to children. Contact your regional poison control center for information and advice.

Safely store firearms If possible, don’t keep firearms in your home or in an area where your child plays. If you do keep firearms in your home, keep the unloaded gun and ammunition in separate locked cabinets.

Preventing burns

Children get burned because they don’t know certain objects may be hot. To prevent burns, follow these burn-safety tips:

Establish ‘no’ zones. Block access to the fireplace, fire pit or grill, so a child can’t get near it.

Use space heaters with care. Make sure a child can’t get near a space heater. Also keep the heater at least 3 feet away from bedding, drapes, furniture and other flammable materials. Never leave a space heater on when you go to sleep or place a space heater near someone who’s sleeping.

Watch where you park. If you park in direct sunlight, cover the car seat with a towel or blanket. Before putting your child in the car seat, check the temperature of the seat and buckles.

Lock up matches and lighters. Store matches, lighters and flammable liquids in a locked cabinet or drawer.

Choose a cool-mist humidifier. Steam vaporizers can burn a child.

Unplug irons. Store items designed to get hot, such as clothing irons, blow dryers and hair irons, unplugged and out of reach.

Practice fire safety. Install smoke alarms on every level of your home, and regularly maintain all alarms in your home. Keep extinguishers near places where a fire might start.

• • • • •

Avoiding lead poisoning

Lead is a metal that’s found in many places — including old homes, drinking water and children’s products — and it can be hard to detect. Children are at especially high risk of lead exposure because they tend to put their hands and objects in their mouths, and their growing bodies readily absorb lead. Even children who seem healthy might have high levels of lead in their bodies. If you suspect that your home contains lead hazards, you can take simple measures to minimize your child’s risk of exposure.

If you think your child has been exposed to lead, ask your child’s medical provider about a blood test to check for lead.

Check your home Homes built before 1978 are most likely to contain lead. Professional cleaning, proper paint stabilization techniques and repairs done by a certified contractor can reduce lead exposure. Before you buy a home, have it inspected for lead.

Keep out of potentially contaminated areas Don’t allow your child near old windows, old porches or areas with chipping or peeling paint. If your home contains chipping or peeling paint, clean up chips immediately and cover peeling patches with duct tape or contact paper until the paint can be removed.

Filter your water Ion exchange filters, reverse osmosis filters and distillation can effectively remove lead from water. If you don’t use a filter and live in an older home, run cold tap water for at least a minute before using it. Use cold, flushed tap water for cooking, drinking or making baby formula.

Avoid certain products and toys Lead may be found in children’s jewelry or products made of vinyl or plastic, such as bibs, backpacks, car seats and lunch boxes. A child can absorb lead found in these products by mouthing or chewing on them or can inhale lead if the product is burned, damaged or deteriorating. Avoid buying old toys or nonbranded toys from discount shops or private vendors, unless you can be sure that the toys have been produced without lead or other harmful substances. Don’t give costume jewelry to young children.

• • • • •

Preventing falls

There’s plenty you can do to prevent falls. Follow these simple tips:

Beware of heights Never leave a small child alone on a piece of furniture. Always use the safety strap on strollers and other infant seats. Don’t allow a young child to play alone on a high porch, deck or balcony. As your baby grows, provide safe places for him or her to climb. Stairways are of particular interest to young kids. Under your close supervision, teach your child how to safely go up and come back down the steps.

Install safety gates Block a child’s access to stairs or doorways you don’t want your child to use with safety gates. Look for a safety gate that a child can’t easily dislodge but that adults will be able to easily open and close. If you’re putting a safety gate at the top of a staircase, attach it to the wall. Avoid accordion gates with large openings, which can trap a child’s neck, leg or other body part.

Lock windows and secure screens A young child may squeeze through a window opened as little as 5 inches. Limit window openings to 4 inches or less. Although all windows that open should have guards or screens, screens often aren’t strong enough to keep a child inside. Discourage young children from playing near windows and patio doors. Don’t place anything a child could climb on near a window. When opening windows for ventilation, open windows from the top.

Use night lights Consider using them in your child’s bedroom, the bathroom and hallways to prevent falls at night. Night lights can be especially helpful for toddlers who are learning to use the toilet or dealing with nighttime fears.

• • • • •

Safety around pets

To prevent your child from being bitten or injured, follow some basic animal precautions.

Never leave your child alone with a pet. Your child might inadvertently provoke an animal to bite him or her through roughhousing, teasing, mistreatment or just curiosity.

Teach appropriate behavior. Don’t allow your child to tease pets. Never let your child pull an animal’s tail or take away its toys or food. Don’t let your child put his or her face close to a pet.

Get your pets vaccinated. Make sure your pets are fully immunized, including against rabies.

Be cautious around new animals. Don’t allow your child to approach unfamiliar animals without permission and guidance from the pet owner.

Show your child how to greet animals. For example, show your child how to let a dog sniff him or her and then slowly extend his or her hand to pet the dog.

Think twice about petting zoos. Young children are at higher risk of contracting an infection through contact with cattle, sheep, goats, and other domestic and wild animals. If you choose to take your child to a petting zoo or other venue where animals might be present, be sure to wash your child’s hands if they become dirty in an animal’s area and after leaving the animal’s area.

• • • • •

Preventing drowning

Swimming pools, hot tubs, ponds and other bodies of water are very dangerous to young children. Buckets of water, toilets and fish tanks also can be hazardous if kids climb in headfirst and are unable to get back out. Close supervision of a child around water is imperative. Multiple layers of protection can help ensure water safety and prevent drowning.

If you have a pool or hot tub, consider these general safety tips:

Fence it in Surround your pool or hot tub with a fence that’s at least 4 feet tall. Make sure slatted fences and openings under fences have no gaps wider than 4 inches, so kids can’t squeeze through. Install self-closing and self-latching gates with latches that are beyond a child’s reach. Make sure the gate opens away from the pool or spa. Check the gate frequently to make sure it’s in working order.

Install alarms If your house serves as part of your pool or hot tub enclosure, outfit any doors leading to the pool or hot tub area with an alarm. Consider adding an underwater alarm that sounds when something hits the water. Make sure you can hear the alarm inside the house.

Block pool and hot tub access If your house serves as part of your pool enclosure, use a power safety cover to block access when the pool isn’t in use. Always secure a cover on a hot tub when it isn’t in use. Sliding glass doors that need to be locked after each use aren’t effective pool or hot tub barriers. Remove aboveground pool steps or ladders or lock them behind a fence when the pool isn’t in use. In addition, empty inflatable pools after each use.

Use life preservers Young children should always wear life preservers when in a watercraft. Don’t use inflatable toys to keep your child afloat, since they can deflate suddenly or your child might slip out of them. Even if your child is wearing a life preserver, you always need to keep a hand on him or her while in the water.

Beware of drains Don’t allow children to play near or sit on a pool or hot tub drain. Body parts and hair may become entrapped by the strong suction. Use drain covers, and consider installing multiple drains to reduce the suction.

Keep your eyes peeled Never leave children unsupervised in or around a pool, pond or other body of water. An adult — preferably one who knows cardiopulmonary resuscitation (CPR) — should always provide supervision. Don’t multitask while watching children in or near water.

Keep emergency equipment handy Keep pool safety equipment beside the pool. Make sure you always have a phone in the pool area in case of an emergency.

Be cautious, not panicked

It might seem as if everything in your home and yard poses a potential threat to your baby. But don’t panic. You can do plenty to childproof your home in a single afternoon or evening. As your baby gets older, continue to stay on the lookout for new hazards. Go through your home from top to bottom every few months to make sure you’re doing everything you can to keep your child safe. Be alert when visiting new places and friends’ or family members’ homes. If your child is going to spend a lot of time at his or her grandparents’ homes, you might consider asking them to do some childproofing, too. The most important safeguard, though, is adult supervision.

CHAPTER 18 Emergency care

Every parent wants a healthy child, but occasional accidents or injuries can happen. Even parents who have plenty of experience with children can occasionally have a tough time distinguishing routine illnesses from more-serious problems.

You can prepare for emergencies by asking your child’s medical provider during a scheduled checkup what to do and where to go if your child needs emergency care. It also is important to learn basic first aid, including CPR, and to keep emergency phone numbers handy.

When to seek emergency care

Seek immediate care for:

Bleeding that can’t be stopped

Poisoning

Seizures

Trouble breathing

Severe head injury

Unresponsiveness

A sudden lack of energy or an inability to move

Large cuts or burns

Neck stiffness with fever, persistent crying or lethargy

Persistent blood in the urine, bloody diarrhea or persistent diarrhea

Skin or lips that look blue or gray

In case of an emergency, call 911 or your local emergency care number immediately. If it’s not possible to call for emergency assistance, take your child to the nearest emergency facility. In case of possible poisoning, call the Poison Help hotline at 800-222-1222 in the United States. Have this number by your telephone. You can also use the online tool at www.poisonhelp.org.

Bleeding

You generally can judge the seriousness of bleeding by the rate of blood loss. Rapid blood loss from injured arteries is serious. Slower bleeding — a steady trickle of dark red blood — generally comes from injuries to veins or the body’s smaller blood vessels (capillaries). Bleeding can be the result of a cut, puncture or abrasion.

How serious is it? The rate of blood loss is a good indicator of the severity. Remember, because babies have a much smaller volume of blood, they can’t afford to lose as much blood as an older child or adult. Serious injuries that result in bleeding from the arteries can cause death in minutes if untreated.

What you can do If the bleeding is serious and it doesn’t stop on its own or if the cut or puncture is large or deep or has rough edges, apply pressure directly to the injury with a sterile gauze pad or clean cloth. Keep pressure on the wound until the bleeding stops. In most cases, you can stop bleeding with direct, firm pressure to the wound. Follow these steps:

Remain calm. This can be difficult, but it’s important.

Immediately apply steady, firm pressure to the wound with a sterile gauze pad, clean cloth or your hand until the bleeding stops. Don’t attempt to clean the wound first or remove any embedded objects.

When the bleeding stops, keep a bandage or cloth in place over the wound by taping, tying or wrapping it securely. If blood seeps through the dressing, place more absorbent material over the first dressing.

If possible, elevate the wounded area.

If the bleeding continues, call 911 or your local emergency number. If this isn’t possible, take your child immediately to the nearest emergency department. In the meantime, maintain pressure on the wound and apply pressure to the nearest major artery above the wound.

Choking

Most of the time when something blocks your child’s throat, he or she will instinctively cough, gasp or gag until the object clears his or her windpipe. Usually children will breathe on their own, and you don’t need to interfere. But if your child cannot make sounds, stops breathing or turns blue, you must act immediately.

Babies and toddlers most commonly choke on small objects or foods that “go down the wrong way.” Keep from a young child’s reach anything that he or she can choke on, such as nuts, whole grapes, hot dogs and any small toy parts or objects that can obstruct a child’s airway.

How serious is it? When your child’s airway is blocked and he or she cannot clear it, the situation is life-threatening. The longer your child is deprived of oxygen, the greater the risk of permanent brain damage or death. If you cannot clear the airway, call 911 or emergency medical help, or ask someone else to call.

What you can do If your child is coughing, let him or her cough until the windpipe is clear. If your child can’t make sounds, stops breathing or turns blue, act immediately. Look into your child’s mouth. If you can see something that’s blocking the throat, carefully pinch and grab the object to remove the blockage. If nothing is visible, don’t stick your fingers into your child’s throat. You don’t want to push the object farther back and have it become more deeply lodged in your child’s airway.

A firm, gentle thump on the back can help clear the airway of a choking infant.

For infants To clear the airway of a choking infant:

Assume a seated position. Hold the infant facedown on your forearm, which is resting on your thigh. Support the infant’s head and neck with your hand, and place the head lower than the trunk.

Thump the infant gently but firmly five times on the middle of the back using the heel of your hand. The combination of gravity and thumps to the back should release the blocking object. Keep your fingers pointed up to avoid hitting the infant in the back of the head.

If the previous steps don’t work, hold the infant faceup on your forearm, with the head tilted downward. Using two fingers placed at the center of the infant’s breastbone, give five quick chest compressions. Press down 1½ inches, and let the chest rise in between each compression.

If breathing doesn’t resume, repeat the back blows and chest thrusts and call 911 or emergency medical help.

Begin CPR (see this discussion) if these techniques open the airway but the infant doesn’t resume breathing. Call 911 or emergency medical help.

For toddlers To help a child over age 1 who’s choking:

Stand or kneel behind your child. Place one arm across your child’s chest for support. Bend your child over at the waist so that the upper body is parallel with the ground. Deliver five back blows between the child’s shoulder blades with the heel of your hand.

Perform five abdominal thrusts (Heimlich maneuver). Make a fist with one hand and position it slightly above your child’s navel. Grasp your fist with your other hand and press hard into your child’s abdomen with a quick, upward thrust — as if trying to lift the child up.

Do this until the blockage is dislodged.

If your baby or toddler becomes unconscious, lay your child down on his or her back and begin CPR or call 911 or emergency medical help. If you’re alone, attempt CPR for two minutes, and then call 911. If someone is with you, have that person call for help while you continue to administer CPR. Continue doing CPR until your child starts coughing, crying or speaking. If your child resumes breathing within a minute or two, he or she will most likely not experience any long-term effects.

After your child is breathing again, look for continued coughing or choking. This may mean that something is still preventing him or her from breathing properly. Call 911 or local emergency services.

Cardiopulmonary resuscitation (CPR)

Cardiopulmonary resuscitation (CPR) is most effective when delivered by a person who’s trained in CPR. It’s a good idea for all parents, and for anyone who provides child care, to take a certified course in infant CPR. You can contact your local American Red Cross or American Heart Association chapter to sign up for a course.

You may need to give a child CPR if he or she experiences the following:

Has no pulse or heartbeat

Has blue lips or skin

Has difficulty breathing or stops breathing entirely

Is unresponsive

The sooner you start CPR, the greater the chances of saving your child’s life or avoiding permanent injury.

Before giving CPR to an infant, tilt the child’s head back to open the airway. If you see an object in the infant’s mouth, try to pinch it out without pushing the object farther back in the airway.

During infant CPR, alternate compression of the infant’s chest with gentle breaths from your mouth. When breathing for the infant, cover the infant’s mouth and nose with your mouth.

What you can do The procedure for giving CPR to a child is similar to the one used for adults. Loudly call out the child’s name and stroke or gently tap the child’s shoulder. Don’t shake the child.

If you’re alone and you didn’t see the child collapse and you can’t find a pulse, provide CPR for two minutes — about five cycles — before calling 911 or your local emergency number. If you see the child collapse and CPR is needed, call 911 immediately and then begin CPR as quickly as possible. If another person is available, have that person call for help immediately while you attend to the child.

Circulation: Restore blood circulation

Place the child on his or her back on a firm, flat surface, such as a table. The floor or ground also will do.

Imagine a horizontal line drawn between the child’s nipples. Place two fingers of one hand — or, if the child is over a year old, the heel of your hand — just below this line, in the center of the chest.

Gently compress the chest about 1½ inches or one-third the depth of the chest.

Count aloud as you perform 30 compressions, pumping at a rate of about 100 to 120 compressions a minute.

Airway: Clear the airway

After 30 chest compressions, gently tip your child’s head back (head-tilt maneuver) by lifting the chin (chin-lift maneuver) with one hand and pushing down on the forehead with the other hand.

Breathing: Breathe for the child

Cover the child’s mouth and nose with your mouth.

Prepare to give the child two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the child’s mouth one time, taking one second for the breath. Give a deep enough breath to cause the child’s chest to rise gently. If it does, give a second rescue breath. If the chest does not rise, repeat the head-tilt and chin-lift maneuvers and then give the second breath.

If the child’s chest still doesn’t rise, resume chest compressions and after 30, examine the mouth to make sure no foreign material is inside. If an object is seen, pinch it out with your finger and then give two breaths. If the airway seems blocked, perform first aid for a choking baby or toddler (see this discussion).

Give two breaths after every 30 chest compressions.

Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the child.

Continue CPR until you see signs of life or until medical personnel arrive.

If you’re unable or unwilling to perform the rescue breathing portion of CPR, continue chest compressions until there are signs of movement or until medical personnel take over.

If you have someone who can help you perform CPR, have one person perform chest compressions while the other performs rescue breaths. Perform 15 compressions followed by two breaths. Repeat this cycle 10 times before switching roles.

Burns

Burns can range in severity from minor problems to life-threatening emergencies. They occur most often on a child’s hands or face. Burns may result from fire, the sun (sunburn is discussed here), heated objects, hot fluids, electricity or chemicals.

Common sources of burns in infants are hot liquids (such as coffee or tea), bottles that have been heated in a microwave, stoves, fireplaces and cigarettes. Some burns result from water heater temperatures that are excessively high (more than 120 F). Be cautious about a child’s clothing catching fire from a spark or ashes.

How serious is it? Burns can range from mild to serious and are classified according to their severity, which consists of three categories:

Superficial burns They cause redness and slight swelling of the skin. These are the most mild and affect only the outer layer of skin.

Superficial partial-thickness and deep partial-thickness burns They generally cause blistering, intense reddening, and moderate to severe swelling and pain. The top layer of skin has been burned through, and the second layer also is damaged.

Full-thickness burns Full-thickness burns appear white or charred and involve all the layers of the skin. There may be little pain with these burns because of substantial nerve damage.

What you can do Minor burns can often be taken care of at home. Major burns require emergency treatment.

Minor burns For minor burns, take the following steps:

Remove any constricting items. Since burned areas can swell, take off any jewelry, belts and similar items. Try to do this quickly and with care.

Hold the burned area under cool (not cold) running water for 10 or 15 minutes or until the pain subsides. If this is impractical, immerse the burn in cool water or use cool compresses. Cooling the burn reduces swelling by conducting heat away from the skin. Don’t put ice on the burn.

After cooling the burn for comfort and cleaning, cover the burn with antibiotic ointment. This will prevent bandages or dressings from adhering to the burn.

Cover the burn with a sterile gauze bandage. Keeping the burn clean and covered provides comfort by keeping air off the injury, and it reduces the risk of infection. Don’t use fluffy cotton or other material that may get lint in the wound. Wrap the gauze loosely to avoid putting pressure on burned skin.

To ease pain, you can give your child an appropriate dose of acetaminophen or ibuprofen. Refer to dosage instructions on the bottle (see this table). Talk to your child’s medical provider if you have concerns.

Minor burns usually heal without further treatment, but watch for signs of infection, such as increased pain, redness, fever, swelling or oozing. If infection develops, seek medical help.

Major burns For full-thickness burns or superficial partial-thickness and deep partial-thickness burns that involve a large area of skin — call 911 or your local emergency number. Until an emergency unit arrives, follow these steps:

Don’t immerse large severe burns in cold water. Doing so could cause a drop in body temperature (hypothermia) and deterioration of blood pressure and circulation (shock).

Check for signs of circulation (breathing, coughing or movement). If there is no breathing or other sign of circulation, begin CPR.

Cover the area of the burn. Use a cool, moist, sterile bandage; clean, moist cloth; or moist towels.

Elevate the burned body part or parts above heart level, if possible.

Remove jewelry, belts or other constricting items. Burned areas can swell rapidly and these items can quickly become restrictive.

Electrical shock

The most common ways that infants and young children receive electrical shocks are by biting into electrical cords or by poking metal objects or their fingers into unprotected outlets. Holiday decorations provide another source of possible injury, when electrical cords and light bulbs are often within a child’s reach.

An electrical injury often results in only minor or local injury at the point of contact, similar to a burn. For example, a less severe shock may burn your child’s mouth or skin. However, a stronger electrical shock may cause your child to stop breathing and may stop the heart’s beating. Internal organ damage may not be obvious, but it may be present.

How serious is it? Depending on the voltage and the length of the contact with electrical current, an electrical shock may range from being mildly uncomfortable to causing serious injury or death.

What you can do If you see that your child is in contact with electricity, attempt first to disconnect the source. If you cannot disconnect the source, attempt to move your child away from the electricity. Don’t attempt to handle a live wire with your bare hands; use an object made of plastic or wood that won’t conduct electricity.

As soon as your child is away from the source of electricity, check his or her breathing and heart rate. If either is stopped or erratic, or if your child is unconscious, begin CPR (see this discussion) and call or have someone else call for emergency help. If your child is conscious, look for evidence of burns and notify your child’s medical provider.

You can prevent accidental electrical shocks by childproofing your home and using safety plugs in all electrical outlets. In addition, avoid stringing long extension cords or electric lights where your child can reach them.

Animal or human bites

If your child is bitten, try to discover the source of the bite as quickly as you can. Household pets are the cause of most animal bites. Although pet dogs are more likely to bite than are cats, cat bites are more likely to become infected. Bites from some wild animals are dangerous because of the possibility of rabies. Most human bites that children get are only bruises and not dangerous. However, human bites can lead to infection if they break the skin.

How serious is it? An animal bite can cause serious wounds — especially to the face — as well as considerable emotional trauma. You should consider any animal or human bite that breaks the skin to be a serious injury. Fortunately, cases of rabies are uncommon today; still, any animal bite caused by a dog, cat, skunk, raccoon, fox or bat should be evaluated for rabies risk. Bites by rabbits, gerbils and hamsters generally are harmless and only require local wound care.

What you can do If your child is bitten, follow these guidelines:

For minor wounds If the bite barely breaks the skin and there’s no danger of rabies, treat it as a minor wound. Wash the wound thoroughly with soap and water. Apply an antibiotic cream or ointment to prevent infection and cover the bite with a clean bandage. If the bite breaks the skin, contact your child’s medical provider to see if your child should receive medical evaluation and treatment with antibiotics.

For deep wounds If the bite creates a deep puncture of the skin or the skin is badly torn and bleeding, apply pressure with a clean, dry cloth to stop the bleeding. See your child’s medical provider or go to your local emergency department. If you’re concerned about the possibility of rabies, tell your child’s provider. He or she may administer a series of shots to prevent rabies infection.

Also seek medical assistance if you see any signs of infection: pus draining from the wound, increased redness and swelling several days after the bite, or red streaks extending from the wound.

Drowning

Infants and toddlers can drown in very shallow water. Never leave your child alone in the bathtub, even briefly. If a phone call, doorbell or something else interrupts your child’s bath, either ignore the interruption or bring the child with you, wrapped in a towel. Keep the toilet lid and bathroom door closed. Fence swimming pools with automatic latching gates, and constantly supervise your infant when near lakes, pools or rivers. Toddlers have even drowned after falling into buckets used for cleaning.

What you can do If your child has been submerged in water and isn’t breathing or has breathing difficulty, has blue skin, is unconscious, or has a decreased level of consciousness, call for emergency help or have someone call for you. If your child has no pulse or isn’t breathing, begin CPR immediately (see this discussion). Continue CPR until medical help arrives.

Injury from a fall

Infants can fall for many reasons. Falls tend to occur when a baby is able to roll or to tip an infant seat — often more easily than a person realizes! — or when he or she begins to crawl or walk.

How serious is it? If your child cries immediately after receiving an impact to his or her head and remains alert, chances are the fall didn’t cause serious injury. Falls can be serious, but babies’ and toddlers’ soft bones don’t fracture as easily as those of older children. Important factors that can affect the seriousness of a fall are the force and distance of the fall and the surface onto which your child has fallen.

What you can do Use ice to control swelling, but be careful not to freeze your child’s skin. In case of a head injury, observe your child carefully for 24 hours for any behavior changes. If the injured body part looks abnormal, or if your child cannot move it, seek immediate care. Also seek immediate care if you notice any of the following signs:

An inability to crawl or walk, if he or she was able to do so before the injury

Persistent irritability, possibly indicating a severe headache

Blood or watery fluid discharge from the ears or nose

Persistent vomiting

Call 911 or emergency help if your child experiences:

Breathing irregularity

Lethargy or excessive sleepiness

A seizure

Loss of consciousness

If your child stops breathing or if you can’t detect a heart rate, begin CPR immediately (see this discussion) and call 911.

Swallowed poison

Almost any nonfood substance is poisonous if taken in large doses. Babies and toddlers explore by putting things in their mouths. Toxicity of substances varies greatly, and with immediate treatment most children aren’t permanently harmed from poisons they swallow.

In the U.S., keep the Poison Help hotline number (800-222-1222) nearby, and be sure to tell anyone who takes care of your child where the number is. Also keep the hotline number in your cell phone.

Some common items you might keep around your house can be quite dangerous to an infant or toddler. These include plants, medications (including pain relievers and aspirin), alcohol, mouthwashes that contain alcohol, automatic dishwasher detergents, pesticides, antifreeze and cleaning substances.

Suspect poisoning if you find your child with an open or empty container of a toxic substance. Look for behavior differences; burns or redness of the lips, mouth or hands; unexplained vomiting; breath that smells like chemicals; breathing difficulties; or convulsions.

How serious is it? Substances vary widely in the seriousness of their effects and the amount required to do harm. Remember, though, that a small amount of some products or medications can be much more damaging to an infant or toddler than it would be to an adult. If you have any questions about whether a substance may be toxic, call the Poison Help hotline for advice.

What you can do If you think that your child may have swallowed a poison, remove your child from the source of the poison and immediately call Poison Help at 800-222-1222 in the U.S. Be prepared to relate as many details as possible. The operator may ask you to read the labels on the container and to describe the substance and amount ingested and when and how your child came into contact with it. Describe any physical changes you detect in your child.

If your child is in obvious distress (unconscious, hallucinating, convulsing, experiencing breathing difficulties), call 911 or your local emergency number immediately. If possible, have the container in front of you when you call so that you can tell emergency personnel what substance caused the problem. If you need to go to the emergency department, bring the product or container with you or take a picture of it, including a close-up of the label.

Don’t give anything by mouth until you’ve received advice from the Poison Help hotline. Inducing vomiting in your child isn’t recommended, as it can cause more damage in some instances.

If your child is vomiting, turn his or her head to the side — or forward if your child is upright — to prevent choking.

Prevention Any medication and many products in your house can be harmful to your child. If you don’t need the medication or product in your house, remove it to avoid accidental ingestion. Be especially cautious when visiting grandparents or “nonchildproofed” homes. Be sure that all substances are in their proper, child-resistant containers and clearly labeled. Be sure to check the label on medicine bottles each time you give a medication, especially in the middle of the night, to confirm that it’s the proper medicine and that you’re giving the proper dose.

Inhaled poison

Inhaling poisonous substances can cause various reactions, including nausea and vomiting, loss of or decreased consciousness, headache, breathing difficulties, coughing, or lethargy. Your child’s reaction will vary, depending on the amount of exposure and the substance inhaled.

Numerous substances are toxic when inhaled. They include carbon monoxide, smoke and fumes from fires, propellants, gasoline, kerosene, turpentine, furniture polish, charcoal, cigarette lighter fluid, glue, paint remover, and lamp oil.

It can be dangerous for your child to inhale toxic substances. Act quickly when you suspect that your child has inhaled a dangerous substance.

What you can do Avoid using aerosol products near your child, because young children can react more severely to a small amount of inhaled poison. Never run your car in a closed garage, and be sure to maintain coal, wood or kerosene stoves regularly. If you smell a strong natural gas odor, turn off the gas burner or oven, leave your house immediately and call the gas company. Avoid breathing the fumes yourself, and get your child to a well-ventilated area. Check your child’s breathing and pulse, and if needed, begin CPR.

Call 911 or your local emergency number immediately if your child is in obvious distress — having difficulty breathing or showing lethargy or a decreased level of consciousness — is without a heartbeat, or is convulsing.

Poison on the skin

If you suspect that a poison has come into contact with your child’s skin, look around nearby your child for some evidence of the poison. Spilled household cleaners would probably leave a young child’s skin looking red and irritated. The chemicals in many household cleaning substances, especially oven and drain cleaners, are caustic and can easily damage your child’s skin.

What you can do Keep all cleaning solutions in a childproof cabinet out of reach. If your child comes into contact with a poison, check with the Poison Help hotline at 800-222-1222 in the U.S. to confirm a method of treatment .

If your child is experiencing obvious distress — unconsciousness, lethargy, hallucinations, convulsions, or breathing difficulties — call 911 or local emergency services immediately.

Poison in the eye

Poison can get in a child’s eye when a liquid splashes into it. Many substances can damage your child’s eyes, but your infant or toddler may not be able to tell you about the problem. Therefore, it’s important that you be alert to possible situations in which this can happen. Acting quickly could make the difference between a temporary problem and a long-term disability.

What you can do Use a large glass or pitcher filled with cool tap water to flood your child’ eye for 10 to 20 minutes. Try to get your child to blink frequently as you flood the area. Keep the child’s hands out of his or her eyes. You may need to wrap him or her in a bed sheet or large towel to keep his or her hands out of the affected eye. Get another adult to help you, if possible.

Call the Poison Help hotline at 800-222-1222 in the U.S. if you’re unsure whether the liquid that splashed in your child’s eye is poisonous or if you’re unsure whether to seek emergency help.

Part 3 Growth and development

CHAPTER 19 Month 1

The first month of your baby’s life can feel like a whirlwind — coming home from the hospital, getting your baby situated in your home, becoming accustomed to the rhythms of parenting, recuperating from childbirth, and so much more. There’s a lot going on!

At the same time, being with a newborn can make you feel like time has slowed down to a crawl. After all, newborns spend most of their time sleeping and eating, with a diaper change and a crying spell here and there. The most exciting times may be when your child’s eyes are open for a few minutes and you can interact for a short while. Even then, you may wonder, should my baby be moving more? Is he or she getting enough to eat?

But that’s what the first month is all about — slowing down enough to rest, recover and get to know each other. By the end of the first month, you’ll be surprised at the changes that have occurred in your little one and the jump in your own self-confidence as a parent.

Baby’s growth and appearance

During the first few days of life, your newborn loses the excess body fluid he or she was born with, which means that by the time you go home your baby will weigh slightly less than at birth. But no worries. Most babies will quickly gain this weight back. And in about 10 days to two weeks, your baby will once again be at his or her birth weight. And growth certainly won’t stop there. Most babies grow rapidly in their first few weeks. By the end of the first month, your baby is likely to weigh around 10 pounds. Your baby’s length will increase by 1½ to 2 inches.

Many people envision newborns as cute, round and smooth skinned, but that’s not always the case. If your little guy or gal doesn’t look exactly like glowing pictures you’ve seen of newborns — those babies are probably 2 or 3 months old already — don’t be discouraged. Passing through the birth canal isn’t an easy journey, and it takes a while for baby’s skin to adjust to the outside world. Most newborn appearance issues pass quickly.

To help you gauge what’s normal, here are some brief descriptions of how a typical newborn is likely to appear.

Head Forging headfirst through the birth canal can put a lot of pressure on a baby! Literally, pressure from the tight birth canal can cause the bones in your baby’s skull to shift and overlap. This can leave your newborn’s head looking slightly elongated or cone shaped at birth. Don’t worry though. Your baby’s head should round out in a few days. Babies born buttocks or feet first or by C-section are more likely to have round heads at birth. Pressure on your baby’s face may leave your newborn’s eyelids puffy or swollen.

The size of your baby’s head is important because the growth rate of your baby’s head reflects the growth of the brain. Both the brain and the skull grow incredibly fast in the first few months. In the beginning, the average newborn’s head measures about 13¾ inches around and grows to about 15 inches by the end of the first month. At birth, baby’s brain accounts for about 20 percent of his or her body weight. By adulthood, this percentage decreases to about 2 percent.

At the top of your baby’s head, you’ll notice two soft areas where the skull bones haven’t yet grown together (see this discussion). These soft spots, called fontanels, allow a baby’s relatively large head to move down the narrow birth canal. They also accommodate a baby’s rapidly growing brain. You may notice slight bulging from these spots when your baby cries or strains.

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Did you know?

Babies usually have a couple of growth spurts within the first month or two, generally around 7 to 10 days and at 3 to 6 weeks of age. During a growth spurt, your baby may want to eat more often, so don’t be surprised if your baby seems to have gone on a feeding frenzy. Hang in there. The frequency of feedings will soon even out again.

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Skin A newborn’s skin can cause considerable distress to new parents. It’s just more blotchy, flaky, pimply and wrinkled than they expected. But most of the time, this is completely normal. For example, switching from the moist environment of the womb to the relatively dry air outside of it can cause the top layer of your baby’s skin to flake off shortly after birth. You may notice plenty of dry, peeling skin for the first few weeks.

Your newborn’s skin may also look slightly mottled, with some patches looking paler or darker than others, especially near the hands and feet. Your baby’s hands and feet may also be colder than the rest of his or her body, and may appear a little blue or purple. But if you reposition your baby or move your baby’s arms and legs a little, they should regain normal color.

In some cases, your baby’s complexion may remind you more of an adolescent’s than a newborn’s, due to the appearance of tiny white pimples. The white pimples are harmless spots known as milia. Later, your newborn may even develop newborn acne, characterized by small red bumps on his or her face. A normal, harmless rash called erythema toxicum often appears in the first few days of life, as well. For more on common infant skin conditions, see this discussion.

Many newborns have birthmarks (see this discussion). You may notice reddish or pink patches above the hairline at the back of the neck, on the eyelids or between your newborn’s eyes. These marks — nicknamed salmon patches or stork bites — are caused by collections of blood vessels close to the skin. Sometimes, babies are born with a large, flat, bluish-gray mark on the buttocks or lower back. This type of birth mark is called dermal melanosis.

Umbilical cord The stump of a newborn’s umbilical cord is usually yellowish green at birth. As the stump dries out and eventually falls off — usually within two to three weeks after birth — it’ll change in color from yellowish green to brown to black. In the meantime, keep the stump clean and dry. Make sure it is outside of the diaper. Stick to sponge baths until it falls off. When it does fall off, there may be a few drops of blood, similar to a healing scab, but this should stop quickly. Don't pull on the cord to help it separate faster.

Breasts and genitalia Before birth, the mother’s hormones pass through the baby’s system. This may lead to swollen breasts at birth — for both boys and girls.

Newborn girls may have a swollen vulva and light mucuslike or bloody vaginal discharge. The swelling typically disappears within two to four weeks. Vaginal discharge may last for several days.

For some newborn boys, fluid can accumulate around a testicle. This swelling, known as a hydrocele, usually disappears within a few months. Frequent erections are common, too. For information on circumcision care, see this discussion.

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Infant jaundice

It’s not uncommon for a healthy newborn to develop a yellow color to his or her skin and eyes in the first few days of life (jaundice). This occurs when the baby’s blood contains too much of a yellow-colored substance formed during the normal breakdown of red blood cells (bilirubin). Jaundice typically develops because a baby’s liver isn’t mature enough to properly get rid of bilirubin in the bloodstream. Mild infant jaundice is harmless and usually resolves on its own within a few weeks. If your baby’s jaundice doesn’t go away after a couple of weeks or gets worse, contact your baby's medical provider promptly. See this discussion.

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Legs and feet A newborn’s legs and feet often look bowed or bent, thanks to the cramped quarters of the womb. As long as your newborn’s legs and feet are flexible and can easily be moved about, there’s no need for concern. These curves typically straighten on their own as your baby becomes more mobile. When a child is born, part of a newborn checkup includes an evaluation of a baby’s hips, legs and feet.

Hair Don’t be alarmed if that great head of hair your baby was born with falls out within the first few weeks. Almost all newborns lose at least some of their baby hair. It will grow back in a few months. Plenty of babies also develop temporary bald spots on the back of the head from regular contact with the crib mattress or other sleeping surface. Once your child starts rolling over and moving around, this won’t be a problem anymore.

Some newborns are covered by fine, downy hair at birth — known as lanugo — especially on the back, shoulders, forehead and temples. Tiny hairs may also appear on your newborn’s ears or in other spots. Lanugo is most common in premature babies. It typically wears off from normal friction within several weeks.

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What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the first month.

Eating Baby will need breast milk or formula generally every two to three hours, although the frequency at first can be pretty variable. The goal is a minimum of eight to 12 feedings a day to make sure your newborn is getting enough to eat. (Chapter 3 discusses nutrition in more detail.)

Sleeping Expect your newborn to sleep about 16 hours a day, in one- to three-hour spurts, fairly evenly distributed throughout the day and night. Place your baby on his or her back to sleep to decrease the risk of sudden infant death syndrome (SIDS).

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Baby’s movement

In this first month, your baby doesn’t have a whole lot of control over his or her movements, which are likely to be jerky and quivering. Your baby may also startle easily and even cry at sudden movements or loud noises. Swaddling or holding your baby close will help bring comfort.

Because your newborn’s brain and nervous system are still immature, movements are largely involuntary or reactive. In order to move purposefully, your baby’s brain must send messages via nerve cells to his or her muscles with specific instructions for movement. In the first few weeks of life, brain and nerve cells are rapidly developing, but they haven’t achieved fluid communication yet.

Over time, the maturation of your child’s nervous system will allow your baby to gain control over different parts of his or her body. This follows an orderly sequence from head to toe, so your baby’s first major milestone is gaining head control, followed later by sitting, crawling and walking. By the end of the first month, your baby’s neck muscles will have developed considerably. When lying facedown, your baby may lift up his or her head and turn it from side to side.

In the first few weeks, your baby’s hands are apt to be curled up into tight little fists much of the time. By the end of the first month, you may catch your baby trying to bring those fists toward his or her face for closer inspection. Over time, your baby’s hands will relax and spread wide, allowing him or her to use them more deliberately.

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Soothing by sucking

Most babies have a strong sucking reflex. Beyond nutrition, sucking often has a soothing, calming effect. That’s where a pacifier can come in handy.

Some babies are interested in pacifiers; others aren’t. If your baby isn’t enthralled at first, you can try invoking your baby’s natural sucking reflex by gently stroking the side of your baby’s mouth while holding the pacifier in his or her mouth until the sucking gets going.

If a pacifier seems to help your baby, feel free to use it. The American Academy of Pediatrics gives pacifiers the go-ahead for soothing between feedings and helping baby fall asleep. Pacifiers used during sleep may even help reduce the risk of sudden infant death syndrome (SIDS). The downside is that you may be woken up more often during the night to retrieve a lost pacifier.

In the beginning, be sure that pacifier use doesn’t interfere with your breast-feeding routine, especially while you and your baby are still learning the ins and outs of nursing. Choose a pacifier that’s made of one piece to avoid any choking hazards and that’s dishwasher safe for ease of cleaning. It helps to have several identical pacifiers handy, so you’re not searching for the lone favorite in a desperate time of need. Also make sure to replace pacifiers that have worn or cracked nipples, as the nipples can tear off and pose a choking hazard. You may wish to eliminate a pacifier by 18 months, but most kids stop using pacifiers on their own between ages 2 and 4.

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Baby reflexes From birth, your baby comes hard-wired with a number of automatic responses (reflexes). Some of these reflexes help your baby survive his or her entry into the big, new world. Automatic reflexes your baby is born with include:

Rooting reflex If you stroke your baby’s cheek or the corner of his or her mouth, your baby will turn toward your hand and move his or her tongue in that direction. This helps your baby find the nipple of the breast or bottle and initiate feeding. This reflex usually disappears around 4 months of age.

Sucking reflex This reflex is present even in utero, and you may have even seen your baby sucking his or her thumb during an ultrasound examination. After your baby is born, placing a nipple in his or her mouth will cause your baby to automatically begin sucking. At first he or she squeezes the area around the nipple between the tongue and palate to force out the milk. Next, your baby moves his or her tongue toward the end of the nipple to move the milk into his or her mouth. The American Academy of Pediatrics reminds parents that even though this rhythmic sucking is a reflexive action, it generally takes a bit of practice for your baby to turn the reflex into an effective voluntary skill. So don’t get discouraged if you and your baby don’t seem to nail breast-feeding at first pass. Give yourselves a little time to practice and adjust.

Grasp reflex Placing your finger in your newborn’s palm causes your baby to grasp your finger, and you’ll find that if you try to remove your finger, he or she will grasp it even tighter. A similar reaction occurs if you stroke the sole of your baby’s foot. These reflexes generally disappear by 2 to 3 months of age.

Startle reflex If your newborn hears a loud noise, he or she will react by throwing out his or her arms and legs and then drawing in his or her arms. This reaction is also known as the Moro reflex. Another time it occurs is if your baby’s head suddenly falls back. Doctors may check this reflex to make sure your baby’s development is healthy. The startle reflex usually disappears by about 2 to 4 months of age.

Tonic neck reflex This reflex occurs when your baby turns his or her head to the side. Simultaneously, his or her arm and leg on the same side will extend out, while the opposing arm and leg flex, giving your baby the look of a fencer. It’s a fairly subtle reflex though, so don’t worry if you don’t notice it every time. The tonic neck reflex disappears around 4 to 7 months.

Stepping reflex If you hold your newborn upright and let his or her feet touch a flat surface, your baby will pick up one foot and then the other, as if walking. Of course, your baby’s not ready to walk yet, and this reflex will disappear around 2 months. It will become a controlled skill by the time he or she is walking, usually around a year or so of age.

Baby’s sensory development

From the get-go, your baby arrives with all five senses intact. Not only does your baby use his or her senses to learn about the surrounding environment, he or she also uses them to form emotional attachments with you and others. By identifying your face, your smell and the sound of your voice, your baby establishes a connection with you.

In addition, your baby rapidly begins using multiple sensory skills to explore and interact with you. For example, your baby will quickly connect the sight of the breast or bottle with a particular scent, all of which equals food!

In the first month, this is how your baby is likely to perceive the world:

Sight At birth, your baby is fairly nearsighted, with the ability to focus on objects that are roughly 8 to 12 inches away. Coincidentally, this is just about the distance between your baby’s eyes and your face when you’re nursing or holding him or her. Thus, from early on, your baby is able to gaze at your face and quickly learns to recognize it. In fact, at this stage, your baby prefers the human face to any other patterns. This is an early opportunity for bonding with your baby. Make eye contact while feeding your baby or changing diapers.

Right after birth, your baby is very sensitive to bright light and is likely to close his or her eyes tightly to keep the light out. Over the next few weeks, though, your newborn’s vision will develop enough so that he or she can see a widening range of lights and darks. The higher the contrast in a pattern, the more likely it is to catch your child’s attention during this first month.

Sound Your baby’s hearing is fully mature at birth, but it takes a little while for your baby to learn how to recognize and react to different sounds. As with your baby’s visual preference for the human face, your baby favors the sound of human voices, reacting especially to high-pitched voices. It’s possible that your baby may even recognize your voice from having heard it in utero and will turn his or her head toward the sound of your voice from the beginning. Talk and sing to your baby.

Some babies are more sensitive to noise than others. Too much noise, for example, and your baby may start to cry. In general, low, rhythmic tones are most likely to soothe your baby.

Smell Your baby already has a keen sense of smell and quickly becomes able to discern his or her mother’s breast milk from other mothers’ breast milk. Other smells new babies seem to like include sweet or fruity smells, such as vanilla and banana.

Taste As a newborn, your baby has more taste buds than does an adult. Therefore, your little one can be fairly picky about different taste sensations, including the temperature of his or her breast milk or formula. Most babies also prefer sweet tastes to sour ones.

Touch New babies have a fully developed sense of touch, as well. For example, they prefer soft, smooth surfaces to coarse or scratchy ones. And they can feel pain at the prick of a needle. Most importantly, they respond to the way they’re touched. In essence, this is the first form of communication between you and your baby. Gentle handling, snuggling and holding are not only soothing to your baby but a sign of your love and affection, as well.

Baby’s mental development

Your baby’s brain has been on a development fast track — generating new brain cells (neurons) at a rate of 250,000 a minute — ever since the early days of your pregnancy. By the time your baby is born, he or she has virtually all of the brain cells that he or she will use in a lifetime.

But having all of these brain cells is just the beginning. As your baby is exposed to a whole new world, his or her brain cells rapidly start making connections called synapses. These connections create pathways between brain cells that, when reiterated through day-to-day experiences and activities, form the basis for knowledge and thought and for skills such as remembering, analyzing and problem-solving. These connections also set the foundation for communication and the interpersonal skills your child will use when relating to others.

Remember, it’s never too early to set the foundation for essential skills such as language. It may still be a number of months yet before your newborn will be talking, but he or she is already forming necessary connections for language development. You can encourage such development by talking and reading to your child. Provide plenty of face-to-face time when your baby is awake and alert.

Your baby’s environment has a tremendous impact on how his or her brain develops. While your baby’s genetic makeup and physical development provide the essential “nature” ingredients, you provide the “nurture” components. You’ll read more in the following chapters on how you can create the best environment for your child’s mental growth and development. But the one thing that is essential to know, especially now in the first month, is that all children thrive in an environment of consistent warmth and positive attention, no matter how old they are.

Communication Of course you knew your baby wouldn’t be able to talk for quite some time, but who knew it would be such an adjustment to stare at your newborn and realize you were temporarily going to have to rely on something other than words to communicate?

You’ll quickly discover, however, that your baby has a few different ways of communicating during this first month.

Crying This is the only way your baby can verbalize his or her needs and feelings. All babies can and should cry, because this helps them receive the care they need. Adults, in turn, have a strong drive to respond when a baby cries, making this form of communication between you and your baby fairly innate. Responding warmly to your baby’s cries helps your baby feel safe and secure in his or her new environment, as well as develop a secure attachment to you.

Lots of crying can be hard to take, of course. If you’ve run through your mental checklist and your baby is dry, full, comfortable and snug, then maybe he or she just needs comforting for a bit. Or your baby may need some downtime without any stimulation, even if he or she does cry for a few minutes. Sometimes you may not know why your baby is crying, and that’s OK, too. Keep in mind that young babies don't cry to manipulate their parents or make them do things. They generally cry to communicate their needs, whether it’s hunger, discomfort or overstimulation.

If your baby cries a lot, it’s OK for you to take a break. Let your partner take over for a while, or lay your baby in a safe place for a few minutes of alone time. Your baby may need a bit of downtime. Crying usually increases over the first few weeks, peaking at about three hours a day at 6 weeks of age and gradually decreasing to about an hour a day at 3 months old (see Chapter 10).

Body language During these first few weeks, your baby also communicates through body language. For example, when awake and alert, your baby may make eye contact with you and carefully scan your face. Or if your baby thinks there’s simply too much going on at the moment, your baby may react by turning away from the source of stimulus, closing his or her eyes or becoming irritable.

Although new babies aren’t capable of responding in so many vocal ways yet, they’re able to receive information and interpret nonverbal signals. Your baby can “read” signals you send, such as the expression on your face and the way you hold him or her.

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Toys and games

During the first month, your baby doesn’t need a lot of toys to be entertained — there are so many other things to take in. Still, you can provide different things for your baby to look at and listen to, which will help his or her brain cells develop more and better connections.

Chit chat Since your face is one of your baby’s favorite things to look at, why not make it available? Position yourself to be face-to-face and have a conversation. Talk to your baby about your day and what you’re planning for dinner. Make faces, smile and sing to him or her. Eye contact is important, so try to minimize distractions such as TV or phones.

Listen to music Play soft music while your baby lies in a crib or swing and you fold laundry or take care of some other chore.

Provide a view During the first few weeks to months, your baby’s neck muscles are still developing. But your baby can look from side to side. Hang a picture with bold, graphic lines near the changing table at baby’s eye level.

Read a book Although your baby isn’t ready to interact with a book yet, it’s never too early to start reading together. Your baby will enjoy the rhythmic sound of your voice as you read, whether it’s Dr. Seuss’ Hop on Pop or your usual news source.

Get some tummy time Place your baby on his or her tummy for a short time while he or she is awake. This will encourage your baby to hold his or her head up and strengthen those neck muscles. Some babies cry at first with tummy time. Stick with it! Try lying next to your baby or placing a mirror or toys on either side of your baby’s head.

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Baby’s social development

The main social event on your baby’s calendar this first month is getting to know you. While you’re occupied trying to figure out your baby, your baby is busy using all his or her senses to become acquainted with you — how you smell, sound, look and feel.

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States of consciousness

Scientists have observed, and you will too, that new babies fluctuate between different states of consciousness throughout the day. Some of these states are during sleep, and some occur while your baby is awake. There’s no need to memorize them, but understanding the different states of consciousness may help you better understand your baby’s moods.

Deep sleep. During the deep sleep state, your baby sleeps quietly and does not move.

Active or light sleep. In this state, your baby moves while sleeping, and may be startled or wakened by loud noises.

Drowsiness. Drowsiness may occur before or after a sleep state. You’ll notice your baby’s eyes become a little droopy, and he or she may yawn or stretch. Keep this one in mind for when you want to put your baby down to sleep on his or her own.

Quiet alert. In this state, your baby looks bright-eyed and bushy-tailed, but his or her body is quiet.

Active alert. During active alert, your baby is wide-eyed and moving actively. He or she may be busy entertaining himself or herself.

Crying. This state of consciousness is not hard to recognize because of the wails coming from your baby’s mouth. When your baby is crying, he or she also tends to flail or thrash about.

The best time to talk and play with your baby usually is during the quiet alert state. In this state, he or she is most likely to be receptive to play and outside stimulation. Be warned, though, that new babies tend to cycle through states of consciousness fairly quickly. So don’t be surprised if a toy elicits attention for a short while and then quickly becomes a source of irritation when your baby starts crying. Just move on to what your child wants next, which is probably comforting or napping.

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Becoming attached Babies' bodies are pretty amazing self-functioning packages when they arrive, but babies still depend on their environment for survival. Every time you feed your baby, change your baby’s diaper, respond to your baby’s cries or simply hold your baby close, you’re establishing a pattern of consistent availability to your baby’s needs. This creates a bond of trust and confidence between the two of you. This bond is the primary building block for your child’s early social and emotional development. It’s also your baby’s template for future relationships. As a primary caregiver, you become your child’s “home base,” to which he or she will repeatedly return over the years for comfort, help and support.

For many women, breast-feeding is a natural way of bonding with a newborn because it covers many of the baby’s needs at once — food, warmth, comfort and security all rolled into one. But breast-feeding is only one way to bond. You also can connect with your baby when you’re feeding your baby a bottle or doing any of the other myriad activities involved in baby care. It’s your general approach of love and gentle care that communicates safety to your child.

For some people, bonding comes more easily than for others. If you don’t feel immediate attachment to your baby on day one, don’t worry too much. After all, this is a new person in your life, no matter how little. As you spend time together and get to know each other’s traits and characteristics, you’ll develop a unique relationship that will only be strengthened in the months and years ahead.

In addition, many new mothers have a mild case of the blues after childbirth, not to mention fatigue and soreness. If you don’t start feeling better and more involved in your parenting role after a few weeks, talk to your medical provider. He or she will help you sort things out and get the right treatment (see this discussion).

Building up to smile Smiles actually take a while to develop, but you may notice over the course of this first month that your baby sometimes smiles during sleep or after a feeding. Around 4 weeks or so, your baby’s smile may evolve a little further, involving the eyes more, and come several seconds after hearing your voice or feeling your touch. Next month, you can look forward to full-blown happy smiles involving the whole face that come in response to your own smiles.

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1st month milestones

In this first month, new babies are usually working on the following skills:

Turning head from side to side

Lifting head for a second while lying on belly

Bringing fists in toward face

Checking out human faces and maybe high-contrast patterns

Visually tracking moving objects that are in close range (eyes may cross at this age as eye muscles are still developing)

Perhaps turning head toward familiar voices and sounds

• • • • •

CHAPTER 20 Month 2

By the beginning of your baby’s second month, you’re probably starting to get a handle on having a new baby in the house. You’re more adept at basic caregiving activities, such as changing diapers or fixing bottles, and you’ve almost gotten your swaddle technique down. If you’re breast-feeding, you’ve probably started ironing out some of the kinks, and you and your baby are feeling a lot more confident in your techniques.

During month two, you’ll still be perfecting a lot of these activities, but you’ll also see your baby’s personality begin to emerge. Your diligent efforts are more apt to be noticed by your little tyke, and you’ll likely be rewarded with the beginnings of true interactive smiles. What’s nice about month two is that the cogs of family life are slowly sliding into place and yet the excitement of it all is still bright.

Baby’s growth and appearance

During the second month of life, your baby keeps growing at about the same rate as he or she did during the first few weeks — gaining about 5 to 7 ounces a week and growing about ½ inch a month. Your baby is starting to fill out — cheeks are getting chubbier and arms and legs fuller!

The head and brain are still growing rapidly so that head circumference increases by about ½ inch a month, as well. It’s normal for your baby’s head to be proportionally larger than the rest of his or her body at this point — it’s still growing faster than anything else. The soft spot on your baby’s head is still open, but toward the end of this month and into the third month, it should start to become more firm and begin to close.

Keep in mind that healthy infants come in a range of sizes. Although it’s easy to cite generalizations, such as the figures just listed, it’s difficult to predict your baby’s exact growth. Your medical provider will monitor your son’s or daughter’s growth at each well-child visit. Where your child’s numbers fall on the growth chart or how they compare with other babies’ numbers isn’t nearly as important as whether your baby is maintaining his or her own steady growth curve.

Baby skin issues start looking a little better. Any jaundice should be gone by the second month. If not, contact your child’s medical provider. Other newborn skin conditions, such as the little white pimples known as milia, are largely disappearing, although newborn acne may stick around for another month or two. If your baby has acne, gently cleanse your baby’s face with baby soap several times a week, and stay away from lotions and oils.

Growth spurts Just when your baby is finally sleeping for several nighttime hours at a stretch, he or she seems to revert to waking up every two hours again. What’s going on? Nothing out of the ordinary, probably. Infant growth and development occurs in spurts. Usually a pause in learning precedes a new leap forward. For example, your baby may be subtly working out the maneuvering necessary to roll over, but until he or she masters the right techniques, your infant may not fall or stay asleep as he or she once did.

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What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the second month.

Eating Feed your child with breast milk or formula exclusively. Breast-fed babies are still likely to want to eat every two to three hours. As the second month progresses, however, your baby’s stomach capacity grows, and he or she may take in more milk at a feeding. This may lead to a dropped nighttime feeding and hopefully more sleep! Formula takes longer to pass through the stomach, so formula-fed babies are more likely to eat every three to four hours. Within a month or two, though, the difference in nighttime feedings between breast-fed and formula-fed babies tends to even out.

Sleeping Your child may sleep between 15 and 16 hours a day. As your baby’s nervous system matures and stomach capacity increases, more of these sleep hours will be consolidated into nighttime hours. At 2 months, your baby may be sleeping for five to six hours at a stretch at night. Always place your baby on his or her back to sleep in a crib with no blankets, pillows or toys to decrease the risk of sudden infant death syndrome (SIDS).

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Baby’s movement

Most of your baby’s movements are still jerky and involuntary (reflexive) at this point. But as the month progresses, these newborn reflexes will begin to give way to more purposeful movements. While this is occurring, your baby may seem less active for a short period until he or she begins to get the hang of major muscle coordination. Your little son or daughter is practicing new positions by stretching, moving and watching.

Your baby’s neck muscles are getting stronger, too. When pulling your baby gently to a sitting position, you’ll notice that his or her head still lags behind a bit. But when upright, your baby can probably hold his or her head steady for a few seconds, although not much longer. Continue to support your baby’s head when holding or carrying your baby. When lying belly-side down, your baby may raise his or her head to look straight ahead for a few moments, rather than just side to side. Lying on his or her back, your baby can keep his or her head centered and look straight up — a handy skill for watching mobiles and looking up at mom and dad!

At this age, most babies aren’t ready to roll from front to back or side to back yet — that generally happens around 3 to 4 months of age. But you cannot be certain that your baby will stay in one place either. Babies this young can use their feet to push off surfaces and scoot around. And even though they’re just learning controlled maneuvers, they can unexpectedly flip themselves over by sudden, startled movements. Don’t leave your baby unattended in a car seat, on a changing table or other elevated surface, and take proper precautions to securely strap your baby in while on a changing table.

Toward the end of the second month, your baby may also start to become aware of his or her hands and fingers and try to bring them together to play with them.

Baby’s sensory development

During the second month, your baby’s eyes are getting better at moving and focusing on objects at the same time, making it easier for your child to visually track moving objects. Your baby’s brain isn’t mature enough to speedily process visual information, but he or she can track a toy moving in front of him or her if it’s moving very slowly. Although your baby is still likely to prefer the sight of human faces, he or she will also enjoy patterns that are more complex and colorful than simple black-and-white checkerboard images.

When you talk to your baby, you’ll find that he or she is actively listening and watching the movements of your lips with interest as you speak. In return, your baby may move arms and legs excitedly or try to make his or her own vocalizations.

Baby’s mental development

So far, your baby has been taking in a lot of information, but by now he or she may be ready for some outward expression, as well. Child psychologists refer to incoming language as “receptive” and outgoing speech as “expressive” language. Receptive language, where your baby listens and absorbs speech and sounds around him or her, almost always precedes expressive language, which is when your baby starts to vocalize his or her own thoughts. This is why it’s so important for you to talk to your baby even if he or she can’t yet talk back. In general, children understand language much earlier than they are able to clearly use it themselves. For example, your baby will understand the meaning of the words “Come to mama” months before he or she can articulate them.

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Toys and games

During the second month, your baby will gradually be awake for longer periods of time and have more quiet alert times. You can take advantage of these times by providing stimuli that encourage your child’s development.

But let your baby guide playtime. Watch for clues that he or she is tired or overstimulated, such as turning away, closing his or her eyes, or becoming irritable. Also, keep in mind your baby’s physical limitations. During physical play, be gentle and careful not to shake your baby or toss him or her in the air. These activities can cause severe injury to your baby’s eyes, neck and brain.

Here are a few suggestions for playtime with your 1- to 2-month-old.

Keep up tummy time Regularly placing your baby on his or her belly for a short time while he or she is awake helps develop neck muscles and increase head control. You can share in tummy-time fun by lying on the floor facing your baby and talking to him or her. Your baby will work neck and arm muscles to lift up and be face to face with you. You can also encourage your child to work those muscles by putting toys just within his or her reach.

Set up a mobile Your baby is better able to hold his or her head steady enough to look straight up while lying on his or her back. Mobiles can become particularly fascinating. When choosing a mobile, look at it from your baby’s perspective. Keep in mind a child’s preference for simple shapes, high contrast and bright objects. Some models will even twirl around to music, engaging both your baby’s eyes and ears. Be sure all items are secured completely and placed out of baby’s reach.

Introduce color As your child’s vision improves, he or she will become more appreciative of bold, vivid colors in addition to high-contrast patterns. Visit your local library to borrow books containing brightly colored art or photographs. Or arrange a still life of bright oranges, tomatoes and asparagus for your baby to contemplate.

Encourage familiarity Try reading the same story several nights in a row to your baby, and see if he or she starts to show signs of recognition. Or play a favorite song several times during the week and see how your baby reacts after hearing it multiple times.

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Cooing and gurgling One of the most gratifying developments for parents this month — generally around 6 to 8 weeks of age — is their babies’ first attempts at expressive language. These are typically soft, single-vowel sounds that sound like oohs and aahs, or like cooing.

As opposed to crying and grunting, which emanate from the chest, cooing and gurgling sounds come from your baby’s larynx. Cooing also involves using different mouth muscles than does crying. Eventually your baby will begin to use his or her tongue and then lips to make more precise vocalizations. This pattern of language development — starting from the center and moving outward — mirrors your baby’s motor development (fine-tuning movement from arms to hands to fingers).

Cooing is a way for your baby to express happiness and contentment. Your baby may coo and gurgle for self-entertainment, but he or she may also do it to attract your attention. If your baby coos at you and you talk back, your baby quickly discovers that this is a two-way game. By talking back, you reinforce the notion that communication is important and, furthermore, that it can be a source of great delight.

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Out of sight, out of mind

At this age, your baby’s young mind has yet to grasp the concept that things continue to exist even if they’re out of sight. For example, if a dog wanders into your 2-month-old’s field of vision and then out again, your baby may stare for a few seconds at the spot where the dog was, not understanding that although the dog isn’t visible it still exists. In other words, once something is out of sight, it’s also out of your baby’s mind. It isn’t until later during the first year — around 8 months or so — that your baby will understand that even if you hide your face behind a blanket, you are still there. Up until that point, peekaboo games can feel pretty magical!

• • • • •

Crying at its peak Your baby still relies heavily on crying to convey his or her needs and moods. In fact — brace yourself — crying tends to reach a peak of about three hours a day right around 6 to 8 weeks of age. This is normal. A lot of babies develop a period of fussiness and prolonged crying at the end of the day, perhaps as a way of releasing pent-up stress (not unlike adults, if you think about it).

If you’ve already accounted for all of your baby’s needs, listening to your baby cry can be difficult. A parent often feels frustrated with his or her parenting skills at this point. But it’s not always possible to calm a crying baby, especially if your baby is just letting off steam. Avoid the temptation to perceive your baby’s crying as a rejection of your efforts or to feel as if you’re a failure at this parenting business. Babies cry; that’s what they do. And eventually, your baby will fall asleep or his or her mood will change. By the time your baby is 3 or 4 months old, the amount of time he or she spends crying will have decreased substantially.

If your baby’s crying is accompanied by other symptoms, or you feel the length or intensity of your baby’s crying is unusual, trust your intuition and call your child’s medical provider. For more on crying, see Chapter 10.

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Big sisters and brothers

Having a new baby in the house brings a special excitement for families that already have kids. Although caring for other children as well as a newborn can be challenging, you’ll also have the rich experience of watching the relationships of your children grow as brothers and sisters.

Generally, children are quite excited at the prospect of having a real, live baby in the house. But what they may not realize is that they’ll need to share you, their parent, with another person. Sometimes this can lead to older children acting out in order to garner more attention, or even lashing out at the baby. With time, though, most children learn to adjust to the household reorganization and find their own special niche. You can help them with this by doing the following:

Postpone major changes During the weeks following your baby’s arrival, try to avoid any drastic changes in older children’s routines. This may mean waiting a while to potty train, switch from a crib to a bed or move to another home.

Let each child set the pace Despite being raised in the same family, each child can react differently to a new baby. Responses may vary from excited giggles to hyperactivity to lack of interest. Sometimes a child’s reaction is delayed for weeks. Allow your children to become accustomed to the baby in their own time.

Set clear expectations Let your older children know what is appropriate behavior around the baby. For example, let your child know it’s never OK to pick up the baby without permission, but that it is OK to sit next to the baby and talk nicely to him or her.

Offer sincere praise When you find your older child behaving well, be sure to acknowledge it. Commend your child for speaking gently to the baby or playing nicely. This kind of positive reinforcement shows your child that you still value his or her presence, and you appreciate his or her contributions to the family.

Make time for older kids Sisters and brothers of babies need lots of personal attention, too. Make plans to leave the baby with your partner or a reliable sitter, and spend some undivided time with your older children.

Be patient and positive Some children start to regress after a new baby arrives, going back to trying on diapers, sucking a thumb or talking baby talk. This isn’t uncommon. Be patient during this period of adjustment. Treat regression in a matter-of-fact way. For example, “I see you wet your bed this morning. We’ll change the sheets.” These simple sentences state the problem and offer a ready solution.

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Baby’s social development

During the second month, your baby still spends a lot of time sleeping and the interaction you experience with your baby is still fairly limited. But at the same time, your baby is making definite strides in his or her social graces. By the age of 1 month, your baby is learning to recognize you, perhaps reacting with a jerky arm wave or a few bobs of the head at the sight of you. By six weeks, many babies start to smile in response to a parent’s smile. After weeks revolving around feeding, diaper changing and trying to catch some sleep, seeing your baby smile back at you can be very rewarding.

By reacting to your baby’s smiles with your own show of delight, your baby learns that his or her actions have an impact, and that he or she has a certain amount of control over what’s happening. This initial awareness is the beginning of your baby’s ability to distinguish between himself or herself and others.

Baby smiles can also be spontaneous expressions of happiness or contentment even at this stage. For example, your son or daughter is starting to recognize certain objects by sight, such as a bottle or bathtub, and he or she may smile or coo excitedly in anticipation of what’s to come.

Spoil away Don’t worry about spoiling your baby during the early months of his or her life. Addressing your child’s physical needs and desire for attention helps establish a pattern of consistent and predictable loving care in your baby’s mind. This allows your baby to establish his or her own emotional comfort level. In other words, your baby is learning to feel safe and secure and to trust you and himself or herself. In addition, when you soothe your baby during a crying spell, you’re teaching your child how to regulate his or her emotions even in times of intense emotion or stress.

So pick your baby up as often as you like, and hold your baby as much as you want. It’s good for both of you!

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2nd month milestones

During the second month, your baby is busy:

Working on lifting up shoulders while lying on belly

Holding head steady while sitting

Becoming aware of own fingers

Relinquishing grasp reflex

Straightening out legs and strengthening kicks

Focusing on objects moving across field of vision

Cooing and making sounds

Recognizing parents’ faces, being reassured by parents’ touch

Learning to smile in response to parents’ smiles

Learning to smile spontaneously to express happiness or contentment

• • • • •

CHAPTER 21 Month 3

While a solid block of sleep may still seem elusive at your house by the third month, your son’s or daughter’s range of motor control, mental engagement and social interaction is widening dramatically. The confluence of a number of factors affecting your baby’s growth and development — maturation of the nervous system, development of the senses, reinforcement of the memory pathways in the brain, expansion of the range of emotions — all contribute to your baby’s burgeoning interest in his or her family and the world around him or her.

Baby’s growth and appearance

In the third month, the rate at which your baby gains weight and grows in length should continue at a good clip and roughly match last month’s rate. Most babies gain between 1 and 1¾ pounds and lengthen by about ½ inch a month during the first six months of life. Head circumference increases by about ½ inch a month during this time, as well.

If you’re worried that your baby seems too thin or too chubby, be careful not to judge by appearance alone. Since infants tend to carry different amounts of weight at different stages of development, making judgments about baby fat on the basis of appearance alone isn’t reliable or effective. Instead, talk to your baby’s medical provider about your concerns. He or she will plot your baby’s growth on charts that show measurements for height, weight and head circumference (see this chart). You can use the charts yourself to compare your baby’s growth with that of other infants of the same sex and age. What really matters, however, is the trend revealed on growth charts — not any particular percentile. Your baby’s provider will look mainly for predictable changes in weight over time.

If you’re following your baby’s hunger cues for feeding and his or her growth is progressing steadily, there’s generally no reason to worry about your baby’s size.

Baby fat Babies need a diet high in fat to support growth during infancy. In addition, a diet high in fat helps to build a thick casing (myelin sheath) around nerve fibers in the brain and spinal cord. This sheath offers “insulation” for nerve fibers and helps ensure that nerve impulses are sent efficiently.

It’s true that many medical providers and medical researchers are concerned about the rise in childhood obesity. Some evidence suggests that this problem may arise earlier than previously believed. For example, some studies have linked rapid weight gain in the first year of life to obesity later on in life. Excess baby fat may also have more immediate consequences, such as delaying the development of crawling and walking.

Yet the first year of life is no time to put your baby on a diet or restrict calories, unless your baby’s medical provider has given you specific feeding instructions. Your baby needs adequate nutrition to develop properly. Steps that may help reduce the risk of later obesity include:

Breast-feed for as long as possible.Several studies have shown a connection between breast-feeding and reduced childhood obesity. The mechanisms for this link aren’t clear, but it may have to do with the ability of breast-fed babies to self-regulate their intake of milk. In other words, baby decides when to stop eating. If you’re bottle-feeding, try to follow your baby’s cues that he or she is full. Don’t make your baby finish a bottle just because the milk is there.

Avoid juice. Don’t give your child juice until he or she is older than 6 months (and even then, you don’t have to). Offering juice before this age may displace regular breast milk or formula feeding, which can leave your baby deprived of necessary nutrients. If you choose to offer juice after your baby is 6 months old, serve it in a cup rather than a bottle, and limit it to no more than 4 ounces a day.

Don’t use food as a pacifier. If you’ve just fed your baby and he or she still seems fussy, try other methods of distracting him or her before resorting to another feeding to quiet baby down.

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What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the third month.

Eating Breast milk or formula exclusively. Longer stretches of sleep at night may mean more-frequent feedings during the day. But through this month and the next, you can expect your baby to gradually take in more milk at a single feeding, perhaps resulting in fewer feedings throughout the day. Between 2 and 4 months of age, the average baby eats around 2 ounces per pound of body weight every 24 hours.

Sleeping About 15 hours a day. By about 3 months old, many babies sleep for a solid six to eight hours during the night. Still, this doesn’t always coincide with your own block of six to eight hours of sleep. Expect to be up once or twice during the night, especially if your baby has a growth spurt and needs more-frequent feedings.

• • • • •

Baby’s movement

By the third month, added muscle strength gives your baby new vantage points from which to peer at the world. As your baby becomes more and more purposeful in his or her movements, you’ll notice those newborn reflexes fade.

Head and neck Lying belly-side down, babies this age can usually lift up their heads and shoulders. Some infants may even extend their arms and rest on their elbows. This gives them even more support for looking around. In turn, looking upward and sideways while on their tummies further increases neck strength and head control.

Increased head control means that your baby’s head lags less when you pull him or her into a sitting position. Also, when you support your baby seated on your lap, your baby can hold his or her head up for longer periods of time instead of just a few seconds. In the third month, you’ll notice your baby’s back still rounds forward. But as your child’s movement (motor) skills develop, the muscles in the upper and then lower back will strengthen, as well. Strong back muscles act as a balance and brace for your baby’s body so that he or she can eventually sit straight unsupported, crawl, stand and then walk.

Hands and arms A favorite pastime for your baby this month is likely to be watching his or her hands, bringing them together at eye level, and trying to bring them to his or her mouth.

You may notice that your child’s hands begin to uncurl from their previous clenched fist position. At this age, babies begin to experiment with opening and shutting their hands and spreading their fingers wide to test and inspect them. Your son or daughter may also start to grip objects intentionally rather than reflexively, but then have a hard time letting go. The next step will be to gain enough finger dexterity to hold on to a toy, and then transfer it from one hand to the other. Eventually, he or she will be able to pick a toy up and set it down again, solidifying basic fine motor skills.

At the same time, your child may start reaching for objects by swiping or batting at them with broad arm movements and clenched fists. As your child’s hands become more open, he or she will have better luck hitting the intended target.

Legs Your baby’s legs are becoming impressively strong, and he or she is likely to experiment with flexing his or her legs and knees at will. Some babies, especially when they’re excited, may even kick hard enough to flip themselves over. In preparation for purposely rolling over, your baby may start rocking back and forth. In fact, by 3 months of age, many babies start to roll from their backs onto their sides and then onto their backs again.

Because your baby is more mobile, always take proper precautions to prevent him or her from wiggling off of a changing table or flipping out of a car seat. Strap your baby in and stay nearby to avoid any accidents.

Baby’s sensory development

Although the development of your baby’s senses isn’t as easy to observe as the development of motor skills and coordination, one is essential for the other. Even though your baby can’t tell you what he or she is experiencing, playing with and watching your baby will help you know how well your child sees and hears.

Vision Your baby’s sight is maturing rapidly. In the next few months, he or she will begin to view the world in much the same way as you do. By 2 or 3 months old, your baby’s ability to simultaneously turn both eyes inward to focus on a close object (convergence) is developing steadily. Convergence allows your baby to focus on and play with his or her hands. At the same time, your baby is learning to focus on distant objects by simultaneously turning both eyes outward (divergence).

As your child’s vision matures, he or she will be able to notice details of a pattern and to tell whether there is more than one object in a picture. As distance vision improves, you may catch your baby studying you across the room or gazing intently at a ceiling fan. Your baby is also getting better at distinguishing between colors, and may especially enjoy primary colors.

Around this time, your baby also learns a skill that encompasses both sensory and social development. Your baby will look at your eyes and then turn to discover what it is that you’re looking at. This is called shared attention.

During the third month, if you still see your baby’s eyes crossing or you notice there seems to be a lag in one eye, let your baby’s medical provider know. If it happens consistently, the provider may refer your child to an eye specialist so that, if needed, steps are taken to correct the vision problem.

Hearing Your baby’s hearing contributes to a growing sense of familiarity and comfort with the world around him or her. Around the third month, your baby may quiet when he or she hears your voice or get excited when he or she hears siblings or a favorite song.

Taste and smell Toward the end of this month, your baby is starting to distinguish between different tastes, such as breast milk versus formula or a new brand of formula. Your baby also is likely to favor certain smells or be turned off by other smells. These factors can sometimes affect feeding preferences, depending on your baby’s temperament. For example, if your baby is very sensitive to odors and finds a smell unpleasant, he or she may not want to eat while the smell is present.

• • • • •

Hold off on the purees and solids

For the first six months, breast milk or formula is generally the only food your baby needs. Its liquid form perfectly matches your baby’s eating skills, habits and digestive abilities.

Before age 4 to 6 months, your baby isn’t developmentally ready for purees and solid foods. At this stage, your baby still manages milk or formula by moving it from the front to the back of the mouth by sucking, then swallowing. This sucking reflex is aided by the tongue-protrusion reflex, in which the tongue pushes forward to help the baby suck. This reflex is still strong during this month and next, which means that it’s difficult for a baby to manage more-solid textures. Babies at this age tend to push out cereals or solid foods rather than swallow them, which can make spoon-feeding a frustrating experience for you and baby.

Signs that your baby may be ready for solid foods include good head and neck control, being able to sit supported, and opening his or her mouth when a spoon approaches — all skills that usually come a bit later (see Chapter 4 for more details).

• • • • •

Baby’s mental development

As the nerve cells in your baby’s brain mature, connect with other brain cells and become insulated with fatty myelin, your baby’s brain is able to assert greater control over the rest of his or her body. You can see this when you observe your baby making purposeful movements, such as bringing a hand up for inspection or reaching out for a toy.

To execute these intentional motor skills requires subtle complexities in thinking, reasoning and planning skills:

Interest. What is that thing dangling in front of me?

Speculation. What happens if I try to touch it?

Trial and error. Moving my arm this way seems to work better than moving it that way.

If your baby succeeds in making the toy rattle or make noise, for example, further information processing and analysis is required. What was that noise? How did it happen? Can I make it happen again?

Laying down tracks Repetition of experience is how memories are created in an infant’s brain. Over time, your consistent response to your baby’s needs — feeding, cuddling, bathing, soothing, carrying — lays down pathways among your baby’s brain cells that become reinforced and streamlined every time you respond in a similar manner.

By the third month, these memory pathways are becoming more clearly defined, and your baby is starting to have a better understanding of the connection between his or her behavior and your reactions. For example, your baby has figured out that by crying, he or she can get your attention fairly quickly, or that by smiling he or she is likely to get a smile in response.

Expanding communication At the same time, your baby is building an increasing repertoire of sounds and gestures as means of communication — squealing, growling, blowing raspberries and experimenting with consonant sounds.

As your baby approaches 3 and 4 months of age, he or she may initiate “conversations” with you by smiling, cooing or squealing. Acknowledging your baby’s overtures is sure to delight. Repeat the sounds your baby makes so he or she knows you’re listening. Also, talk back to your baby in “parentese” — use real words pronounced correctly and clearly but at a high pitch and with exaggerated tones. This helps your baby learn the sounds of your language. Most parents naturally use parentese when they talk to babies. So don’t be embarrassed; go ahead! Your baby will love it.

Once you’ve said your piece, pause to allow your baby to respond with a look, wiggle or sound. This will help him or her learn the rhythm and timing of effective communication.

• • • • •

Toys and games

As your baby becomes more interactive, it becomes even more fun to play together, especially when your baby discovers the ability to laugh sometime during this month or next.

Around this time, your baby may also become more interested in objects or toys that he or she can touch or hold. Choose toys that are lightweight, easy to grasp, drool resistant, too big to swallow and that don’t have sharp edges. Some examples include board books, soft blocks, wooden and plastic spoons, measuring cups, empty containers, rattles, balls and squeeze toys. As long as the toys are safe, let your creativity flow. (Avoid shiny plastic wrap or plastic bags, though, which can easily cover your baby’s mouth and nose and cause suffocation.)

Here are some other ideas for fun and games in the third month:

Get rolling To help your baby practice his or her rolling skills, lie side by side with your baby and encourage him or her to roll toward you. Your baby will try to do this with his or her whole body, which essentially means rolling over. In the beginning, babies usually find it easier to roll from back to side and then back again. Congratulate your child when he or she manages a roll. There’s no need to push or pull, though, as your child will perfect this skill in his or her own good time.

Touch and feel As your baby’s hands gradually open up, try placing different textures in his or her palm — soft, smooth, fuzzy, bumpy. See what textures your baby likes most.

Get a grip Place a toy or object in your son’s or daughter’s hand. Let him or her hold it, feel it and move it. Also, try this with objects that rattle, squeak or make noise. Share in your baby’s surprise when he or she succeeds in producing sound.

Set up batting practice Place your baby on an infant floor gym or play mat — the kind that usually has brightly colored, different-shaped objects dangling from it. Your baby can practice reaching and batting at the toys, as well as discover different shapes and textures. Another way to encourage reaching and grasping is to place your baby in an infant seat and offer items that are in front, just above or below, or just to the side of your baby’s eye level. These games also help your baby develop depth perception and hand-eye coordination.

Get giggling Almost all little kids love gentle tickling, especially if you deliver it with laughter and exaggerated facial expressions. Or try blowing a raspberry on your baby’s belly. Your baby may register surprise at first, but eventually these activities are sure to generate not just chuckles but deep-down belly laughs.

• • • • •

Baby’s social development

It doesn’t take long for parents and family to become the most important people in an infant’s life. Your baby’s world is centered entirely around you and your family. He or she is involved in your everyday lives, watching, listening and picking up clues on how humans interact. And your family will be the first people with whom your baby interacts.

• • • • •

View timetables with caution

Don’t worry if your baby doesn’t follow the exact timetable of development milestones outlined in these chapters. In some cases, your baby’s development may be well into the next chapter; in other cases the last chapter may be more appropriate. All babies go through the same progression of milestones, but each baby reaches them at his or her own individual pace (even babies with developmental disabilities). The timing of social development is likely to be even more variable than other aspects of development.

• • • • •

A real charmer Around this time, your baby is not only pleased with your attention but is starting to discover his or her own powers of attraction. With a smile or a squeal of excitement, your baby knows he or she can draw you out to respond in kind. Your baby is able to make and maintain eye contact, and interact more vigorously with those around him or her. Make your attention available when your baby seeks it. Try to carve out time away from distractions such as phones, TV and other devices.

Some babies even start to giggle or laugh in response to facial and vocal expressions or in response to touch. In general, laughter usually comes about a month after social smiling and is a great addition to your relationship!

At this stage, your baby has yet to develop anxiety about meeting strangers and may even be fairly outgoing and happy to meet other people. This may be an opportune time to introduce your baby to the concept of staying with grandparents or a baby sitter for a few hours and to develop a bond with these trusted adults. In a few months, your baby may not be so keen to be separated from you. But if he or she has been accustomed to the idea that although you may go away for a short while, you always come back, this may make it a little easier when it is necessary for you to temporarily leave your child in the care of another.

• • • • •

Returning to work

Around this time, many working mothers — and increasingly, fathers — are preparing to end family leave and return to work. It’s certainly not easy to leave a new little one in the care of someone else, even if temporarily, and especially after spending so much time together. In the meantime, though, nothing can change the fact that you are now a mom or dad and you have a baby who thinks the world of you. To make the transition back to work a little smoother, try some of these suggestions:

Let go of the guilt. Returning to work after having a baby often leaves many new mothers feeling particularly torn. But working outside the home doesn’t make you a bad parent — and it’s OK to look forward to the challenges and interactions of your job.

Talk to your boss. If you’re interested, you might ask about flexible hours, telecommuting or working part time.

Plan for feeding changes. If you’re breast-feeding and plan to continue doing so after returning to work, ask your employer about a clean, private room for breast pumping. About two weeks before returning to work, change your nursing schedule at home so you’re pumping during the day for at least one to two feedings and nursing before and after your upcoming work hours. Have someone else feed your baby a bottle of stored breast milk to help your baby adapt.

Start short. If you can, go back to work late in the week. That’ll make your first week back to work more manageable.

Get organized. Sketch out a daily to-do list. Identify what you need to do, what can wait — and what you can skip entirely.

Stay connected. Keep in touch with your baby’s caregiver to see how your baby is doing. Some caregivers may be willing to email or text you a photo or short video clip of your baby during the day.

Make backup plans. Know what you’ll do if your baby is sick or your baby’s caregiver is unavailable on a workday — whether it’s you or your partner taking the day off or calling a friend or loved one to care for your baby.

Maintain a positive attitude. Tell your baby how excited you are to see him or her at the end of the day. He or she may not understand your words but will pick up on your emotions.

• • • • •

Wanting attention During this month, you may also notice that your child cries not just to express a need or feeling, but in order to get your attention. In the coming weeks, crying in general will decrease (thankfully), but it’s likely to become more purposeful and directed at bringing you back to your baby’s side. Continue to respond quickly (or, as quickly as possible) and warmly, even if just by calling out to your child. This will help reassure your baby that you’re still there. This continued responsiveness helps to cement the trust and sense of security your baby feels in you.

• • • • •

3rd month milestones

During the third month, your baby is busy:

Raising head and chest to look around while lying on belly

Working on supporting upper body with arms while lying on belly

Holding head steady for longer periods while sitting

Playing with hands at eye level

Trying to bring hands to mouth

Swiping at dangling objects

Opening and closing hands, stretching fingers wide

Holding toys briefly

Stretching and kicking legs

Developing distance vision

Recognizing familiar people and objects from a distance

Using eyes and hands in coordination

Distinguishing between different colors, tastes and smells

Increasing repertoire of sounds to include squealing, growling, consonant sounds and maybe even giggling

Turning head toward sound

Making eye contact

Enjoying family and familiar faces, maybe even new people

Using expanding communication skills to express emerging emotions

Imitating some sounds, movements and facial expressions

Learning to self-entertain

• • • • •

CHAPTER 22 Month 4

Before you delve into month four, pat yourself on the back. You’ve made it through the first few months of parenthood, quite possibly one of the biggest transitions of your adult life. At this age, most babies have begun to adjust to life in this brave new world. They’ve also become much more secure in their relationship with their parents and their own abilities to adapt and react to their environment.

New families often find the next few months to be a joyous time. You’ve probably settled into a familiar routine, and eating and sleeping schedules are becoming more regular. The amount of time your baby spends fussing is probably on the decline. Your baby’s brain and nervous system have matured enough that he or she is ready to become much more interactive with family and friends, while continuing to explore new sights and sounds. Newborn reflexes are fading and your little one is starting to move and do things by design now. In addition, your infant is getting much better at conveying emotions and desires, and you’re getting much better at understanding him or her. In other words, the bond between the two of you is truly blossoming!

Take advantage of this time to enjoy each other’s company and revel in the little things — a giggle and a smile, a splash in the tub, or a bug on a window. Who knew life could be so exciting?

Baby’s growth and appearance

Between 3 and 4 months old, your baby’s growth is likely to slow a little, although you can still expect your baby to gain between ¾ and 1½ pounds over the course of the month and grow about ½ inch in length. Some babies may have doubled their weight by the end of the fourth month. Head circumference increases by about ½ inch. You’ll be able to compare notes with your baby’s medical provider at the 4-month well-child visit. Keep in mind your baby’s individual growth rate.

Skin rashes You’re getting ready to change your baby’s diaper, and there, right there, under your baby’s shirt is a bright red rash. Alarm bells go off and you rush to the phone to call your baby’s medical provider. This happens to just about every parent. And while you should always call your baby’s provider if you notice something unusual or are concerned about your baby’s health, you should also know that most skin rashes in infants are common and usually not serious. If the rash occurs along with a fever, call your baby’s provider promptly.

Rashes in babies often result from skin irritants, such as soap or scratchy fabric, or an underlying viral infection, such as a parvovirus infection or roseola. Because rashes are so visible, they’re a common cause of concern for new parents. Most of the time, though, rashes aren’t a sign of a serious problem and may not even require treatment other than proper skin care and perhaps a mild cortisone cream, as indicated by your child’s medical provider.

Some general rules of thumb for baby skin include avoiding long, hot baths and staying away from any substances or textiles that seem to cause a reaction. Using gentle moisturizers daily can help soothe and protect the skin. You can read more about common skin rashes in Chapter 7.

Bedtime routine It’s probably a safe bet that almost all new parents are hoping to find somewhere — in the pages of a book, in advice from a friend or on a website — the secret to getting their kids to sleep. Alas, there is no simple solution. Your child’s sleeping habits depend on a number of factors, including his or her age, the length of time he or she can go without feeding, and his or her personality. Some babies snuggle down without a peep and waken briefly for feedings. Others cry every time you put them in the crib and have a hard time lulling themselves to sleep.

During the first few months of your baby’s life, it’s important to respond to your baby’s cries and provide enough soothing to optimize sleep. But around the third and fourth month, you can start taking steps to help your child fall asleep on his or her own, an important skill that every child must eventually learn.

Parents at this stage often worry about letting their babies “cry it out.” There is plenty of advice out there on the “best” way to get your baby to sleep. See what method works best for you. In the meantime, there are a couple of things to keep in mind. One, a little bit of crying won’t harm your baby, and it won’t affect his or her attachment to you. Your overall approach of loving care is what bonds the two of you together. Two, if your son or daughter isn’t keen on self-soothing at first, hang in there. It can be tough initially, but one thing is for sure: This phase won’t last forever, and if you establish consistent bedtime practices, your child eventually will be “sleeping like a baby.” (Oh, the irony.)

For tips on how to help your little one sleep well, see Chapter 9.

• • • • •

What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the fourth month.

Eating Feed breast milk or formula exclusively. During this month, the number of daytime feedings generally decreases to about four or five, but a midmonth growth spurt may lead to more-frequent feedings for a few days. Although it may be tempting to get your baby started on cereal or other solid foods during this month, hold off a little bit longer until your baby shows clear signs that he or she is physically ready for solids (see Chapter 4).

Sleeping Expect your child to sleep about 15 hours a day, including more predictable nighttime hours of sleep — generally six to eight hours, although every baby is different. Around this age, babies become more-active sleepers, making noise, scooting around and often waking their parents. It’s OK to give your baby a few minutes to settle back down without your help. This allows your baby to learn to self-soothe upon waking at night. Although your baby is moving around more — maybe even starting to roll — it’s still important to put your baby on his or her back to sleep. By this time, your baby may also have settled into two to three daytime naps, lasting about an hour or two each. See Chaper 9 for more on sleep.

• • • • •

Baby’s movement

Around the fourth or fifth month, the newborn reflex that makes your child look like a baby fencer — when your baby’s head turns in one direction, the arm on that side straightens and the other arm bends over the head (tonic neck reflex) — begins to fade. This clears the way for further development of your baby’s gross motor skills — skills that involve his or her large muscles. At this stage, babies often seem “fidgety,” but they’re really exploring purposeful coordination of their large muscle groups to move around.

At 4 months old, most babies are exercising their arm muscles by pushing up with their elbows or hands when on their tummies. These minipushups give your baby a new vantage point and help strengthen muscles necessary for rolling. Some babies may even use this newfound arm power to scoot around in a circle or move around a few inches.

At the same time, your baby’s fine motor skills — skills that generally involve the hands and fingers — are being refined, as he or she works to improve his or her grasp.

Head and back control As your baby’s 4-month birthday approaches, he or she is achieving good control of the head and neck. Full head control is an important milestone that’s essential for other motor skills, including sitting, crawling and walking.

While lying down, your baby is apt to lift the head and shoulders to look straight ahead while resting on his or her hands and arms (a favorite portrait pose of photographers, and who can blame them? It’s downright cute).

When pulled up to a sitting position, about half of 4-month-old babies are able to keep their heads in line with their bodies. In fact, your baby may even lift his or her head to try to “help” himself or herself sit up. By the middle of this month, most babies can keep their heads steady when held in a sitting position.

While sitting, your baby’s back muscles are working on keeping the spine straight, reducing the hunched appearance.

Rolling over On average, this is the month that babies really get rolling. Some may have started rolling even earlier. But don’t worry if your baby isn’t there yet by age 4 months. You’ll probably notice some rolling attempts in the near future. A few babies even skip this milestone altogether.

Rolling from front to back, which requires only a shift in gravity, is generally easier than rolling from back to front. This is why many babies roll from front to back first. Giving your baby a little floor space and plenty of tummy time while he or she is awake will provide him or her with opportunities for practice.

Rolling from back to front, which tends to occur a little later, requires more complex maneuvering, such as rocking, arching the back, and twisting the legs to flip over. Each baby is different, though. Some roll one way; others another. Whether your baby is rolling or not, and which way, isn’t as important as whether he or she shows interest in moving from one spot to another.

Don’t wait to discover your baby’s ability to roll until he or she ends up on the floor from having rolled off the couch or bed. Take precautions not to leave your baby unprotected on elevated surfaces.

Standing By the end of the fourth month, most babies can, with a little help, bear their own weight on their legs. If you hold your baby upright, he or she will likely push down with his or her feet. In fact, you may start to feel as if your lap is an infant trampoline as your baby learns to bounce vigorously in that position. Standing and bouncing while well supported won’t hurt your baby’s legs or hips, but will give them (and you) a good workout. Just make sure you’re not trying to hold a hot cup of coffee or tea at the same time.

If your baby doesn’t push off with his or her feet right away at age 4 months, don’t fret. If your child still doesn’t do this at 6 months old, you might mention it to your child’s medical provider so that he or she can determine if further investigation is necessary.

Reaching and grasping During this month, your baby is likely to be busy waving his or her arms about, batting at nearby objects, and trying to reach them. If you present your baby with a rattle or similar toy, he or she is likely to grasp it, shake it, and maybe even bring it to his or her mouth.

You may notice that sometimes your baby intentionally looks at and reaches for an object. Other times, your baby’s hand may touch something and instinctively grab it, and your baby may seem surprised or intrigued by what has unexpectedly appeared in his or her hand. This change from grasping as a reflex to reaching for things voluntarily is gradual.

• • • • •

Keeping playtime safe

Your baby might not be crawling yet, but it’s around this time that babies start putting whatever (literally) they can in their mouths. Take advantage of this limited period of immobility to make sure the spaces you use to play with your baby are free of any potential hazards. Get into the habit of doing a “baby-level” safety check each time you put your baby down on the floor to play. Get down on your hands and knees, at your baby’s level, and look for these items:

Small objects your baby could accidentally swallow, such as coins, button batteries, magnets, paper clips, or small pieces of food or candy

Toys with small parts

Balloons

Uncovered electrical outlets

Pulls for window blinds, in which your baby could get entangled

Electrical cords to irons, lamps or other appliances that could fall if the baby tugs on the cord

Plastic bags or wrappings that could suffocate your baby

Newspapers and magazines

A pet’s toys or treats

Houseplants

These safety searches can become fun and helpful activities for older siblings to get involved in. Help them understand the things that can be harmful to a baby. This will increase their awareness about the hazards of leaving toys and objects around the play area.

• • • • •

Baby’s sensory development

Throughout these months and until your baby’s sixth month, your child will do a lot of exploring by touching, feeling and mouthing whatever comes across his or her grasp. Combined with hearing and seeing, these sensory skills promote the development of your child’s motor, mental and social skills. Seeing an object encourages your baby to reach for it. Grasping and touching the object helps your infant become familiar with it. Shaking and hearing it make noise helps your child learn about cause and effect. Listening to you respond to his or her accomplishment aids in his or her language development and social interaction. You can see how various aspects of development form a complex interplay that contributes to your child’s overall growth as a person.

Mouthing At this stage, your baby’s mouth is more sensitive to an object’s characteristics than are his or her fingers. Your baby also lacks the dexterity to manually investigate an object, but tongue and lips are perfect! And if your baby can’t bring the object of interest to his or her mouth, he or she will likely bring mouth to object by bending down to suck on it.

You can spend a lot of time discouraging your son or daughter from putting things in his or her mouth, or you can stockpile a variety of safe toys with interesting textures that will further pique your child’s curiosity and encourage oral exploration.

If your baby reaches for something dangerous, your best bet is to quickly remove it from sight and distract your baby with a more appropriate toy. At this age, your baby doesn’t understand that something may be harmful and is only interested in its appearance. This is why it’s especially important to safeguard your baby’s play area and remove any potential hazards.

Hearing Listening is another way of exploring an environment. By the fourth month, your baby may not only quiet at the sound of your voice but turn his or her head toward you, as well. He or she may also turn his or her eyes toward a specific sound, for example, a rattling sound or the sudden onset of music, to find out where the sound is coming from.

Vision By 4 months old, many babies have improved visual tracking abilities and can watch a brightly colored object as it moves in a slow arc overhead. You might also notice your baby focusing on very small objects, such as a piece of yarn or a crumb, and regarding things in the distance with great interest, such as a tree outside the window. Improving hand-eye coordination — being able to both see and reach for an object — further encourages his or her exploration instincts.

Baby’s mental development

Brain activity during these early months is at one of the highest peaks in a person’s lifetime. And as your baby becomes more mobile, you can really observe his or her curiosity begin to emerge. Everything is an object of interest, and your baby uses all of his or her powers — looking, touching, smelling, chewing — to discover and explore whatever’s nearby, including his or her own hands, cheeks, legs and other body parts.

Language skills Since birth, your baby has been building language skills by listening to others and by picking up communication clues from the inflection and tone of their voices. Although words are still a jumble by age 4 months, your baby is familiar with many of the sounds you make and may begin to experiment with making some of these sounds on his or her own. Warmly encourage these baby “conversations.” Talk about your surroundings and what you’re doing. Imitate your baby’s sounds. These exchanges between you and your baby are key to developing the nerve cell networks that form the foundation of your baby’s brain architecture.

Laughter During this month, your baby probably laughs out loud frequently. Laughter evolves out of cooing and gurgling and usually comes about a month after your baby’s first real smile. At first, the laugh tends to come in response to something — a laugh from you, a funny face from an older sibling. Your baby may also laugh to get your attention or just for the experience of making noise. In the coming months, though, you’ll notice the beginnings of a sense of humor. For example, something out of the ordinary may strike your baby’s funny bone.

• • • • •

Laughter as a life skill

Encouraging laughter and humor in your household can have benefits for both you and your family. Laughter can be a:

Bonding agent When people laugh together, they bond together over the shared experience and emotion. Laughing with your baby helps you become closer.

Stress reliever When the house is a mess, your clothes smell like spit-up and dinner is mediocre at best, balancing it all with a good laugh can diffuse the stress you might be feeling and unconsciously passing on to your children. Even babies sense when their caregivers are stressed and tend to reflect these emotions. So instead of rushing to load the dishwasher or check your work email, take a few minutes to giggle and laugh with your baby after a long day. It’ll make you and your child feel better.

Immune system booster Evidence suggests that a good belly laugh can actually increase immune system cells that fight viral illnesses and various cancers.

Resilience maker If you habitually show your children that you can still laugh, despite life’s curveballs and momentary imperfections, you’re ultimately teaching them about resilience and the ability to withstand distress, a skill that will serve them well throughout life.

• • • • •

Baby’s social development

During the fourth month, your baby likely is starting to show clear signs of recognizing you and other members of your family. If you have other children, they may be your baby’s most popular playtime friends. Children can easily make a baby smile and laugh.

For siblings, this is a “honeymoon” time. The baby is old enough to thrill an older brother or sister with smiles and giggles but still too young to be “trouble,” getting into toys and interrupting play.

At this age, your baby has yet to develop stranger anxiety and is likely to enjoy meeting new people, smiling, wriggling and laughing with anyone who will respond. This is a comfortable time for most parents. The baby is big enough that you’re not overly concerned about safe handling, and you know the baby is comfortable with someone else. At this age, it’s easy to share the fun of your baby with others.

• • • • •

Toys and games

Promote your baby’s motor development, pique his or her curiosity, and encourage exploration of the world around him or her with some of these activities and toys:

Practice sitting Once your baby can hold his or her head up fairly well, try sitting your infant up in a baby seat or against cushions for support. This will improve your baby’s sense of balance and help strengthen back muscles. Sit face to face and play singing and clapping games together. You can also set him or her up against the curve of your own body while you lie on the floor. Don’t expect the sitting to last too long at this point, though. After your baby topples over a few times or tires of sitting, switch to a different activity, such as belly play or reading a book together.

Choose toys that stimulate the senses Keeping in mind your baby’s penchant for mouthing at this age, choose toys that won’t be harmed by a little dampness or chewing. Soft books with textured corners and squeaky pages are both fun and practical. Other ideas include a bumpy teething ring, a ring of big plastic keys, measuring cups or soft blocks. Also, look for toys or everyday objects that your baby can practice holding on to, shaking and manipulating. Make sure the toys you choose have no small parts that can come off and pose a choking hazard to your baby.

Play mimicking games Starting around this age, your baby is becoming intent on studying the sounds you make and trying to produce his or her own versions. Take the time to listen to your baby’s vocalizations, then try to imitate his or her sounds. Talk back to your baby, speaking slowly and clearly, and allow him or her time to try to make the same sounds. If you speak a second language, use it with your child. Mimic facial expressions and laughter, too. This encourages your baby’s language skills and social interactions.

Enjoy bath time As it becomes easier for babies to sit when supported, parents often turn bath time into playtime. The weightlessness of the warm water and the freedom from restrictive diapers and clothing all make for a great sensory experience. However, remember that bubble bath and soap can be irritating to a baby’s eyes, skin and genitals. And keep a close eye and good grip on your baby. The water makes your wiggly, active baby extra slippery. Never leave your baby alone in a tub.

• • • • •

Distractions As your baby nears 4 months old, feeding times become less frequent, and his or her attention is drawn to other people and activities during feeding. Your baby may move around or stop feeding to play or “talk” to you. This distraction isn’t a sign that your baby is rejecting breast-feeding or is bored with formula. An easily distracted baby is normal as the baby discovers and explores the world. Your baby may discover that feeding time can be more than a time to eat; it’s also a time to socialize, experiment and assert some independence. As much as you want your child to learn through exploration and interaction, it can be frustrating to feed a distracted baby. You might try a quiet, uninterrupted feeding place. Early morning feedings — when your baby is still sleepy and the room is dark — may be the best feeding of the day.

• • • • •

4th month milestones

During the fourth month, your baby is busy:

Pushing up on elbows and hands to look around when lying on belly

Sitting supported with head steady

Practicing moves that enable rolling over

Bearing weight on legs, bouncing with arms supported

Grasping and shaking toys, practicing letting go

Bringing hands to mouth, exploring items with mouth

Studying small items

Gazing at things in the distance

Looking for the source of a sound

Becoming more communicative with body language and vocalizations

Laughing

Imitating language sounds

Engaging in back-and-forth “conversations” with you

Enjoying playing with others, capturing attention

• • • • •

CHAPTER 23 Month 5

Many parents eagerly look forward to this month because it means you can finally start introducing your baby to foods other than breast milk or formula. Food is a big part of human culture, and it plays a role not only in survival but also in societal traditions and pastimes. So it’s natural for parents to want to share the joy of eating favorite foods with their children. It’s also another step toward integration into the family when baby gets to join the others at the dining table.

As much as you may be excited to embark on culinary adventures with your baby, keep in mind your baby’s stage of growth and development. In this chapter you’ll read about signs that indicate that your baby is ready for solid foods, as well as tips on a successful introduction. You can read a more in-depth discussion of infant nutrition in Chapter 4.

During the fifth month, your baby gains increasing control over his or her body, enthusiastically exploring each newfound function. He or she is also continuing to discover new emotions, ranging from happy to grumpy, and solidly establishing his or her place in the family.

Baby’s growth and appearance

Between 4 and 5 months old, your baby’s growth rate is likely to match last month’s, which is a little slower than the first three months, but not by much. Most babies gain anywhere from just shy of 1 pound to 1½ pounds or more. Length and head circumference both increase by about ½ inch during this month.

Introducing solid foods Between this month and next, your baby will begin to develop the coordination to move solid food from the front of the mouth to the back for swallowing. At the same time, your baby’s head control will improve, and he or she will learn to sit with support — essential skills for eating solid foods.

Breast milk or formula is enough to meet your little tyke’s needs in the first four to six months. But eventually additional nutrition is necessary so that your baby can continue to thrive. After 6 months of age, for example, breast milk alone generally isn’t enough to provide your baby with the amount of energy, protein, iron, zinc and other nutrients he or she requires.

Is your baby ready? Sometime between ages 4 and 6 months, most babies are ready to begin eating solid foods as a complement to breast-feeding or formula-feeding. But age should not be the only determining factor. You want to make sure your child is both physically and socially ready. And you shouldn’t feel pressured to begin solids. The American Academy of Pediatrics prefers that parents wait until a child is 6 months old to introduce solids, if possible. If you’re not sure whether your baby is ready for solids, ask yourself these questions:

Can your baby hold his or her head in a steady, upright position?

Can your baby sit well with support?

Is your baby interested in what you’re eating, perhaps eyeing your breakfast toast or opening his or her mouth if you offer a spoon?

If you answer yes to these questions and you have the OK from your child’s doctor or dietitian, you can begin supplementing your baby’s liquid diet. Read more about what to serve when and which foods to avoid in Chapter 4.

Tips for a successful meal Once your baby starts eating foods besides breast milk or formula, feedings are likely to become a lot more interactive and, most probably, a lot messier! But that’s OK. It’s all part of the process of exploring new things. Here are some suggestions for when your little one reaches the point that he or she is ready to try solids:

Pick a happy time For your first try, choose a time when your baby’s most likely to be open to adventure, such as when he or she is alert, dry, comfortable and not starving. If your baby’s very hungry, you might want to start off with a little breast milk or formula first and then switch to solids.

Set your expectations Remind yourself that the goal of these first solids is to introduce your baby to the experience of food, rather than to meet your child’s nutritional needs. In fact, it will likely be several weeks before the amount of food that actually gets into your baby’s belly is contributing to his or her overall nutritional requirements.

Sit up At first, try feeding your baby propped up in your lap or in an infant car seat. When your baby can sit without support, you can move him or her to a highchair.

Try a spoon The American Academy of Pediatrics recommends encouraging your baby to use a spoon or fingers to self-feed. A small espresso spoon or a rubber-coated baby spoon usually works well. Eating off a spoon helps your baby learn to swallow without sucking, and allows your baby to learn the process of eating in the same way the rest of the family eats. Avoid giving your child cereal in a bottle, which may encourage excessive calorie intake.

Start small For your baby’s first meal, start out with just a couple of spoonfuls of food, such as cooked cereal or pureed meat or vegetables, in a bowl. Thin the complementary food with breast milk or formula until it’s the consistency of heavy cream, to help ease the transition from bottle to spoon. Over the next few meals, you can gradually make the consistency thicker as your baby becomes accustomed to swallowing solid foods.

Be patient Although some babies seem thrilled with their first bowl of “big kid” food, others may not be convinced of its joys the first time around. If your baby flat-out refuses the first feeding, don’t give up hope. Clear the food away and try again a few days later. Focus on enjoying mealtime rather than getting your baby to eat solid foods by a certain date. He or she will have plenty of time to warm up to the spoon as another vehicle for gastronomic delights.

The scoop on poop Once you start feeding your baby solid foods, you’ll likely notice a difference in the texture, color and smell of your baby’s stools. Solid foods make for more solid stools. Foods such as peas, blueberries and beets can make noticeable differences in the color of stool as well. Last but not least, get ready for stinky stools. The added sugars and fats in solid foods can lead to a stronger odor.

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What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the fifth month.

Eating Breast milk or formula still plays the central role in your little one’s nutrition, although some parents begin to introduce solid foods during this month. Be sure your baby is developmentally ready for solid foods before starting them, such as being able to swallow, hold his or her head steady, and sit with support.

Sleeping Your baby is more likely to sleep six to eight hours at night with no interruption. Some babies still wake up once or twice during the night for a feeding. Total sleep may add up to between 14 and 15 hours in a 24-hour period, including a couple of daytime naps, usually one in the morning and one in the afternoon. Some babies may need a third nap late in the afternoon.

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Baby’s movement

Between 4 and 5 months old, most babies achieve the first big milestone — good head control. By the end of this month, your baby is likely to be able to hold his or her head up steadily while sitting. He or she will also learn to turn the head from side to side, making it easier to track moving objects and identify different sounds and voices.

Once your baby has full head control, he or she has the skills necessary to move on to sitting. And just in time, too. As your baby gets older, he or she may become increasingly less satisfied with lying either faceup or facedown and will probably want to spend more time upright. During this month and next, your baby is working toward sitting up without help. Playing facedown on the floor and lifting the head and chest to see toys are good exercises to help your baby strengthen neck muscles and develop the head control necessary for sitting up.

Rolling over At this point, most babies are making progress in their attempts to roll over, too. By the end of this month, some babies can even roll both ways without help. Once babies learn to roll from front to back and back to front again, they may start out sleeping on their backs just the way they were laid, but then flip over in the middle of the night. If this happens with your baby, don’t feel compelled to flip him or her back again. The risk of SIDS begins to decrease once your baby gains head and neck control and is able to roll over.

Reaching and grasping During the fifth month, you may notice your baby start working for a toy or other object. At first, this may mean that he or she reaches out for a toy but may not be able to grasp it on the first try. At 4 months of age, your baby still manipulates objects by batting at them. But eventually he or she may try to pick up a larger object by pressing it with the palm of the hand and curling the fingers around the object. When your baby does get a hold of a toy, he or she may grasp it with both hands and have fun shaking it around. Dangling toys are still a source of entertainment at this age and help your child further develop his or her hand-eye coordination.

Bouncing Your 4-month-old most likely gets great joy out of being upright and “standing” on your lap, and perhaps bouncing. All the bouncing your baby does is a part of normal development and isn’t harmful to your baby’s hips, legs or feet. By about 5 months, you will notice that your baby can probably bear full body weight on his or her legs. Standing alone and walking are still a long way off, but you can see how the small stages of development are preparing your baby for greater mobility.

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Getting kids to like fruits and vegetables

A common battle parents face as their kids begin to eat solid foods is getting them to eat their fruits and vegetables! Scientists are finding that part of the solution to this dilemma may very well go back to the mother’s own eating habits, perhaps even before a baby is born.

Since a number of food flavors are transmitted via amniotic fluid or breast milk to a baby, what the mom eats affects the baby’s early experiences with flavor. Some evidence suggests that the more often a baby experiences a particular flavor — such as carrots, for example — during pregnancy or breast-feeding, the more accepting the baby is likely to be of that taste when he or she begins eating solid foods. And because breast-feeding offers a child a greater variety of flavor experiences due to a mother’s varying diet, breast-fed infants seem less picky and more willing to try new foods.

Another finding suggests that flavor learning after the introduction of solid foods is based on repeated exposure to new foods. One study, for example, found that the first time a group of babies tasted green beans, many squinted, raised brows or upper lips, or wrinkled noses. But after repeated offerings of green beans, expressions of surprise or distaste were fewer, and willingness to eat the vegetables was greater, especially if the green beans were followed by a sweet-tasting fruit, such as peaches.

This type of research is ongoing, but in the meantime, it doesn’t hurt to eat well yourself and keep setting the good stuff out there. Chances are good that eventually your kids will enjoy it for themselves, and not just because you said so.

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Encouraging physical activity Take a look around your local baby supply store, and you’ll see an amazing range of infant equipment — swings, playpens, infant seats, stationary activity centers, walkers, baby gyms, bouncy chairs — oh my! And with your baby learning so many new skills, it’s tempting to try to physically help him or her along with the latest gadget. Quite a lot of infant equipment is marketed with the idea of helping your baby reach a new milestone, such as sitting or walking.

Truth? What infants need more than anything to develop their motor skills is freedom of movement in a safe space that allows them to explore their surroundings and to practice their budding skills under the watchful eye of a nearby caregiver. Warm interaction with a supportive caregiver during playtime also is important.

Does that mean you have to be constantly down on the floor with baby? Not always. Certain pieces of baby gear can definitely come in handy, such as a stationary activity center where your baby can sit and bounce or play with attached toys, or a molded seat that helps your baby sit up. Swings and playpens also can be essential at times. But keep in mind that these items are mostly for your convenience, allowing time for you to move about unrestricted, to do some chores, say, or eat breakfast. Try to limit the amount of time your child spends in these devices, as extended movement restriction in turn may limit your child. Be sure to supervise older siblings around these devices, too, as they may become overenthusiastic in “helping” the baby use them, potentially causing unintentional harm (think “Mom, look how fast Sammy can go in the swing!”).

The American Academy of Pediatrics (AAP) advises specifically against using mobile walkers. These devices generally have a cloth seat set in a frame with wheels that allow the baby to move around the room even though he or she might not be able to crawl or walk yet. A number of studies have shown that these devices can make a baby more prone to injury, such as falling down steps or reaching for dangerous objects. Even under supervision, the AAP contends that walkers are simply too fast for a parent to reach before an accident happens. Other experts have cautioned against the use of door jumpers — seats that hang from a door frame — as well. If you need a place for your baby to safely amuse himself or herself for a few minutes, consider a stationary activity center or playpen instead. A highchair also can serve this function, once your baby is able to sit in it safely.

Keep in mind that if your baby has a developmental disability, his or her medical provider may in fact recommend certain pieces of equipment to help your baby sit with support or move with help.

Baby’s sensory development

During this month, mouthing becomes an even more important avenue of exploration for your young child. Keep offering him or her safe toys and everyday objects to practice the art of picking things up and bringing them to the mouth. This helps your baby develop sensory and motor skills. At the same time, keep a sharp eye out for anything that might be a choking or poison hazard for your baby.

Vision Earlier, your baby was learning to distinguish between similar bold colors. Improved visual awareness during this month and the next helps your baby discern more subtle shades of color, such as soft pastels, although bold colors may still be favorites. Improved visual tracking and coordination also help your baby become more adept at reaching and grabbing larger objects and toys. Small objects are definitely catching his or her attention at this point, but he or she doesn’t yet have the dexterity to pick these up.

Babies at this age are also starting to discriminate between the different emotions they see in others — such as joy, fear or sadness — and to make similar responses.

Hearing Between 4 and 5 months, about half of all babies turn their heads toward a voice. Most babies at this age will turn toward a rattling sound to investigate its source. At this age, babies also learn to distinguish emotions by tone of voice.

If by this month your baby doesn’t respond to sounds, talk to his or her medical provider. Although newborns are generally checked right after birth for hearing loss, your observations at home are key to identifying the need for further testing.

Baby’s mental development

As the brain develops, and more and more connections are made between brain nerve cells, your baby’s memory of faces, sounds, places and event patterns increases. Although your baby has been absorbing information about the surrounding world since birth, he or she has had only limited ability to respond to this new knowledge. But as his or her motor skills increase, you can observe your infant begin to apply the knowledge stored in his or her memory.

This is evident in the way your baby reacts to seeing you or to certain daily routines, such as a feeding or a bath. If you sit in your favorite chair for breast-feeding or a bottle, you may notice that your baby quickly settles in with you and may make noises or kick in anticipation of what he or she knows is coming. And if for some reason what’s expected isn’t forthcoming, you may hear a squawk or two of displeasure.

Learning how things work At the same time, your baby’s curiosity and attention span are increasing. This allows him or her to spend more time examining things and observing how things work. This natural curiosity also drives your baby to start to work for objects that are out of reach. Even if he or she can’t quite get to a toy yet, you can see the focus and concentration in your child’s eyes.

During this month, your baby is also learning more about cause and effect. When he or she cries, you come. When he or she bangs a toy on the table, it makes noise. When he or she giggles, siblings giggle, too.

Like a scientist, your baby may test different actions over and over to see if they always get the same effect. And, like a successful scientist, your baby will be proud every time the response is the one expected. You’ll appreciate your baby’s smiles and squeals of accomplishment and self-confidence.

Language skills Your 5-month-old may have already started imitating some of the speech sounds you make, even though it will be a few more months before he or she understands how these sounds work together to communicate. During this month and the next, your baby is likely to pick up on a single sound — such as ah or oh — and repeat it over and over, and then a few days later discover a new sound and practice it repeatedly. Babies seem to enjoy playing with a new sound as much as they delight in playing with a favorite toy. Pretty soon, your baby will be babbling away at you, excited to hear sounds emanating not just from others, but from his or her own mouth.

Continue talking to your baby every chance you get. Regular face-to-face interaction with your baby is a key building block for mental, emotional and social development. When you respond positively to your baby’s bids for interaction, you’re teaching him or her how relationships work and solidifying the secure attachment your baby has to you.

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Toys and games

At this young age, babies are interested in very simple objects and toys. They also don’t need a heap of toys to stay occupied. In fact, too many toys or too much activity can overwhelm your baby and lead to tears. Limit toys to just a few at a time. That way your baby can take the time to study each one and see what it can do. Toys and games your baby may enjoy during this month include:

Toys that make noise By now, your baby is starting to play purposefully with rattles and toys that squeak or make noise. Offer him or her toys that make noise to enhance his or her discovery of cause and effect as he or she bangs and rattles about. Infants also seem to derive great joy from pressing buttons that make things happen, such as on a pop-up toy or a baby phone.

Music to bounce, sway or swing to Music can help express emotions and thoughts when the words aren’t quite there yet. Most babies love music and will move along to a rhythm they find catchy. Make a playlist of your favorite kid-friendly (but not necessarily kiddy) songs, and play them for your baby. Better yet, pick your baby up and sing and dance around the room together in accompaniment to the music.

The company of a mirror Place an unbreakable mirror in front of your baby and watch as he or she and “the other baby” get acquainted. At this age, your baby probably won’t know that it’s his or her own reflection, but will have fun watching his or her antics, regardless of perception.

Stuff to reach for While your son or daughter is lying prone on the floor or sitting upright, place a couple of bright toys or objects just out of his or her reach. This will encourage your child to practice reaching skills and improve his or her hand-eye coordination.

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Baby’s social development

At this age, your baby is quickly figuring out how to express a variety of emotions through facial expression, vocalizations and body language. For example, he or she now uses laughter to express happiness and excitement. At the same time, your baby may start to show dislikes, making a face or turning away from things he or she doesn’t care for. You may notice this latter type of reaction more as you introduce new foods to your child or you start to set limits to your child’s actions for safety’s sake.

Growing attachment By the fifth month, your baby is establishing a solid place in the family structure and clearly knows who his or her loved ones are. Your baby feels comfortable with the family routine and indeed expects it. Spending time with you is still his or her favorite activity. In fact, this closer sense of attachment to you and other family members may lead your baby to feel upset and display unhappiness when you stop playing a game or leave the room. He or she may even need a little extra reassurance that you’re still available — perhaps by talking to him or her or singing a song — and will return as soon as possible.

This narrowing focus of attachment goes hand in hand with a gradual realization that some people are strangers. Although your baby likely still has an accepting, welcoming response to unfamiliar people, in the months ahead, you’ll notice that he or she is becoming increasingly picky about the company he or she wants to keep.

Emerging personality As your baby matures, his or her personality traits will rapidly become more apparent. Is your baby bouncy and full of energy? Or perhaps more quiet and cautious? Is he or she easily frustrated when a goal can’t be obtained? Or is your infant persistent to the point where you might call it stubbornness? Does your baby adjust easily to new environments, or does he or she take a while to warm up?

Everyone is born with certain behavioral characteristics that form his or her basic temperament. Depending on the situation, a temperamental trait can be pleasing or frustrating to you as a parent. For example, the same high energy that makes your baby so fun to play with — pleasing — can also make for difficult diaper changes or wriggly feedings — frustrating!

Generally, your baby’s natural traits can’t be changed — it would be like trying to change his or her personality. But by learning your baby’s normal behaviors and understanding his or her temperament, you can better appreciate your infant and adjust your parenting style to bring out the best in him or her. How you interact with your baby now can set the stage for your relationship throughout childhood, adolescence and even adulthood. You can read more about temperament in Chapter 11.

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5th month milestones

During the fifth month, your baby is busy:

Perfecting mini-pushups while lying on belly

Sitting balanced by hands on floor in front (tripod style)

Bearing weight on legs

Rolling over from front to back, maybe even back to front

Working to get to a toy

Grasping with both hands

Exploring with mouth

Studying small objects

Locating sounds and voices by turning head

Imitating speech sounds

Repeating single sounds

Laughing, squealing

Expressing dislikes, making faces

Enjoying playing with others, crying when playing stops

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CHAPTER 24 Month 6

As you approach your baby’s half-year mark, think about how far you’ve both come. By now, that little person in the nursery is no longer a baby, but a world-class explorer. And you have become an ever more confident parent, familiar with the rhythms of baby care and more secure in your ability to meet upcoming challenges.

During this month, your baby is becoming more adept with his or her hands and may even start to sit unsupported by the end of the month. Each aspect of your baby’s motor and sensory development gives your baby new tools to explore the world and expand his or her mental and social development. This is a fun time as your baby babbles and laughs, excited to be part of his or her family.

Baby’s growth and appearance

By the time the sixth month rolls around, many babies have doubled their birth weight. Your baby’s growth rate this month is likely to be similar to last month’s — weight gain of 1 to 1½ pounds or more and an increase in length and head circumference by about ½ inch. But don’t be surprised if the growth rate starts to slow down in a few weeks. Most babies grow a little more slowly during months seven through 12 than they did in the first six months.

Teeth! Drooling, crankiness and tears — could it be baby teeth coming in? Although timing varies widely, many babies begin teething by about age 6 months. The two bottom front teeth (lower central incisors) are usually the first to appear, followed by the two top front teeth (upper central incisors).

Classic signs and symptoms of teething often include:

Drooling, which may begin about two months before the first tooth appears

Irritability or crankiness

Swollen gums

Chewing on solid objects

Many parents suspect that teething causes fever and diarrhea, but researchers say this isn’t true. Teething may cause signs and symptoms in the mouth and gums, but it doesn’t cause problems elsewhere in the body. If your baby develops a fever, seems particularly uncomfortable, or has other signs or symptoms of illness, contact your child’s medical provider. Otherwise, teething can usually be handled at home.

If your teething baby seems uncomfortable, consider these simple tips:

Rub your baby’s gums Use a clean finger, moistened gauze pad or damp washcloth to massage your baby’s gums. The pressure can ease your baby’s discomfort.

Offer a teething ring Try one made of firm rubber. The liquid-filled variety may break under the pressure of your baby’s chewing. If a bottle seems to do the trick, fill it with water. Prolonged contact with sugar from formula, milk or juice may cause tooth decay.

Keep it cool A cold washcloth or chilled teething ring can be soothing. Don’t give your baby a frozen teething ring, however. Contact with extreme cold may hurt, doing your baby more harm than good. If your baby’s eating solid foods, offer cold items such as applesauce or yogurt.

Dry the drool Excessive drooling is part of the teething process. To prevent skin irritation, keep a clean cloth handy to dry your baby’s chin. Saliva is used in the digestion of food. So it makes sense for the body to produce more saliva at the time when infants typically begin solid foods.

Try an over-the-counter remedy If teething is making your baby especially cranky, acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others), if your baby’s 6 months or older, may help. Don’t give your baby products that contain aspirin, however, and be cautious about teething medications that can be rubbed directly on a baby’s gums. The medication may be washed away by your baby’s saliva before it has the chance to do any good — and too much of the medication may numb your baby’s throat, which may interfere with his or her normal gag reflex.

Caring for new teeth Ideally, you’ve been running a clean, damp washcloth over your baby’s gums every day. If not, now’s a great time to start. The washcloth can keep bacteria from building up in your baby’s mouth. When your baby’s first teeth appear, switch to a small, soft-bristled toothbrush. Use a small smear of toothpaste, about the size of a grain of rice. If you have well water or you use bottled water in your home, your baby may not be getting necessary fluoride for healthy tooth development. Discuss this issue with your child’s medical provider.

It’s also time to think about regular dental checkups. The American Dental Association and the American Academy of Pediatric Dentistry recommend visiting the dentist after the first tooth erupts, although many dentists recommend visiting by age 3 if there are no concerns. Your baby’s teeth and gums will also be examined at well-baby checkups. Regular childhood dental care helps set the stage for a lifetime of healthy teeth and gums.

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What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the sixth month.

Eating Breast milk or formula still plays the central role in baby’s nutrition, although most parents will begin to introduce solid foods by the end of this month. Be sure to feed your baby in a seated position, and avoid hard, chewy or round pieces of food that could potentially seal off your baby’s airway.

Sleeping Your baby is more likely to sleep six to eight hours at night without interruption. Some babies still wake up once or twice during the night for a feeding. Total sleep may add up to between 14 and 15 hours in a 24-hour period, including a couple of daytime naps, usually one in the morning and one in the afternoon. Some babies may need a third nap late in the afternoon.

• • • • •

Baby’s movement

By 5 or 6 months old, most babies have achieved pretty good head control and are rolling over both ways. By now, they may be ready to move on to learning how to sit without help. By 7 months or so, most babies have learned to sit independently, but some may wait until 9 months to do so, which is within the typical range.

At the same time, baby’s hand control skills are rapidly improving, allowing your child even more flexibility in exploring his or her surroundings, and even other parts of his or her body.

Tripod sitting Your baby’s first attempts at sitting will probably be very entertaining. At first, he or she will sit hunched over, balancing on arms extended to the front. Experts sometimes call this the “tripod sitting” stage. Almost anything will topple a baby in this position — leaning a little to one side, a distraction that makes the baby look in another direction or any attempt to shift weight.

This hunched-over sitting takes all of your baby’s energy. He or she probably can’t do much else but hold his or her head up without falling over. In a few weeks, though, your baby’s strength and balance will improve and he or she will be able to sit upright.

Toes, toes, toes! If your baby hasn’t discovered his or her toes yet, he or she is likely to do so this month. When fingers don’t seem so novel anymore, baby may catch sight of those wiggly things at the end of his or her feet and bring them up for investigation. At first, your baby may explore those little toes just by grabbing and feeling them. But sooner or later — with the help of incredibly flexible limbs — your baby is likely to bring toes to mouth for a good sucking.

Picking up and letting go By age 5 or 6 months, your baby’s hand control is good enough that he or she can reach for a desired object using a rake-like motion and grasp it. After learning to grab a toy, your baby will practice moving things from hand to mouth, using both touching and tasting to explore the toy. You may even see your baby repeating the hand to mouth to hand movement, taking the object out of his or her mouth with alternating hands. By 6 months, your baby may learn to move something directly from one hand to the other.

Your baby will soon discover that letting go of something is as much fun as picking it up. At first, letting go is almost accidental. As soon as your baby learns to hold something, he or she will also drop it. But over the next few months, he or she will begin to let go more purposefully. By the end of your baby’s first year, he or she will have acquired other means of getting rid of unwanted objects, such as throwing them or pressing them down on a surface.

At this age, babies still use their whole hands to pick things up. When babies are relaxed, their hands are open; by now, they’ve outgrown the closed-fist pose of younger babies. You can see the slow progression from that tight-fisted infant to a more mobile and coordinated baby. Right now, your baby is just beginning to use hands for small tasks. And it’s hard work! Watching your baby, you can probably see the amount of effort that goes into this kind of “play.” When your baby reaches for an object, his or her other hand may mirror the movement of the reaching hand. Both hands may close as one hand reaches for and grasps a toy.

• • • • •

A lefty or a righty?

At this age, it’s too early to tell whether your baby is left-handed or right-handed. For now, babies may seem to favor one hand for a while, then switch and use the other hand more often. A 1-year-old may use both hands equally. By 18 months to 2 years, toddlers start to show a preference for which hand they use. Still, true handedness isn’t usually determined until a child is about 3 years old.

Handedness develops naturally, although scientists still aren’t sure what role genes play in it. Children with left-handed parents have an increased chance of being left-handed, but the inheritance pattern isn’t clear-cut.

If you do notice when your child is an infant that he or she favors one hand over the other, let your medical provider know. Sometimes, further investigation is necessary to make sure that both hands do, in fact, work equally well.

• • • • •

Baby’s sensory development

Although your baby’s senses will continue to mature throughout early childhood, they’re now almost as fully developed as those of an adult. Your baby sees and hears the world almost as clearly as you do, and this ability allows the two of you to understand and share many of the same experiences.

Vision By 6 months of age, your baby has more clearly focused vision and can probably track the course of a falling toy or other object quite smoothly. Ongoing development of your baby’s visual system allows for greater depth perception. And now that your baby is sitting upright more often, he or she can gaze across at you and at other things, rather than just look up. Both of these skills — increased depth perception and the ability to look across — come in handy, such as when baby is learning to eat solid foods, and you’re aiming a spoon full of cereal at his or her mouth.

During this month, your baby is also able to take in more-complex visual images and observe them studiously. You might notice this increased visual curiosity when your baby picks up a toy and examines it, although eventually it’s likely to end up in his or her mouth for a truly thorough examination. Looking at picture books together is great fun at this age, as are sturdy board books that provide visual interest as well as something for your baby to practice manipulating with his or her hands.

Hearing By the end of this month, most babies respond readily to sound and turn their heads quickly toward the direction of a voice or other noise. With improving memory and increasing exposure, they may even be able to distinguish between male and female voices.

Touch In addition to exploring his or her environment, your baby is discovering all sorts of new things about himself or herself. By touching his or her own cheeks, nose, toes and genitals, your baby is becoming familiar with the contours and shapes of his or her body. Baby also continues to explore textures and shapes. Offer new surfaces and objects for your baby to touch, such as a branch or smooth rock. Be aware that most objects will quickly go to your baby’s mouth, so be sure to supervise baby’s tactile exploration.

Baby’s mental development

Between 5 and 6 months, your baby is working out some of the first inklings of his or her own identity, what it feels like to be a separate person with individual powers of action and reaction. In parallel with these discoveries, your baby is uncovering the possibilities that exist for interaction with others.

As your baby’s memory expands, he or she can start to roughly catalog his or her experiences — the kitchen floor is hard, daddy’s beard is prickly, this toy is fun to gum, the music comes from there, and so forth.

Me, myself and I Combining sensory, motor and mental skills, your baby begins to realize that moving certain muscles always produces physical sensations that correspond with specific visual results. For example, baby’s effort to kick his or her legs is always accompanied by the sight of these legs moving.

Sensations associated with self are easier to reproduce with regularity than sensations associated with others. Every time your baby kicks, he or she can see his or her legs move. But every time he or she cries, the sight of you may or may not appear immediately.

Playing becomes serious business At the same time, playing rises to a new level. Toys that stimulate the senses and simple games, such as peekaboo or mimicking games, become the tools and experiments of your small adventurer. Even the process of getting your attention requires a certain amount of strategy and can become a game for baby.

Again, you don’t need expensive toys to stimulate your child’s mind and senses. Common household items with different shapes and textures — such as cardboard boxes, egg cartons, lids, paper towel rolls, spoons, tea towels and nesting bowls offer plenty of opportunities for sensory exploration and discovery. Homemade noisemakers (think tightly capped containers filled with rice) are fun to shake and prod, and a plastic lid filled with water placed on the highchair tray is sure to intrigue.

Peekaboo is still fairly magical because your 5- to 6-month-old hasn’t quite grasped the concept that you’re still there behind the blanket even though he or she can’t see you. This memory of things not immediately visible is called object permanence. Your little one may, however, look for a dropped toy but give up quickly if it’s not in sight.

Mimicking games become more important as your baby strives to match your facial expressions and imitate the sounds and cadences of your voice.

• • • • •

Toys and games

Now that your baby is becoming more comfortable sitting upright, he or she has a whole new vantage point from which to watch, play and interact with the world. And as baby’s sensory and motor skills continue to develop, he or she will become much more interested in anything that provides additional opportunities for adventure and discovery.

Colorful books and magazines Your baby’s vision is such that now he or she is able to focus on an entire pattern and distinguish a range of colors. Reading colorful board books together becomes especially fun at this age. Simple texts allow you to repeat sounds that your baby can try to repeat. Don’t be offended if baby decides to take over, though, turning the pages or flipping back to the cover every time you try to read the next page. At this age, the main idea isn’t to understand the story line but to make sounds, look at pictures and chew on the covers. Old magazines that you don’t mind being torn up can also be fun to look at; just make sure baby doesn’t eat the pages.

Short trips Once your baby is able to sit up in a stroller, walks around the neighborhood or the park take on a whole new dimension. Now your baby can see most of the things you see and will enjoy the sight of a passing dog or a squirrel hopping to the nearest tree. With a turn of the head, your baby can locate different sounds, too, such as the honk of a goose or the sounds of children playing. If it’s nice out, place your baby on a patch of grass and let him or her feel the differing textures. Trips to the zoo or your local library also become more entertaining at this age, but don’t expect them to last too long — it’s probably best to keep them to under an hour or two to match your baby’s finite stamina and short attention span.

Bouncy lap games Good head control also allows for slightly more-physical games. Almost all babies seem to love bouncing around on a grown-up’s lap. Have your baby sit on your lap facing you, hold his or her hands, and bounce him or her gently on your knees while singing a song. If you don’t know any kid songs, ask your parents or grandparents. They’ll probably remember some, and it will be fun to hear what they sang to you at one point. Or try looking up nursery songs and rhymes. Here’s a classic to get you started:

Pat-a-cake, pat-a-cake, baker’s man,

Bake me a cake as fast as you can.Roll it, and prick it, and mark it with a B

And put it in the oven for Baby and me!

Reach! Once baby is able to raise his or her body up on straight arms while lying belly down on the floor, you can start encouraging him or her to reach out with one arm for a toy just ahead. Eventually, your baby will lean on one arm and reach for toys with the other. This act of reaching forward is generally the first step toward crawling. Rolling balls or other toys also provide an incentive for chasing.

• • • • •

Babbling Babbling usually begins with babies trying out vowel sounds, something you may have already noticed your baby doing. A few weeks later, baby may start to add in consonant sounds. By 6 months, about half of all babies babble by repeating one syllable over and over, such as mah or bah. Some babies may even have started adding more than one syllable to their babbling. You may hear your baby cheerfully practice one kind of sound, then move on to something else and not repeat the first sound for several days.

Much of your baby’s “talking” may seem more like sound effects than babbling. Squeals, sliding pitches and bubbling sounds are all common for babies at this age. Giggles and laughter are favorite sounds for both babies and parents.

• • • • •

Playing with siblings

An older brother or sister can get a lot of enjoyment out of a 5- to 6-month-old baby. By six months, the baby has moved beyond face-to-face interaction and may even play with toys offered by an older child. Your baby can probably entice a bigger brother or sister into picking up dropped toys or playing passing games.

At this age, it’s important that your baby have personal toys separate from an older sibling’s toys. Illnesses can be easily spread from one child to another through shared toys. Keep the baby’s toys clean. Plastic toys should be washed often, and fuzzy toys that aren’t as easily washed should be reserved just for the baby’s play.

Babies love older kids mostly because they’re fun to watch. Although babies will play some turn-taking games, they delight in being an audience and responding to what older children do. For safety reasons, always supervise playtime between your baby and an older child.

• • • • •

Baby’s social development

This is a fun age to socialize and play with your baby. Adults have the remarkable ability to show almost any emotion through facial expression, and babies love to watch and try to imitate these expressions. Sharing emotional states with someone else is vital for social development and is one of the basic foundations for communication.

Don’t be discouraged if playing with your baby seems uncomfortable at first. Remember, it’s been a few years since you spent your evenings on the floor with rattles and a box of blocks. Watch the “expert,” observing which toys your baby is drawn to and what he or she does with them. Then join in. Soon you’ll know what games and toys make playtime fun for your baby. Your baby will give you the kind of immediate response — giggles, turn-taking, smiles — that make playtime rewarding for both of you.

Your baby will let you know if playtime is too intense or has gone on too long. Watch for clues that he or she is overstimulated, such as turning away or becoming grouchy or tense.

Don’t be surprised if you feel your baby needs even more attention now than in the newborn days. Your baby wants and needs stimulation, especially from you. Left alone in a playpen, crib or infant seat, he or she is apt to become bored. But life doesn’t have to be all games and playtime. You can meet many of your baby’s social needs by including him or her in your daily tasks or just by positioning baby where he or she can watch you at work.

• • • • •

6th month milestones

During the sixth month, your baby is busy:

Maintaining good head control

Rolling both ways

Working toward sitting independently

“Raking” small objects toward self

Picking up toys with both hands

Bringing toys to mouth

Exploring with mouth

Learning to self-feed

Perhaps transferring an object from one hand to the other

Repeating single syllables, maybe even combining sounds

Giggling, laughing

Exploring own body

Differentiating between self and others

Enjoying simple games

Looking briefly for dropped toy

Mimicking and sharing your emotions

• • • • •

CHAPTER 25 Month 7

The next few months are a time of growing independence for your little one. This can be both exhilarating and frightening for an infant. You may find your baby vigorously venturing into new things, but afraid to be too far away from the security of what he or she already knows — you. By sharing in your child’s curiosity while still providing lots of affection and comfort, you can help your baby become more confident and competent in his or her evolving skills.

From month seven on, mobility starts to take off. Day by day, your baby will build on existing motor skills, such as reaching, rolling over and sitting, and move on to new ones, such as crawling and standing (some faster than others).

Since you can’t predict when your baby will make his or her first move across the floor, now is a good time to review your home safety. (See Chapter 17 for more information on childproofing your house.) Keep an eye out for dangling cords and unsteady furniture. As your baby’s mobility progresses, he or she will latch on to nearby items to help himself or herself along or even up. Removing treasured or breakable items and creating a safe environment will give your baby the freedom and confidence to explore and learn. At this age, it’s generally easier to modify the environment than to teach a child not to touch.

Baby’s growth and appearance

During these past months, your baby’s growth rate was on fast forward. Once your baby reaches 6 months, though, you’ll find that growth tends to slow a bit. Previously, your baby was likely to gain over a pound a month. Now, his or her weight increase is more likely to be just under a pound each month, and his or her increase in length around ³∕8 inch or less. You can also expect the growth of your son’s or daughter’s head to begin to slow, too.

From here on out, your child will continue to grow steadily, with additional growth spurts here and there. But he or she will never grow quite as fast as in those first six months.

• • • • •

What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the seventh month.

Eating Breast milk or formula is still the primary part of your baby’s diet, but by this time you should be introducing additional foods. Around 7 months, most babies can begin the transition to soft foods or foods with tiny lumps without gagging. Your baby’s airway is still very small, however, so avoid foods that could pose a choking hazard, such as those that are small, round, hard, elastic, slippery or crunchy. See Chapter 4 for more on introducing new foods.

Sleeping Baby is more likely to sleep six to eight hours at night with no interruption. Some babies still wake up once or twice during the night for a feeding, although they’re unlikely to need middle-of-the-night feedings by this age. Total sleep may add up to between 14 and 15 hours in a 24-hour period, including a couple of daytime naps, usually one in the morning and one in the afternoon. Some babies may need a third nap late in the afternoon. As your baby becomes more curious and mobile, it may be harder to settle down to sleep at night. Establishing and maintaining a consistent, relaxing bedtime routine — such as having a bath, reading books together or singing a quiet song — can be a great help in getting your child used to the idea of going to sleep at night.

• • • • •

Baby’s movement

When your baby was younger, indications of developing motor skills were subtle, with some so basic as to go almost unnoticed. Fidgeting, for example, is a normal phase of growth and development, but it isn’t nearly as exciting as the motor skills that are now blossoming. Between now and baby’s first birthday, noticeable changes take place that transform your son or daughter from a dependent infant to a trundling, independent toddler.

Sitting At 6 months, many babies sit up with help or sit alone by leaning forward, hands to the floor. Over the next few weeks, your baby is perfecting the art of sitting — keeping the head steady and back straight to maintain balance. By 7 months, your baby may be sitting alone with no support, even working to put arms to the side to avoid toppling over. By his or her ninth month, your baby may be steady and strong enough to play for longer periods while seated on the floor, even pivoting and reaching to get to different toys.

Hand and finger coordination At 6 months, babies have very clumsy hand movements and pick up objects by pressing all their fingers against their thumbs (“mitten grasp”). But between now and the ninth month, most babies will learn to use a more refined “pincer” grasp, using the thumb and index finger to pick up small objects.

The transition from a mitten grasp to a pincer grasp is gradual. First, you may notice your child using a cross between the two, picking up objects with the thumb, index and middle fingers. You may also see baby resting his or her arm and hand on a surface to steady the hand and pick up a small object.

At the same time, your baby is also getting better at transferring an object from one hand to the other, turning it around and upside down, holding it this way and that, and getting to know how it feels. About half of babies this age gain the ability to hold an object in each hand. Eventually, they’ll delight in banging objects against each other, but for now your baby may simply enjoy banging objects against a leg or table.

Baby’s sensory development

By 7 months, your baby’s eyesight is nearly mature. His or her distance vision is continuing to improve so that faraway people and objects appear clearer and more distinct. Your baby is also able to track faster movements with his or her eyes and follow moving objects closely. In fact, if you roll a ball to your baby, he or she can monitor its path and probably put a hand out to it as it gets near.

By age 6 or 7 months, your baby’s hearing is almost fully developed. He or she is also becoming more selective about the sounds he or she reacts to. For example, your baby at this age can quickly and accurately locate you when you speak. He or she may also stop to listen to quieter sounds.

Watch to see if your baby turns toward a sound, even if the sound comes from outside his or her line of vision. If you notice that he or she doesn’t respond to surrounding sounds, talk to your baby’s medical provider. If there’s a problem with your baby’s hearing, it’s better to identify it sooner rather than later. Untreated, hearing loss can interfere with other aspects of development, such as language and social development.

• • • • •

Toys and games

As your baby becomes more interested in interacting with the outside world, give him or her new opportunities to do so.

Introduce the high chair By this month, your baby is likely to sit well while supported. Putting him or her in a high chair can be a great way to include baby in family mealtimes. It can also be an interesting new vantage point for your baby to sit and watch daily household activities and play with small toys on the high chair tray (he or she can start working on thumb-finger coordination). Choose a high chair that has a comfortable seat and straps to keep your baby safely positioned. A detachable tray that you can take to the sink to wash is convenient. Experienced parents may advise removable washable parts in general, as high chairs invariably become a backdrop for bits of cereal, splattered applesauce and mashed up yams. Hosing off the entire apparatus in the backyard or shower isn’t unheard of.

Provide warm-up time If baby is shy or cautious, offer him or her plenty of time to warm up to a new situation or activity. Allow your child to sit and observe on the sidelines for a while. This will give him or her time to assess the situation and approach it on his or her own terms. Once your baby feels secure, he or she will become more involved in what’s going on.

Make new friends If you haven’t already done so, now might be a good time to introduce your baby to other children. Although they likely won’t play together for some time yet, at this age, babies will play side by side. Also, they’re intrigued by others who are similar in size and behavior. Exposure to other children can help expand your baby’s social horizon. But be sensitive to when your baby has had enough “socializing.”

Check out activities at your local library Many libraries have special activities for infants, such as story time. Often a staff member will read a book aloud and include activities, such as singing silly songs and interacting with puppet shows. Libraries also may have play areas designed especially for younger children. This may be a good place to meet other parents and children. Plus, having all those books to look at can’t hurt, right?

• • • • •

Baby’s mental development

During month seven, your baby continues to pick up on language skills from listening to you and others speak. Before, your son or daughter may have focused on imitating specific sounds, such as mmm or bbbb. In these next few weeks, you may notice him or her start to combine different sounds together, such as consonants and vowels. By 6 or 7 months, your baby should make more-complex sounds such as dadada and mamama. As tempting as it may be to think your baby is referring to you when saying these sounds, it will likely be several more weeks before he or she is able to attach names to people.

The art of conversation In addition to imitating sounds and even combinations of sounds, your baby may also begin to follow your pattern of speech — pausing between “sentences” or ending a string of sounds with an upward inflection, as if posing a question. You can help your baby practice the art of conversation by talking to him or her and acknowledging his or her efforts with your own warm responses.

An infant’s understanding of words is far ahead of his or her ability to use them. At this age, your baby understands the meaning of what you say by listening to your tone of voice. Even the word no (which you may find yourself using more often as your baby starts to push against the limits you’ve established) is understood by your inflection and tone and not necessarily by the word itself.

The more you talk to your son or daughter — whether it’s while you’re driving around town, doing chores around the house, or changing or feeding him or her — the more your little one learns about all facets of communication, including sounds, inflections and tone of voice, as well as facial expression and body language.

The science of experimentation As your baby’s understanding of his or her own power to make things happen grows, you can see how he or she begins to test the limits of what he or she can achieve. How far can I push this train over the edge of my tray before it falls out of sight? Does mommy bring it back intact every time? How much can I kick during a diaper change before I receive a frown?

Amid all of this experimentation, you will find that your son or daughter is likely to waver between feeling confident and exuberant, and needy and cautious. By helping him or her feel secure — creating a safe environment to explore and practice, offering warm praise and support, setting firm yet practical limits — you can encourage experimentation and promote competence. In this type of setting, your baby learns to tackle challenges with enthusiasm, adding skill upon skill.

Finding the energy to repeat the same game or story over and over again can be challenging at times. But keep in mind that the process of repetition is essential to your baby’s learning and mastering key skills.

• • • • •

Baby screen time

Chances are if you’re an American parent of a young child, at some point you’ve found yourself downloading an app, streaming a video or holding a DVD intended to improve your baby’s intelligence. You wondered if it could help promote junior’s brain cell connections.

Turns out human interaction still is likely to trump anything on a screen. While games or videos might catch your baby’s attention, the screen time probably won’t contribute to his or her development. In fact, research shows that an infant learns most when interacting with you or other caregivers.

Studies examining the specific effects of baby DVDs and other infant programming are limited and research on the impact of newer technology, such as touch screen devices, on infants is even more scarce. Study results generally aren’t positive. In one study, children ages 8 months to 16 months who were exposed to baby videos scored lower on a language development test than did babies who had no screen time. Another study of children ages 2 months to 4 years showed that turning on the television reduced verbal interaction between parents and children — which may delay language development. In addition, studies indicate that when parents spend time on their phones, it reduces the quantity and quality of parent and child interaction. In contrast, research has shown that regularly reading to and interacting with young children boosts language ability for both babies and toddlers.

Many pediatricians discourage screen time for children younger than age 2. Instead of relying on videos or smart apps, concentrate on proven ways to promote infant development — such as talking, playing, singing and reading to your baby. Even if your baby doesn’t understand what you’re saying, or grasp the plot of a story, he or she will soak in your words and revel in your attention. These simple activities form the foundation for speech and thought.

• • • • •

Baby’s social development

Between 6 and 7 months, your baby is becoming quite the expert at nonverbal communication, expressing his or her emotions in a variety of ways — laughing, crying, shrieking, squealing and cooing.

Stranger anxiety Even as your infant becomes more expressive around you, he or she may begin to show the first signs of reticence around strangers. Your child has come to associate you with his or her own well-being and is increasingly reluctant to let you go. He or she is also becoming keenly aware of who is familiar and who isn’t. By 8 or 9 months, your baby may openly reject strangers, clinging to you and even crying if unknown people come too close.

This is a normal phase of development and is a sign of the strong bond your baby has developed with you. Shyness toward strangers can last months and even years, depending on your child’s personality. Some children are naturally more shy than are others.

Discipline in infancy Discipline is a concern that arises in every parent’s mind at some point, perhaps even before a baby is born. You may have definite ideas about guiding your child’s behavior, or you may not. It can be a fuzzy topic, especially if you have little previous experience. During the first six months, distracting your baby from unwanted behavior is usually enough to stop it. But by the time your baby reaches the seventh month, you may need to start setting some additional limits.

Keep in mind that true discipline — throughout the childhood years — is positive in its approach, with the ultimate goal of teaching rather than simply punishing. Your goal as a parent is to help your child become a secure, independent and well-adjusted adult who is able to successfully navigate almost any social environment. You can start this process early on by establishing a trusting relationship between you and your child and setting simple, consistent limits.

Create a foundation of trust During your baby’s first year, you can set the foundation for a pattern of parent-child interaction that will serve you well in later, potentially more trying times. This is done in the way you nurture and react to your infant, including simple things such as following a consistent schedule, attending to your baby’s needs promptly and spending time bonding as a family.

As your baby gets a little older and more independent, he or she will likely start testing the boundaries you’ve carefully created. This is not “misbehaving” — it’s how a baby explores the world. If you manage that exploration safely, you can prepare the way for your child to become a happy, competent and confident member of your family and, ultimately, of society at large.

Be gentle yet firm By this time, your child’s needs and wants have already started to separate. For example, your son or daughter might still like to have a nighttime feeding, but he or she probably doesn’t need a midnight snack. If you haven’t yet done so, start phasing out nighttime feedings. Establish a consistent bedtime routine that helps your baby learn to self-soothe rather than rely on you to fall asleep (see this discussion). This is a first step toward independence and will make bedtime much easier in the future. In addition, it’s likely that your baby will get better rest this way, and so will you.

Likewise, at this age your baby’s sense of curiosity and touch have kicked into a higher gear. As your baby discovers the use of his or her hands, those hands will grab keys, hair, earrings, a nose — anything within reach. He or she will judge what’s OK by your reaction. Use your tone of voice and facial expressions to express disapproval. If baby pinches your nose and it hurts, make a funny face or set your baby down and say “No,” or “Ouch.” Your baby can’t control the impulse to touch and grab, so gently guide him or her to what is acceptable.

Being consistent and firm in your limits will make it easier for your child to remember what’s OK and what’s not. Establishing your authority now — showing that you have the final say — will make your life and your baby’s life easier as he or she grows up.

Be proactive Once your baby is crawling — then walking — your baby thinks everything in the house is there for him or her to touch, pull, mouth, open and, in general, spread around the room. This is normal and expected behavior. Take a proactive approach and prevent problems before they happen. Set up boundaries by childproofing your house. Gates, cabinet locks and outlet covers can help you establish a positive learning environment for your baby and you won’t have to constantly say “No.”

What to avoid Day-to-day management of an active, curious child can be frustrating at times. If you lose your patience with your infant, give the baby to a partner or set the baby in his or her crib and take a break to cool off. Never shake your baby. If you’re struggling with your child’s behavior or how to handle your frustrations, talk to your child’s medical provider. If your child has a physical or developmental disability, managing behavior can be even more challenging. You may need more-intense strategies, so don’t be afraid to ask for help.

• • • • •

7th month milestones

During the seventh month, your baby is busy:

Learning to sit unsupported

Sitting and looking around

Perhaps getting into a crawling position, while reaching out with one hand

Using hands to rake up small objects

Getting better use of thumb and fingers

Transferring objects from one hand to the other

Visually tracking rapid movements

Readily responding to sounds

Looking for sounds outside of field of vision

Starting to look for dropped toys

Combining different sounds together

Imitating patterns of speech

Distinguishing strangers from loved ones

Starting to test limits and boundaries

• • • • •

CHAPTER 26 Month 8

By month eight, most of your baby’s newborn reflexes have faded away and are now replaced by intentional, purposeful movements. This is a result of your baby’s maturing nervous system. As more and more nerve endings become encased in protective coverings (myelin sheaths), the nerves become more efficient at carrying messages from the brain to muscles, making your baby’s movements increasingly “smarter” and more refined.

At the same time, your 7- to 8-month-old’s brain is developing the ability to attach meaning to different sounds and gestures. For example, he or she may quiet at the sound of his or her own name. Or if you have a dog in the house and the dog’s name is often repeated in conjunction with its appearance on the scene, your baby may begin to associate the dog with the dog’s name.

Your child’s thinking processes are becoming ever more complex, and you can see this by the way he or she begins to indicate likes and dislikes, and be fairly emphatic about them. This may be especially apparent in your infant’s social preferences, as he or she becomes increasingly aware of the difference between familiar and unfamiliar people.

Your child’s conceptualization of object permanence is setting in as well. He or she is starting to realize that although people and things may temporarily disappear from his or her line of vision, that doesn’t mean they’re gone forever. This realization tends to coincide with less tolerance for being separated from you, making transitions to child care and baby sitters a little more challenging for a while.

Baby’s growth and appearance

During this time, your baby is growing steadily but probably at a slightly slower rate than in previous months. The average baby at this age tends to gain just under a pound over the course of the month. He or she also grows about 3/8 of an inch in length. Your baby’s head circumference is still increasing but only slightly compared with early months.

As long as your baby is following a steady growth curve based on measurements by your baby’s medical provider, there’s no need to be overly concerned about specific numbers. At this stage, your baby’s nutritional intake is starting to become a little more varied. But keep in mind that he or she still needs a proper balance of fats, carbohydrates and protein. Be sure to discuss your baby’s diet with his or her provider, who can help you decide how to best meet your child’s nutritional needs.

Establishing good eating habits As you introduce new foods to your son or daughter, take the opportunity to establish good eating habits right away. Here are some tips to help your baby develop healthy eating patterns (see Chapter 4):

Offer a wide variety of foods You still want to introduce new foods one at a time, but that doesn’t mean you have to stick to a single food for weeks on end. By this age, you can experiment with a variety of foods. If your baby does well with pureed yams, try some ground chicken after a few days. Or after a successful course of mashed peas, provide a dessert of mashed bananas.

Include a good balance of foods Prioritize fruits, vegetables, meats and healthy carbohydrates over processed foods and baked goods. Instead of a cut-up hot dog, for example, offer bits of turkey. Or instead of a soft cookie, offer pureed peaches. Minimize salt and offer sweet foods in moderation. Examples of not-so-obvious salt-rich foods include processed cheese, cold cuts, pizza, canned vegetables, beans and soups.

Avoid overfeeding Watch your baby for cues to know when he or she is full. While you control what and when your baby eats, let your baby determine whether to eat each food you offer and how much.

Enjoy food for its nutrition But avoid using it as a reward or as a comfort item. Instead, reward and comfort your baby with hugs, kisses and attention.

Introducing a cup You can give your baby a cup as soon as he or she starts eating solid foods. A two-handled sippy cup is usually easy for baby to use. This will help your child become familiar with the idea of using a cup. But at this age, your baby will probably bang, drop and dump the cup more than drink from it. It will probably be another few months before he or she is using it properly.

Even if your baby uses a cup at mealtimes, you may decide to continue breast-feeding or using a bottle for supplemental feedings, simply because baby can’t get much out of the cup just yet. Feeding your baby breast milk or formula from a cup at mealtime may help pave the way for weaning when you’re ready.

• • • • •

What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the eighth month.

Eating As you begin altering your child’s diet to add cereal and other foods, you may wonder whether breast milk or formula still plays an important role in your baby’s diet. Even though solid foods are beginning to supplement some of your baby’s feedings, they can’t completely replace the balance of nutrients that breast milk or formula provides. Breast milk is designed to be an excellent source of nutrients for your baby through the baby’s first year and beyond.

Many parents wonder whether their babies can drink whole milk at this age. It’s best for your baby to have breast milk or formula for the first year. Avoid cow’s milk until your baby is a year old. Your baby’s delicate digestive system isn’t able to adequately handle the type and concentration of selected nutrients found in cow’s milk. And cow’s milk is lower in iron and vitamins C and E than is breast milk or formula.

Sleeping Most babies are able to sleep well through the night — between 10 to 12 hours — around age 8 months, to the relief of their weary parents. Total sleep for baby may add up to about 14 hours in a 24-hour period, including a couple of daytime naps, usually one in the morning and one in the afternoon.

But beware: New skills such as pulling up to stand and cruising are near if not already learned, and your baby may waken during the night and want to practice. If he or she can’t quite return to a sleeping position on his or her own, your help may be needed.

In addition, if your baby gets anxious when separated from you during the day, that anxiety will likely be compounded at bedtime and in the middle of the night. You’re caught in the dilemma of wanting to reassure your child and also wanting your baby to learn good sleep habits. For more information about helping your son or daughter develop good sleep habits, see Chapter 9.

• • • • •

Baby’s movement

Your child’s rapid development during these months can be astonishing. In just a few weeks, he or she may go from barely sitting up without your help to bustling around the room by scooting, crawling and cruising.

Sitting up By 8 months, your baby is literally sitting pretty and is steadier than ever on his or her bottom. His or her sense of balance is improving, and he or she will be able to sit up unsupported for longer periods of time without falling over. Your baby may even start to reach with his or her arms while sitting to try to grasp nearby toys. These exercises will help further strengthen your baby’s core muscles, which are important for standing, walking and any kind of forward-propelling movement.

Getting around After your baby learns to sit up without too much effort, you’ll notice other movements that are predecessors to crawling — rolling, twisting, crouching, and rocking back and forth on the knees. In fact, it will be hard for your baby to be still for long. If lying tummy-down, he or she will push up on hands and arms to look around. Lying faceup is an incentive to kick and grab for toes. Your baby can now also flip around at will. Some babies even roll repeatedly as a means of getting from one place to another.

Because your youngster is getting so mobile, it’s important to take appropriate safety precautions, such as swapping the changing table for the floor or bed to change diapers and installing safety gates at the top and bottom of stairs to avoid an accidental, and potentially serious, tumble. (See more about making your home safe in Chapter 17.)

Hand and finger coordination Once your baby is able to sit well, he or she is also able to maintain upper torso balance while coordinating simultaneous movements of arms and hands. Most babies this age are able to hold a toy in each hand. Eventually they’ll develop enough coordination to bring both hands inward and bang the toys against each other.

During this month, your baby probably still uses a raking motion to bring small objects closer. But he or she is also working on coordinating the thumb and first or second finger to pick up small objects (pincer grasp). Baby will practice this technique until he or she achieves such a grasp. This usually happens by his or her first birthday.

Your baby is also learning to let go of items at will. This is evident by his or her enthusiasm for dropping and throwing things — again and again!

• • • • •

Baby sign language

By age 8 months or so, many infants begin to know what they want, need and feel, but they don’t necessarily have the verbal skills to express themselves. Baby sign language allows children to use their hands to bridge the communication gap. Slightly older children who have developmental delays may benefit, too. Limited research suggests that using baby sign language may improve a child’s ability to communicate and ease frustration, particularly between ages 8 months and 2 years. Teaching and practicing baby sign language can also be fun and give you and your child an opportunity to bond.

At the same time, don’t neglect your baby’s verbal skills. Continue to talk to your child, and encourage him or her to use spoken words (or what may only sound like words in the beginning) to express himself or herself. Voice the meaning of a sign each time you use it.

A variety of books, websites and other resources are available to help you learn baby sign language. You can also use variations of American Sign Language. Start with signs to describe routine requests, activities and objects in your child’s life — such as more, drink, eat, mother and father. Keep these tips in mind:

Set realistic expectations. Feel free to start signing with your child at any age — but remember that most children aren’t able to communicate with baby sign language until about 8 or 9 months.

Stay patient. Don’t get upset if your child uses signs incorrectly or doesn’t start using them right away. The goal is improved communication and reduced frustration — not perfection.

Be consistent. Repetition is the best way to ensure your child’s success in using baby sign language. Encourage your child’s other caregivers to use the same signs, too.

• • • • •

Baby’s sensory development

During this month, your baby’s senses continue to contribute lots of information to his or her brain. This stimulates the development of other skills, such as reaching and crawling, and drawing conclusions about spatial relationships.

Vision Your son’s or daughter’s vision is now almost adult-like in clarity and depth perception. By 8 months, most babies’ vision is 20/40. Although he or she still sees things better at a close range than far away, your baby’s vision should be clear enough to recognize people and objects across the room. Increased depth perception helps your baby accurately reach for objects and judge distances correctly when moving forward.

Touch Between 7 and 8 months old, your budding physicist is learning rapidly about the way matter takes up space, how different surfaces feel and how they’re related. For example, he or she may start to realize that balls are round and roll, boxes have flat surfaces, and some toys have a top and a bottom part. Objects with tags, handles and parts that can be manipulated are especially intriguing at this point.

Baby’s mental development

Around this time, your son or daughter is beginning to understand that certain things have meaning beyond the immediate sensory experience. For example, words and gestures, besides being seen and heard, can convey messages. And things your baby once thought were there and then gone when out of sight are actually still there even if hidden from view. Your child’s brain is starting to make connections between what is seen and unseen and draw conclusions from repeated experiences. Although it will be a while before your child can actively formulate and express symbolic thought — such as pretend play, which usually develops in the second year — the very first formations of abstract thought are emerging.

Attaching meaning By 8 months or so, you may notice your child quiet or perk up at the sound of his or her name, or even turn toward you when you say it. He or she doesn’t fully understand at this point that this word refers to himself or herself, but your baby is becoming familiar with hearing that word when you actively seek a face-to-face connection with him or her.

Other words are starting to become significant, too. You’ll probably notice that your baby is gaining a better under-standing of the word no. He or she may hesitate when he or she hears the word, especially when it’s delivered with a sharp inflection. At this age, baby begins to associate words with specific objects and actions, including gestures (see “Baby sign language” here). About half of babies at this age begin to wave bye-bye.

Object permanence Previously, if your baby dropped something, he or she likely thought it was gone entirely and made no effort to look for it. Now he or she is starting to realize that, in fact, it may still be there and will look for a hidden toy. Games of peekaboo take on a new significance as your baby realizes that if he or she pulls the blanket away — aha! Dad is still there! And now that baby knows you’re still around even if you leave the room, he or she may make more of a fuss to get you to come back.

Language skills By this time, your baby is likely becoming a proficient babbler, repeating not just single sounds but combining syllables, such as bah-dah. Some babies are very expressive and jabber away like excited squirrels. Others are a little quieter and may listen more than chatter. But this doesn’t mean they’re not absorbing what’s being said around them. Be sure to talk to your little shy one as much as you might to a little chatterbox, encouraging him or her to communicate verbally as well as non-verbally.

• • • • •

Toys and games

Around this age, most babies enjoy toys they can bang, poke, twist, squeeze, drop, shake, open, close, empty and fill. Toys should be lightweight with no sharp edges. Remember that all toys will end up in your baby’s mouth, so don’t give your baby toys with small parts.

For the most part, your child’s playtime will center around playing on the floor, working on crawling, sitting and standing. You can encourage these skills by putting a toy just beyond your baby’s reach and encouraging baby to move toward it. Other playtime ideas include:

Peekaboo Games of peekaboo take on a new dimension around the time your baby develops a sense of object permanence. He or she will enjoy games in which objects and people “disappear” and your baby finds them again. Use a small blanket to cover toys, and let your baby uncover and discover them. Your baby may even cover them up again only to rediscover them.

Mirror games Your little one is starting to learn the concept of three-dimensional space. Contrast two-dimensional images with three-dimensional ones by playing games in the mirror. If your son or daughter is looking in a mirror and you suddenly appear in the mirror too, he or she is likely to turn around and look for you instead of believing you’re in the mirror itself.

Buckets of stuff Your baby is also learning how objects relate to one another. Infants at this age start to understand that smaller objects fit inside bigger ones. Stacking toys appeal at this age. Games in which toys can be put into a container and dumped back out again are popular as well. For a quick and easy version, fill a plastic mixing bowl with odds and ends from the kitchen — measuring spoons, plastic lids, small containers, empty baby bottles — and let your baby sort through them, dump them out and put them all back in again.

Book of animals As your baby begins to understand that things have names and labels attached to them, introduce him or her to a book with simple pictures of various animals and their names. You can read it together. As you point to the picture and name the animal, your baby will eventually start to associate the name with the animal. In time, you can introduce animal sounds, too. For a more lyrical version, read Brown Bear, Brown Bear, What Do You See? by Bill Martin Jr. and Eric Carle, which contains rhythmic prose and colorful illustrations that are favorites of children and parents alike.

• • • • •

Baby’s social development

As your baby learns new skills and becomes more mobile, he or she is torn between two desires: to be with you and to experience some independence. You may notice this struggle surface in many situations as your baby searches for both predictability and adventure. Living with this new assertiveness may take a bit of adjustment for all parties involved. But understanding it as a normal phase of development helps most parents take the new challenges in stride.

Separation anxiety At 8 months, most babies are clearly attached to the parent providing most of their care. Your baby may seem most assertive when you make any attempt to separate from him or her, whether it be for a few hours or a few minutes. He or she may become more clingy — not wanting to let you out of sight — and may grasp or cry if you manage to break away. Your baby may even begin to prefer the parent he or she spends the most time with. Both parents should understand that this situation is normal and will diminish with time.

Every baby goes through a stage of separation anxiety, which often begins around this age, peaks between 10 and 18 months, and gradually fades as the second birthday approaches. Some babies pass through this phase fairly quickly, but others remain reluctant to part for quite some time.

Part of baby’s frustration stems from not having the motor skills to follow you or keep up with you, coupled with the budding realization that you’re still there even if baby can’t see you. The positive side of this development is that your baby has clearly established a strong bond with you and wants to make sure you stick around. Eventually, as your baby realizes that you’re a permanent part of his or her life despite temporary separations, this anxiety will ease.

• • • • •

Enjoying a relaxing night out

Because babies react so strongly to separation from their parents, parents are often reluctant to leave their babies with baby sitters. You might even wonder if a night out is worth the heartbreak your baby seems to endure when left with a sitter. You can help yourself and your baby through this stage by taking these steps:

Practice Take advantage of occasions at home to leave your baby alone for a few minutes (in a safe zone, of course) while he or she plays. If your baby becomes upset at your absence, call out to him or her, but wait a few seconds before coming back. Eventually, your baby will learn that it’s OK to be away from you and that you always do come back.

Get acquainted If a baby sitter is new, take some time to let your baby become acquainted with him or her. Hold your baby on your lap while you and the baby sitter talk, and then gradually engage the baby in the conversation. Once your baby seems comfortable with the sitter’s presence, put your baby on the floor with a favorite object and the baby sitter, and let them get to know each other. Once you’re comfortable with your baby sitter and you feel assured your baby is getting loving, qualified and competent care, you will be less bothered if your baby should cry when you leave.

Say goodbye When you’re ready to leave, tell your baby goodbye and provide reassurance of your eventual return. Although it’s tempting to just sneak out when baby is preoccupied with something else, this approach won’t help your baby overcome this anxiety (instead, he or she may become more clingy, never sure when you might leave). At the same time, there’s no need to prolong the farewell. Have a distraction ready to go — a bath or new toy — and a few minutes after your departure, your baby’s short attention span will be directed elsewhere.

• • • • •

Smoothing the way This strong attachment to the primary caregiver can result in a seeming dislike for everyone else, which can be crushing to grandparents, other relatives and friends who feel close to the baby. You can ease feelings of rejection by explaining separation anxiety as a normal phase and helping to create a time of adjustment and transition.

If someone approaches your baby quickly, eagerly trying to engage the baby, the baby will probably cling to you even more tightly. Encourage others to spend some time just talking with you while you let your baby watch and listen. Your baby may eventually open up and jabber or want to play.

Peekaboo can be an icebreaker at this age because this game is so tempting for most babies. But don’t be surprised if your baby will play this game only when you’re close by. Assure others that your baby will outgrow this exclusivity.

• • • • •

8th month milestones

During the eighth month, your baby is busy:

Sitting up straight and looking around

Reaching out with one hand while in a crawling position

Rocking back and forth on all fours, rolling over repeatedly, scooting on bottom, or expressing some form of desire to move around

Using hands to rake up small objects

Getting better use of thumb and fingers

Transferring objects from one hand to the other

Using touch to learn about the physical properties of different objects

Looking for you or dropped toys (establishing object permanence)

Attaching meaning to words and gestures, such as no or a farewell wave

Combining different sounds

Distinguishing strangers from loved ones

Cementing the parent-child bond

Starting to test limits and boundaries

• • • • •

CHAPTER 27 Month 9

Your baby has a lot going on these days. And get ready for a big change! During the ninth month is when most babies learn to crawl, and once your baby is on the move, life changes forever. No longer is your baby content to stay in one spot. There are so many places to go, so many things to see, so much stuff to get into! Daily life with an emerging toddler can be a challenge. But it’s also a happy time of having fun and discovering new skills. With a little bit of prep work, you and baby will be all set to enjoy life on the go.

Baby’s growth and appearance

During this month, your baby is growing steadily at about the same rate as the previous month. The average baby at this age tends to gain just under a pound a month, and grow about ³∕8 of an inch in length. Your baby’s head circumference is still increasing slightly every month.

By now, your baby may have a nice head of hair. And now that he or she can flip and turn at will, bald patches are a thing of the past. At 9 months old, most babies still look like little butterballs. But within a few short months of growing, walking and running, your baby will stretch out into a full-blown toddler.

• • • • •

What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the ninth month.

Eating During this month, you may start introducing to your baby slightly coarser foods that require more chewing. You might also notice that your baby’s more interested in the food on your plate than on his or her own. During the next few months, you can work your way toward feeding baby what the rest of the family is having. At first, you might try overcooking or finely chopping the food. Some parents use a food processor or blender to get the food to the right textures.

Breast milk and formula may start to take on a more supplemental role, but are still irreplaceable sources of nutrition. If you wean your baby from breast-feeding before his or her first birthday, replace the breast milk with iron-fortified formula. Your baby isn’t ready for whole milk until that time.

Sleeping By 9 months old, your baby has probably settled into a regular napping and sleeping schedule. He or she may take two naps a day and sleep as long as 12 hours at night without waking to feed. But even if your baby has been a good sleeper up until now, you may face some new sleep challenges during this month and the next few months.

When your baby is learning to crawl and pull up to a standing position, he or she will probably work vigorously on these skills all day. During brief awakenings in the night, baby may automatically start practicing crawling and standing. But early on, your baby knows how to do only half a skill and may get in the frustrating position of being able to stand up but not get down again. Even after baby learns how to get out of these situations, the physical activity may be enough to make it hard to get back to sleep.

Your baby may let you know — loudly — how frustrating this situation is. At this age, he or she can shake the crib and may cry or scream to get your attention. Double-check the safety of your baby’s crib and make sure there’s nothing in the crib that your baby could stand on. Once the novelty of your baby’s new skills wear off, he or she is likely to start sleeping better.

• • • • •

Baby’s movement

It’s around this time that many babies catapult forward to a new level of mobility and independence. All that wiggling and fidgeting, rocking and rolling is paying off. Your baby is up and moving!

Crawling Crawling uses the complex give-and-take movements of all four limbs that are necessary for walking later. It takes some time to understand how to make those little arms and legs work together. The average age an infant starts to crawl is 9 months.

At first, a baby’s arms are stronger than the legs, which makes for some funny crawling variations. Many babies begin crawling by using just their arms, scooting across the floor like a soldier in training. Others may find themselves up on their knees, give their arms a good push and begin moving backward.

Eventually, most babies will become experts at using their legs and arms simultaneously when they crawl. You might look away for a minute, then look back and wonder, “Where did my baby go?”

If your baby isn’t interested in crawling, or crawls just for a short time before moving on to something else, remember that moving is the goal. How your baby moves isn’t as important as the fact that he or she is interested in getting around.

Standing At 8 or 9 months old, if you stand your baby up next to the sofa, he or she will probably be able to stand there, using the furniture for support. When your child realizes how much fun standing is, he or she will probably start figuring out how to pull up to a standing position without your help.

By 8 months old, most babies can stand up with support. At age 9 months, more than half of all babies can pull themselves into a standing position, and some may even begin “cruising” around the room, holding on to furniture for support.

At first, your baby may not know how to sit down from a standing position and, instead, may just fall on his or her bottom. Soon he or she will learn how to lower himself or herself down without falling. You can show your baby how to do this by gently helping him or her bend at the knees and then squat down to a sitting position.

Sitting By now your son or daughter is likely a proficient sitter. Indeed, at this age, babies love to sit and play and may do so for extended periods of time. From a seated position, your baby has a wider vantage point from which to observe and interact with the world and delights in taking full control of his or her view. Between ages 8 and 9 months, your child is learning to point to desired objects and lean forward while sitting to reach toward you or an interesting toy.

As a result of your child’s improved stability and balance, he or she can now sit unsupported and turn his or her head to look at things. He or she may even twist his or her torso to peer around — although leaning sideways may not be possible quite yet.

Hand skills Baby is working steadily on his or her thumb-finger (pincer) grasp. With the pincer grasp, your baby can — and probably will — pick up objects as small as a piece of lint. Self-feeding also is likely to become a popular activity during this month, if it hasn’t already. And by now, your baby may have learned to hold a cup or bottle and drink independently. Because almost everything your baby touches goes directly into the mouth for further exploration, be sure to remove anything from baby’s reach that could cause choking.

Your baby is also learning to move his or her fingers individually, so that he or she can soon hold a string between finger and thumb and pull a toy along. Letting go voluntarily is becoming easier, allowing baby to set one thing down in order to pick up another. Other impressive hand skills your child may develop during this month include pointing toward things he or she wants, clapping, and waving goodbye. These are also forms of communication. Encourage your child’s development in this area by using these skills yourself, such as pointing at different objects and naming them, or playing clapping games.

A common milestone achieved during this month is the ability to bang toys together. This is no mean feat, as working both arms simultaneously in this fashion requires an infant to sit upright steadily without support and display a fair amount of balance.

• • • • •

Battle of the spoons

Some babies are determined to eat without help — or at least play with eating utensils without your interference. Every time you try to slide that spoon in with some food, up comes the little hand to grab it, and splat goes the food. How to get your baby to eat?

If this is the case, provide different ways for your baby to get food and entertain himself or herself at the same time. Put some finger foods on the baby’s tray. Give baby his or her own spoon and use a spoon yourself. You may need to be persistent in finding opportunities to get some food into the baby’s mouth.

You can try to teach your baby to eat with a spoon, but if you’re not successful, let your baby eat with hands and fingers. For now, these handy utensils are generally faster.

If your baby truly isn’t doing any eating, only playing, he or she probably isn’t hungry at the moment. You can call it quits for this particular meal and try again later.

• • • • •

Baby’s sensory development

By age 8 to 9 months, your child’s sensory skills are fairly evolved and a great help in practicing his or her new motor, mental and social skills. Combined with your child’s expanding memory skills and understanding of object permanence, his or her sensory abilities make for easy recognition of recurring sights, sounds and patterns. They’re helping your young one in gaining knowledge of the general order of things.

Vision Your baby’s visual acuity is constantly improving, and he or she can see things clearly from across the room. At this age, your baby is quick to recognize familiar faces and objects. He or she may adjust his or her position to get a better look at something and is more likely to look for a hidden toy.

Crawling and moving about helps develop your baby’s depth perception, as he or she studies one hand moving forward and then the next, over the varying ground beneath. Better depth perception leads to an increased awareness of heights and a better timed, more cautious approach to obstacles.

Hearing Your son or daughter now recognizes sound without difficulty and probably responds to his or her own name. He or she may respond to other familiar words, as well, such as bottle, mama, dada and no.

Touch Your baby is learning how to wrap his or her hands around a cup or bottle, how to pick up a spoon, and how to handle different toys appropriately.

• • • • •

Finger foods for little ones

As your baby develops a better pincer grasp and more-advanced chewing skills, you can start offering finger foods. Self-feeding can be great entertainment. What could be more fun than exploring things that actually are supposed to go in the mouth (even if they end up on the floor)? And it helps foster your child’s sense of independence and ability to accomplish a task on his or her own.

Parents were once told to avoid feeding young children eggs, fish and peanut butter. Today, however, researchers say there’s good evidence that introducing some of these foods early on, especially peanut butter, helps reduce development of food allergies (see this discussion). Keep in mind, however, your baby’s ability to handle textures and foods of various sizes. Soft and mushy is the way to go. Small, hard, round, sticky or chewy bits of food can be choking hazards. Here are some suggestions for finger foods to get you started:

Well-cooked diced vegetables (yams, potatoes, carrots, green beans)

Soft ripe fruits, cut up into small pieces (berries, mangos, peaches, bananas)

Whole-grain breakfast cereals (with no nuts or chunks)

Teething biscuits or crackers

Cut-up, well-cooked pasta

• • • • •

Baby’s mental development

By age 9 months, your infant is sophisticated enough to be bored. (So quickly does it set in!) This is because his or her memory is developing and what was once new and interesting isn’t so much anymore. Your baby is on the hunt for new stimulation and is keen to try out new games and skills.

This is certainly a fun age, but it can also be frustrating for baby and parents alike if baby moves quickly from one thing to the next, leaving little time for mom or dad to get other things done.

Don’t fret too much, though. As your child develops further and becomes more mobile and independent, he or she will be more capable of creating his or her own fun. In the meantime, swap out some of your child’s simpler toys for more complex ones (but still age-appropriate), or fill a basket with board books that your child can easily access on his or her own. For the time being, you might also spend a little extra time on the floor each day with your youngster to bridge the gap until he or she is better able to self-entertain.

Language and understanding About 3 out of 4 infants are jabbering away by age 8 months or so. Most are starting to combine syllables and vocalize in strings of sounds pulled together. By age 9 months, you may even notice your baby start to use the words mama and dada to refer specifically to you.

Your child’s understanding of language is increasing, as well, even more rapidly than his or her vocal expressions. By now, your baby likely understands the meaning of a number of words, including his or her own name, as mentioned previously. He or she is also starting to understand simple games and rhymes and will laugh and giggle at appropriate parts. For example, about half of babies can play clapping games by age 9 months. You can also try games that involve you showing your baby how to do something and then giving him or her a chance to do it — “My turn.” “Your turn.”

As the understanding of object permanence becomes more established in your baby’s mind, he or she will persist longer in searching for something he or she knows is there, such as a key you’ve folded in your hand. Object permanence also helps your baby understand the physical nature of the world, such as the ability of balls to roll, and its social nature. When your baby waves bye-bye as you walk out the door, he or she acknowledges you’re leaving but also is coming to expect that you’ll be back.

• • • • •

Toys and games

Physical games are fun at this stage of your baby’s development and can help him or her hone new motor skills. At the same time, your child’s communication and language skills are rapidly progressing, so include games that stimulate his or her mind, too. Try some of these.

Indoor gym Once your baby learns to crawl, getting through, in and around things is a great source of entertainment. Create your own gym with stuff you already have on hand:

Drape a blanket or a sheet over a table to make a tunnel. Place an unbreakable mirror inside for a visual surprise.

Create an obstacle course with pillows, laundry baskets and rolled-up towels.

Use yourself. Lie down with an interesting toy in front of you and baby behind you. Encourage your baby to climb over your legs to get it.

Walk together Your baby may not be walking independently just yet. But you can get him or her acquainted with the necessary leg movements by holding his or her hands and helping your child take small steps forward.

Clapping games To help your baby practice arm coordination and build balance skills, teach him or her clapping games, such as pat-a-cake or “Miss Mary Mack.”

Nursery rhymes Never underestimate the power of a few silly rhymes to make your child laugh. There are plenty of oldies but goodies, such as “Old MacDonald” and “Little Miss Muffet.” If you find yourself a little rusty on some of these, you can look them up on the internet or borrow a book from the library. In fact, chances are, there’s a mobile app out there to help you learn some ditties on the go, whether in a crowded restaurant or on a long drive home.

• • • • •

Baby’s social development

Once your baby starts to crawl and move around, limits begin to play a larger role in both baby’s life and yours. Before, there wasn’t much your baby could do without your help. Now that he or she can crawl and climb and discover without you, there are bound to be necessary limits — “No, you can’t climb the bookshelf,” or “No, don’t pull the cat’s tail.”

• • • • •

Get ready

It’s tempting to think that as your baby gets older, he or she will require less time and attention. But once your son or daughter is on the move, he or she actually requires more supervision. Before, your baby would wait for you to come. Now that your child is mobile, he or she can come to you. You are still your child’s primary love and favorite companion, and there is so much your baby wants to share as he or she scoots around and explores.

Very active or very curious babies may need especially careful supervision. Once they discover their ability to move, they are off and into everything, touching, pulling, tasting, testing. Babies on the go need your presence to ensure that heads don’t get bonked, fingers don’t get pinched, small objects don’t get swallowed and prized possessions remain intact.

This period of intense supervision generally lasts until about 3 years of age, when children are more accustomed to limits and spend more time playing alone or with friends. If you think you’ll never make it that long, take heart, you will. This is a time-intensive period of parenting, but it’s also one of great joy as you watch your child grow and develop into a walking, talking toddler with some very definite opinions of his or her own.

• • • • •

Oh, the frustration Setting limits can be an adjustment for children and parents alike. Not having been stopped from doing much before, a 9-month-old is understandably confused and frustrated when all of a sudden mom and dad are shouting “No!” when he or she reaches for an interesting electric cord, or they make unhappy faces when an innocent roll of toilet paper is torn apart. Your child has no way to differentiate between what’s safe and what’s not, and won’t really understand the reasons behind your rules until much later, around age 4 or 5 years. In fact, at this age, redirecting your child to a different, acceptable activity is generally the most effective deterrent.

With his or her increased capability for expression, your infant is likely to let you know just how he or she feels about these new restrictions, too. At this point, your child has clear likes and dislikes and will communicate them through body language — pointing, clapping, making faces, or stiffening or arching his or her back — and vocalizations such as squealing, howling and jabbering.

To a parent, this period can be frustrating, as well. The orderly routine you finally seemed able to carve out is now being completely turned on its head. Turn your back for a moment, and the basket of folded laundry that you had set on the floor (in blissful ignorance) is now strewn around the dining area. The mail littering the coffee table and living room floor is a shocking discovery that your child can now pull to stand.

Also, it can be difficult to move from being the nurturing parent to being the limit setter, as well, and having to deny some of your child’s wishes.

Making life easier Neither you nor your baby will be happy in a home in which you must constantly keep a close watch and remind baby to keep away from dangerous situations and objects. So many things around the house are tempting, and it’s unreasonable to expect much self-control from your child at this age. Instead, try these strategies:

Childproof regularly Maintaining a safe space for your child to explore on his or her own will make things easier for all parties involved. Soon after babies learn to crawl, they can also climb stairs. Keep gates at the top and bottom of stairs and use them properly. Make sure heavy bookcases and TV stands are securely anchored to the wall so that curious climbers can’t pull them down. Pad coffee table corners, and remove dangerous items from the reach of little fingers.

Offer safe opportunities for exploration Think about ways you can let your child explore without getting into trouble. Some parents reserve a low kitchen cabinet for items the baby can safely get into. Or set up an “activity center” with pillows to climb and empty boxes to investigate. If the weather is nice, a small pop-up tent in the yard can provide lots of fun.

Provide comfort but stay firm When your child is frustrated, provide some help and comfort but realize that overcoming frustration is a skill he or she will need to develop. Distraction or redirection from a forbidden object or activity usually works well. Kids need consistency, so stay firm with the safety limits you’ve set.

Keep your baby busy Most 9-month-olds are active and need a lot of stimulation, but they don’t like to be apart from mom or dad. It can be difficult to give your baby that attention and get anything else accomplished. One option is to fill a small basket with toys for each room of the house; then take the baby with you as you go from room to room, and let your baby play while you work.

Family life Although your baby may not feel comfortable around strangers, he or she loves to be around you and the rest of the family. Your baby may show affection by patting you on the back or even start imitating fond gestures such as hugs and kisses. He or she definitely wants to be a part of the family commotion.

Big brothers and sisters still love the baby and want to play, but the initial enchantment may largely be over, especially once baby can scoot around and get into a sibling’s toys. Try to encourage a spirit of cooperation with an older child.

• • • • •

9th month milestones

During the ninth month, your baby is busy:

Learning to crawl

Standing with support

Working on pulling up to stand

Using thumb and first finger together (pincer grasp)

Banging toys together

Learning to let go voluntarily

Learning to point, clap and wave goodbye

Feeding self

Recognizing and responding to familiar words

Babbling, stringing syllables together

Working on verbalizing familiar words

Holding toys and objects appropriately

Rattling, shaking, dropping toys

Looking for toys that have dropped out of sight

Testing limits and observing parental reactions

Avoiding strangers yet interacting more with family

• • • • •

CHAPTER 28 Month 10

Many of the motor skills your baby has been working on since birth are starting to come together this month. These basic skills enable his or her transition from infancy into toddlerhood. From this point forward, your child is moving steadily toward an upright view of the world. And even though he or she may still only see knees and legs and the lower half of the world for a while, his or her ability to maneuver about is a very exciting development.

During month 10, many babies practice pulling themselves up to stand with the help of furniture or a parent’s leg. By the end of the month, some babies are even able to stand on their own for a few seconds.

Babies also start to be big copycats around this time, which can provide for some enjoyable and laughable moments. Copying the facial expressions, gestures and vocalizations of adults and older children is one of the primary ways a baby learns how to fit into the family and society at large.

Baby’s growth and appearance

Baby is growing at much the same rate as last month — gaining just under a pound a month and growing about ³∕8 of an inch in length. Your baby’s head circumference is still increasing slightly every month.

When your baby first starts to stand and then walk, you might notice that his or her legs appear slightly bowed. This is normal. In most babies, legs become straighter within the next year or so.

• • • • •

What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the 10th month.

Eating During this month, your baby may start eating more of the same foods that the rest of the family is eating. Be sure the food you give to your baby is of the size and texture that he or she can handle. Overcooked or finely chopped foods are still the way to go, or you can use a baby-food grinder to get the food to the right textures.

Breast milk and formula start to take on a more supplemental role, but are still irreplaceable sources of nutrition. If you’ve decided to wean your baby from breast-feeding, replace the breast milk with iron-fortified formula. Your baby isn’t ready for whole milk until after his or her first birthday.

Sleeping By 10 months, you and your baby have developed a regular napping and sleeping schedule. The general expectation is that most 9- to 10-month-olds take two naps a day and sleep as long as 12 hours at night without waking to feed. But then again, it’s common for babies practicing new skills, such as crawling and standing, to wake up at night and pull themselves into positions they need help getting out of. Even after baby learns how to get out of these situations, the physical activity may be enough to make it hard to get back to sleep.

If your baby is safe and dry, it’s OK to let him or her settle back to sleep on his or her own (which might involve some fussing and crying). Once your baby’s new skills become routine, he or she is likely to start sleeping better.

• • • • •

Baby’s movement

By month 10, you can really start to see how your baby’s early motor accomplishments are building on each other. Good head control, along with strong muscles conditioned by months of pushing up, looking around, wriggling and rolling, allow your baby to become proficient at more-advanced motor skills, such as crawling, standing and walking.

Most babies can now sit unsupported with a straight back for an indefinite period. For baby, this is a comfortable position from which to play and engage the world. In a matter of weeks, your baby is becoming an efficient crawler, moving with singular ambition from one place to another. And he or she can bear weight on his or her legs, holding on to something to stand upright. Refinements of these basic skills accumulate this month.

Switching it up By the end of month 10, most babies have learned how to pull themselves into a sitting position — bringing the torso up from lying down, flopping over from crawling or squatting down from a supported standing position. Being able to switch positions at will gives your child a little taste of the mobile freedom and independence ahead.

Pulling to stand Although baby probably still needs support while standing, he or she is working steadily at pulling himself or herself up to stand. He or she might do this by grasping whatever support is handy, such as the rails of the crib, your pant leg or even a patient cat’s tail.

Since your baby doesn’t know the difference between what’s safe to climb and what’s not, it’s important to keep safety a priority. Empty the crib of things your baby might use to climb too high and unintentionally pitch forward out of the crib. Also, keep heavy bookshelves and cabinets anchored to the wall so that baby doesn’t accidentally pull down an unsteady structure.

Picking up, pointing and poking By month 10, most babies are refining their heavy-handed grasp of small objects and graduating to a more delicate thumb-finger grasp. As well as manipulating items with a greater degree of accuracy, babies are also getting better at releasing things at will. Letting go at this age (and for a while to come), however, tends to mean throwing a toy aside rather than gently laying it down.

Your little one has also discovered the power of the index finger, using it to point, prod and poke at items of interest, including you. Picture books are great for practicing pointing and learning the names of things. Use the same words each time for each picture, and your son or daughter will soon start helping you out. Some books feature different textures, such as furry or rough patches, or foldout flaps, which make them doubly interesting for baby.

• • • • •

Prepare for some bumps

As your baby starts to stand and move around on two feet, falls and short tumbles naturally become more frequent. This isn’t really a big deal, as your baby doesn’t have very far to fall and is unlikely to get hurt landing on his or her bottom.

Often, when your baby falls, he or she will look at you first to gauge your reaction before committing to his or her own. Among childhood experts, this is called social referencing. Babies will look to trusted adults for emotional guidance before proceeding with a novel experience.

You can help your child understand that a minor tumble is no obstacle to getting back up by treating it matter-of-factly and offering cheerful reassurance. Some babies will cry no matter what. But if you offer loving encouragement accompanied by positive facial expressions, your baby will quickly learn to shrug off such small setbacks.

At the same time, be sure to provide a forgiving environment for your baby to knock about in. For example, pad sharp coffee table corners and keep loose cords out of sight and reach to avoid accidents.

• • • • •

Baby’s sensory development

As your child approaches the end of his or her first year, he or she is becoming skilled at using his or her senses to learn and explore.

Hearing By 10 months, your baby recognizes sounds without difficulty, such as the sound of his or her name, familiar songs and words, your dog’s bark, and even the doorbell.

Your son or daughter is also becoming more selective as to what sounds he or she listens to. For example, he or she can listen to other people talking and pay attention to conversations without being distracted by other noises.

Touch With the expansion of your baby’s mental and fine motor skills — such as increased memory and individual finger skills — he or she now enjoys more control over his or her exploratory activities. Some things are even starting to become routine. By now, for example, your child knows that a maraca can be shaken, a cup goes to the mouth, buttons are pushed and a favorite doll is gently patted (just like Mommy does it).

Your baby also enjoys self-feeding. Let your baby explore with finger foods (see Chapter 4). And even though it’s bound to be messy, it’s important to let him or her practice self-feeding, as this is the only way your baby will get better at it. To make cleanup a little easier, consider spreading a splat mat or newspapers under your baby’s highchair.

Baby’s mental development

It’s during the last quarter of your baby’s first year that his or her language skills really start to blossom. Not only is your baby’s comprehension of what’s being said expanding, he or she may also be on the way to saying his or her first words. First words are cause for excitement, and deservedly so. There’s so much to say!

Your child’s ability to think as a separate individual is becoming more sophisticated, and you may see clues of this expressed through your baby’s nonverbal communication, as well.

First words During this month, many new parents start to hear baby sounds bound to warm their hearts. About half of babies use dada and mama to refer specifically to father and mother at this point. A few babies even start to use one other word in addition to dada and mama, such as baba for bottle or mok for milk. These words are often hard to understand at first, and it may be a while before you figure out that your son or daughter is saying something meaningful. In general, a word at this age is any sound used consistently to refer to the same person, object or event.

When opportunity presents itself, you can reinforce the correct way to say the words your baby is learning. For example, readily acknowledge your child’s request for a baba, and then say the correct word, bottle, when offering it back to him or her.As you feed or play with your child, regularly describe what you’re doing. Eventually, your child’s language skills will develop enough for him or her to use the correct words.

Conversation As a result of listening to you talk, your child’s own babbling will start to sound more like the ups and downs of a real conversation. Even if most of it makes no sense, join in the conversation and repeat your baby’s sounds back to him or her. Try to discern any words that might be popping up in the middle of all the jabber. Respond positively to your baby’s talking, and pause at times to encourage a rhythm like that of real conversation. Your baby will be delighted that you’re interested and paying attention.

• • • • •

Toys and games

Go for toys and games that help enrich your child’s growing awareness of the way things work, from toys that stimulate exploration of different functions to ones that allow baby to mimic grown-up behaviors. Games made up of simple actions can be fun, and silly songs with accompanying gestures are sure to be a hit.

Busy toys With your child’s growing dexterity, he or she may enjoy toys that feature multiple functions, such as pushing buttons, opening drawers, making noises and lifting lids. Stacking toys and nesting toys are fun for baby to assemble and disassemble.

Mimic Offer your child toys that resemble adult accessories, such as a toy phone, plastic keys, a comb, pretend food or a teacup. See what your child does with them. Or make a silly face or gesture and encourage your child to imitate you. Wait to see if he or she makes a funny face or odd gesture at you. Return the favor and imitate him or her.

Give and take Many 9- to 10-month-olds enjoy simple games that involve passing an object or toy back and forth. Offer your child a ball. Once he or she grasps it, ask for it back. This may sound a bit tedious to an adult, but your baby will probably love it, and it helps him or her learn the concept of game play and following simple instructions.

Silly songs Babies at this age delight in silly songs that have accompanying hand gestures. These help stimulate not only your child’s funny bone but also hand-eye coordination and fine motor skills. “Itsy, Bitsy Spider,” “I’m a Little Teapot” and “This Little Piggy” will never go out of style with this crowd.

• • • • •

Nonverbal communication Although your baby still has few words with which to express himself or herself, this won’t stop him or her from communicating with you. Now that your baby is starting to discover personal likes or dislikes, he or she will communicate wants and desires through pointing, shaking his or her head no, reaching and making sounds, and pulling or holding arms out to be picked up.

Not only does this nonverbal communication show that your child is trying to relay ideas to you but also indicates an increase in your child’s self-perception. He or she is now able to formulate thoughts related distinctly to himself or herself, apart from others, and to his or her own personal desires. Your child is also developing thinking skills sophisticated enough to communicate those wants and devise ways to achieve them.

Along with simple expressions of his or her own thoughts, your son or daughter is beginning to understand brief requests of action from you. He or she may do what you ask if you use hand gestures with your request, and it involves some sort of interaction with you. If you ask your child for one of his or her crackers and hold out your hand, indicating what you want, he or she may comply.

• • • • •

A two-way street

Multiple studies have shown that a child’s mental development and grasp of language, specifically, are strongly associated with the amount of language a child is exposed to in the first three years of life. The greater variety of adult words an infant or toddler hears early on, the greater his or her language skills tend to be in the preschool years.

Because of this strong association, parents are encouraged to expose their children to as much language as possible, through reading, storytelling or even just narrating the day’s activities.

One study in particular, published in the journal Pediatrics, sought to expand on the kind of adult language exposure that might be most beneficial to a young child. If simply hearing adult vocabulary is the only requirement for child language acquisition, then you could reasonably assume that turning on the TV would help your baby develop his or her language skills. But evidence indicates that heavy TV exposure tends to have a negative impact on a child’s language, reading and math skills.

To conduct their research, the authors of the Pediatrics study fitted each participant in the study, ranging in age from 2 to 48 months, with a digital recorder worn throughout the day. Using special software, the investigators differentiated between three types of speech that a child might hear: adult speech, television and adult-child conversations. During the study, the children’s language development was assessed several times by a speech-language pathologist.

When evaluated alone, adult speech had a positive impact on language development and TV had a negative impact, as you might expect. But when all three types of verbal input were evaluated simultaneously, only adult-child conversations continued to have a significant effect on a child’s language skills.

This suggests that more important than merely hearing adult vocabulary is hearing adult speech that elicits a child’s response. More conversations with you, for example, mean more opportunities for your child to practice verbalizing and conversing. They also mean more chances for your child to learn as you correct his or her mistakes. From your perspective, frequent back-and-forth conversations with your child helps keep you in tune with your child’s evolving abilities. This awareness helps you calibrate your speech so that it’s neither too simplistic nor too difficult for your child.

Granted, when your child’s vocabulary consists of one word, having a full-blown conversation may seem a little hard. But as you’ve probably noticed, communicating with your child need not always involve words. Teaching your child that conversation is a two-way street can be done with facial expressions, sounds and gestures. Doing this will set the foundation for further language skills as your child’s vocabulary expands.

Bottom line: Keep on reading and talking to your child, but be sure to include some “conversation” time — such as discussing a picture book — as well!

• • • • •

Baby’s social development

As your child’s skills and independence increase, he or she will still look to you for safety and security. Even if you have officially “bonded” at this point, hugs, kisses and warm affection are still vital to expanding on the trust your baby has placed in you. Giggles and laughter and quiet times together deepen your relationship and further cement the bond you have.

Since birth, your baby has been learning through listening to and watching you. In earlier months, it may have felt like your baby wasn’t paying much attention to your day-to-day activities. But soon you’ll notice you have a “mini-me” at your heels, imitating many of the activities you thought had gone unnoticed.

Mimicking Around this age, babies like to mimic the gestures, facial expressions and some of the sounds made by adults and older kids. If your baby gets hold of the remote control, for example, you might find him or her pointing it at the TV. Or if baby’s older brother blows a raspberry, the baby will try to do it, too (a scenario that all too often unfolds at the dinner table when you’re engaged in the serious business of trying to eat a meal). After a meal, your baby may try to wipe your hands and face.

Babies also like to initiate copycat games, making a sound or gesture and looking to see whether you will do the same thing back.

Mimicking is an important way of learning essential skills. Even adults make use of this form of social learning when they are confronted with new cultural situations. Your actions and behaviors as a parent can be powerful teaching tools for your child. For example, if you consistently use the words “please” and “thank you,” and you always treat your partner with kindness and respect, you’ll find your child eventually doing the same.

• • • • •

Sharing

Between months 10 and 12, babies love to be with other babies and watch them play. But they’re still not capable of playing with each other. Interactive play usually doesn’t take place until around 2 to 3 years of age.

What babies are capable of right now is taking an interest in another child’s toy. This can lead to some tussles over toys and other playthings. It would be nice if babies had an innate ability to share and be polite, but at this stage it’s all about them and what they want. In general, kids don’t understand the concept of sharing or taking turns until the age of 3 or so. And even when they do understand the concept, they may not always put it into practice.

If conflict arises around a toy or other object, your best bet is to distract your baby with something else. Aided by his or her short attention span, it’s fairly easy to engage your baby in a different activity, making the sharing issue a moot point. Eventually, you can start showing your child how to share with someone else. For now, though, the lesson is likely to be lost on your baby (especially if it’s a longwinded one).

• • • • •

Eyeing mom and dad By 9 to 10 months, your child’s awareness of strangers is obvious. Although he or she may be affectionate and playful around you, the same is generally not true for strangers and even relatives or baby sitters. In addition, separation anxiety tends to peak sometime between 10 and 18 months. While playing, your baby may repeatedly look for you in a room to make sure you’re still there. This makes it hard to leave your baby with other caregivers without some emotional stress.

As you probably realize, this is a sign that your child is strongly attached to you. It can be amazing to realize how much this little one loves and depends on you, but at times your baby’s neediness can make you feel suffocated and guilty when you need to leave. This is normal. Bear with your tiny guy or gal for a little while, and try to make him or her feel as loved as possible. Take breaks when you need to. As your child becomes more secure in his or her independence, emotions will become more stable.

• • • • •

10th month milestones

During the 10th month, your baby is busy:

Mastering crawling

Standing with support

Pulling up to stand

Maybe standing alone for a few seconds

Using thumb and first finger together (pincer grasp)

Manipulating toys appropriately

Learning to let go voluntarily

Using gestures to communicate, such as shaking his or her head for no

Feeding self

Recognizing and responding to familiar words

Babbling, stringing syllables together

Saying mama and dada

Verbalizing other familiar words

Looking for hidden toys

Imitating the activities of adults and older kids

Testing limits and observing parental reactions

Avoiding strangers yet interacting more with family

• • • • •

CHAPTER 29 Month 11

Wow. It may seem like just yesterday that you brought your baby home from the hospital. But here he or she is, fast closing in on the end of his or her first year. So much has happened since birth that those early months may now start to seem like a blur. And in the eagerness to celebrate your baby’s first birthday, month 11 might feel like it gets a little lost in the shuffle.

But there’s plenty going on. Your little one is headed toward an upright view of the world, which allows him or her to see so much more. This vantage point also places more toys and other objects within easy reach. Your baby will start inching, or cruising, along furniture to get to things and places. These are the first steps toward walking without help.

Your son or daughter can also see clearly and is learning to listen and look at the same time — a big step forward in the ability to focus and concentrate. His or her language skills are building as understanding increases, and he or she starts using meaningful “words” to indicate people, places and things.

Baby’s growth and appearance

As your child heads into toddlerhood, you can expect his or her growth rate to begin to slow down quite a bit compared with the first year, which is the period of most rapid growth a person experiences in a lifetime.

For example, during baby’s second year, he or she is likely to gain about half the amount in a month that he or she gained in months six through 12. Growth in height slows down considerably, too, from about a 10-inch growth spurt in the first year to about 5 inches in the second year. Head growth also is much slower in the second year, totaling about 1 inch for the whole year.

For month 11, however, your son’s or daughter’s growth rate will likely be the same as last month’s. Keep in mind, though, that babies tend to grow in fits and starts, so don’t be surprised if a period of very little growth is followed by a big growth spurt.

• • • • •

What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the 11th month.

Eating During this month, your baby is probably eating many of the same foods that the rest of the family is eating. Be sure the food you give to your baby is of the size and texture that he or she can handle. Overcooked or finely chopped foods are still appropriate, as are small chunks of foods that are easy to chew and swallow. Breast milk and formula take on a more supplemental role, but are still necessary sources of nutrition.

Sleeping Most 10- to 11-month-olds sleep as long as 10 to 12 hours at night and take a couple of naps during the day. A few babies may start giving up their morning naps during this month. If that’s the case for your baby, try starting the afternoon nap a little earlier and make bedtime a little earlier, as well. This will help avoid overtiredness. Pay attention to your child’s cues, too, and adjust his or her sleeping schedule to accommodate his or her need for sleep.

• • • • •

Baby’s movement

On average, month 11 is when many babies start “cruising,” shuffling alongside furniture, going from one piece to another as they make their way around the room. It doesn’t take long for a baby to become quite good at this method of traveling. Although walking without help is just a few steps away, crawling still rules for most babies, affording the most efficient way of getting from point A to point B.

Crawling With added experience, your baby is getting faster and more confident at crawling (whatever his or her technique might be). Crawling around helps develop your child’s ability to absorb slightly differing views from both eyes, so that his or her brain can see with three-dimensional capability. This ability provides new depth perception. As your baby’s depth perception improves, his or her movements become more controlled, and he or she may become more cautious about heading down a slight slope or up a gradual incline.

If your baby has started cruising, he or she will drop down to crawl if there’s nothing to hold on to. And many babies continue to crawl even after they start walking. Kids are fairly efficient creatures, though. Once walking becomes the fastest way to get around, they’ll stick mostly to walking.

Standing Your baby is getting pretty good at staying upright, too. Most babies this age can stand with support, such as while holding your hand, for at least a couple of seconds. Some babies even start to stand alone for a brief second or two.

Around 11 months, the average baby is also able to maneuver himself or herself into a sitting position from a standing position without just falling on his or her bottom. He or she will probably need to hold on to furniture or your leg, for example, for support while doing this.

Cruising Some babies walk sooner than do others, and a few babies will start to take their first independent steps during this month. However, most continue to rely on nearby furniture to support their movements. You’ll see your baby slide his or her hands along a piece of furniture, taking small sideways steps to get around. Every so often, he or she may pause to examine a toy or a scratch in the wood, or to bang vigorously and happily on the coffee table.

At first, your son or daughter will likely keep one arm on one piece of furniture and reach out with the other arm to secure himself or herself to the next piece — from couch to coffee table to chair, for example. Gradually, he or she will become confident enough to move between pieces that are farther and farther away, such as from couch directly to chair if it’s close enough. You might even catch your son or daughter taking a few quick steps unaided.

Finger skills Passing objects back and forth is a fun game for baby, giving him or her lots of practice in using the thumb-finger grasp and in deliberately letting go. Your baby also enjoys pointing at things he or she finds interesting.

Your child’s improved depth perception helps him or her realize that an empty cup has space inside of it and that, amazingly enough, things can be put into the cup. By the end of month 11, about half of babies are adept at putting things in a container. The new big attraction will be dumping everything out of a basket or a bucket and then putting the things back in again, or at least some of the things.

Having greater depth perception also makes it possible for your son or daughter to take part in simple ball games, such as rolling a ball back and forth.

• • • • •

Shoes: Does your baby need them?

When their babies start standing and cruising, many parents wonder whether shoes are necessary. At this age, your baby doesn’t need shoes for standing or walking. You might put shoes on your baby because they look cute, to keep your baby’s feet warm or to protect the bottoms of the feet. But your baby doesn’t need shoes for any other reason and is probably growing so fast that buying shoes seems impractical.

You may think your baby’s feet look flat and seem to be supported by unstable ankles. This is normal. All babies have chubby, thick feet with a fat pad that hides their arches. And they are generally unsteady on their feet. They are just learning to walk, after all. But putting your baby in shoes with special arches, inserts, high backs or reinforced heels won’t change your baby’s feet or help baby walk more easily. On the contrary, your baby may benefit from being barefoot to get a “feel for the road” when learning to walk.

If you do buy shoes for your baby, make sure they’re comfortable and have nonskid soles to avoid slips. You should be able to feel a space as wide as your index finger between your baby’s big toes and the tips of the shoes. Shoes should also be wide enough across the front to allow your baby’s toes to wiggle.

• • • • •

Baby’s sensory development

By month 11, your child’s sensory abilities are running in practically full gear.

Vision Although your baby is still nearsighted, he or she can see as clearly as you can, recognizing familiar faces from 20 feet away. Your little one has become a keen observer, watching the movements of others with interest. He or she can visually track moving objects with no problems. And now that your baby knows that things continue to exist even when out of sight, he or she is able to look in the right places for playthings and objects that have dropped or rolled out of sight.

Hearing and listening Your baby’s hearing and listening abilities — along with an increasing ability to focus his or her attention — are improving to the point where he or she is starting to listen and look at the same time. These skills help your child pull in valuable information about the surrounding world.

Touch During this month, your child is learning about concepts such as behind and inside, which is one of the reasons why taking inventory of a purse or bag becomes so much fun at this point. Your child will probably also delight in poking his or her fingers into holes, tearing up paper, or putting his or her fingers into something wet or gooey.

• • • • •

Getting your child to listen

During this past year, you’ve had the luxury of being the center of your baby’s universe. It’s likely that every time your little guy or gal hears your voice, his or her ears perk right up, and he or she turns to you with full attention.

But as your child gets older and interested in more and more things, you might find that it gets a little harder to capture and keep his or her attention (see your older kids, or consult any parent of an older child for expert testimony). To get good at commanding your child’s attention in the face of outside forces — such as TV, warring siblings, and other various and sundry onslaughts — requires a bit of practice. If you start working on your skills now, you’ll be one step ahead in helping your child become a better listener, and in making yourself heard:

Eliminate background noise. It’s hard for your little one to concentrate if there are a lot of other sounds swirling around.

Go to your child. Don’t shout from across the room. Stop what you’re doing and go directly to your child. Your child is more likely to hear, understand and respond if you are right in front of him or her.

Get down to his or her level. Being face to face helps your child focus his or her attention on you.

Say his or her name. Do this clearly and loudly. Then pause before continuing to allow your son or daughter time to shift his or her attention away from current activities to you.

Maintain eye contact. This helps your child stay focused and increases his or her concentration on what you’re saying.

• • • • •

Baby’s mental development

Your little one’s receptive language skills, what he or she understands, are still way ahead of his or her expressive language skills, what he or she can say. Around this age, your baby is becoming adept at using body signals to communicate, such as nodding, waving goodbye, pointing, and shaking his or her head for no. But if you pay careful attention, you may notice that amid all of the babbling, your baby constantly uses particular sounds (“words”) for certain things.

Capitalizing on body language If you say, “It’s time for breakfast!” your son or daughter may smile and nod enthusiastically in response. While the two of you are communicating, use signs or hand motions. Doing so will help your youngster communicate his or her immediate needs (and minimize frustration) while learning verbal expression.

Increasing vocabulary About half of infants have learned their first words by the end of their first year, but it’s not unusual for some to wait until their second birthday to really start talking. Boys usually say their first words later than do girls.

Other factors affect language development, such as whether your child has a cautious temperament or is the youngest child in a large family. If there’s no need for your baby to talk, he or she may not view it as a necessary skill just yet.

Also, babies tend to work separately on different skill sets. If your toddler is working hard at walking, he or she may not have any energy left to work on talking. Once an active toddler is walking well, he or she is more likely to devote attention to learning words.

Once first words arrive, vocabulary can increase fairly rapidly in the months that follow. The best way to help your child increase his or her vocabulary is to talk with him or her. You want your child to not only hear words, but hear them as part of an interaction with others. Once you hear your child working on a new word, incorporate it into your conversations. Use it in ways that are easy for your child to understand.

Take the words mama and dada, for example, which are typically some of the first words a child learns. Hang around parents of young children for any length of time and you’ll hear them frequently referring to themselves in the third person. “Do you want mama to help you?” “Can dada put you in the swing?” Doing this accomplishes several things: It reinforces who mama and dada are, places the words in a context that’s easy for the child to understand and helps the child learn to vocalize them. So go ahead and do it. It helps!

• • • • •

Toys and games

This is often a good month to introduce toys that complement your toddler’s growing skills, such as cruising, walking or sorting through objects.

Push toys These are toys your child can push around while standing upright, such as a toy grocery cart or stroller. Such a toy can help your child practice walking while still offering some support. Stay close, though, to offer a hand when your child gets tired of pushing.

Fill a basket Place a variety of small, nonhazardous objects in a basket or plastic bowl. Let your child sort through the items, dump them out and put them back in again. You’ll be surprised at how entertaining this can be for your little one.

Play catch Although your son or daughter can’t catch a ball in midair yet, he or she will have fun corralling a ball that’s rolled in his or her direction.

Godzilla Give your child a chance to unleash some energy and laugh in the process by building a tower of soft blocks for your child to knock down. In a few months, he or she will have the skills to build a tower himself or herself, just to knock it down again, of course.

Create an exploration zone To build on your child’s ability to pull up to stand and cruise, place some interesting objects on a low table that will attract his or her attention. This will give your child extra motivation to stand and move around while holding on to the table.

• • • • •

Baby’s social development

When your baby was born, he or she had no sense of himself or herself as a separate entity from you or the rest of the world. But from about 8 months or so, your child starts to figure out that, “Hey, I’m Sam. I have my own face, hands, fingers and toes. I can wiggle my body when I want, and when my dad makes a funny face, I can make it myself!”

You might notice this when you and your child are in front of a mirror. Before, your baby may have thought the image in the mirror was a different baby. Now your child is starting to recognize that it’s his or her own image and may touch his or her nose or pull a strand of hair to confirm the physical feeling with the actions in the mirror. When you make a face in the mirror, your baby may try to copy you while watching his or her own reflection.

As your child’s self-concept grows, it affects the way he or she interacts with the world. You may notice a growing self-confidence, as well as a newfound wariness of things that may previously have had little to no effect on your child.

• • • • •

Bilingual babies

If you speak a second (or third) language, feel free to use it with your baby. The rule of thumb is that the younger a person is when exposed to a different language, the less difficulty he or she will have in acquiring it. Giving your child the gift of a second language is a gift he or she can use throughout life.

Some parents are concerned that their child will become confused if presented with two languages at the same time. But there is little evidence to support this concern. In fact, research suggests that the human brain is adaptable enough to learn two languages simultaneously just as well as one. Consider also the millions of families around the world who speak more than one language at home and in their communities.

Although bilingual kids may mix words from different languages or attach verb endings from one language to words in another, research shows that eventually they sort it out. If they consistently use one language over another, that language may become the dominant one — for example, if English and French are both spoken at home but English is used everywhere else, English is likely to become the dominant language. Nonetheless, the child can still become proficient in French if he or she uses it often enough.

Even if your partner doesn’t share your second language, you can still expose your baby to it by using it to narrate your day, read books in that language or have the same kinds of “conversations” with your baby that you would have in your family’s primary language. You might feel funny at first, but it will be worth it when you hear your child say his or her first words in English and in Vietnamese or Spanish or Russian.

• • • • •

Increased assertiveness The more practiced your son or daughter becomes at new skills, the more assertive he or she is likely to become. This growing independence is good and a sign of healthy development, but it raises the potential for the first power struggles between you and your child. Your child’s discovery of his or her own will may make him or her more likely to refuse certain foods, demand more privileges or protest your restrictions more loudly.

Your baby’s personality starts to shine through more clearly when he or she can assert both likes and dislikes. For example, you can now see evidence of your child’s amazing persistence when he or she insists on finding that hidden object. Or when your son or daughter crawls off to play alone for a while after being surrounded by other people, you realize that he or she may need some downtime to recharge his or her batteries before interacting with people again.

Newfound fears As your baby’s brain continues to develop, so does his or her perception of danger and sense of fear. This is a primal step in the development of a child’s judgment and ability to recognize unsafe situations. Things that may not have bothered your child before, such as the dark, thunder or loud noises, may now become scary and provoke intense feelings of fear. At this point, it’s easier to remove or minimize the sources of fear than to attempt to rationalize them. For example, you might install a night light in your child’s room or leave a closet light on at night. If a scary something is impossible to avoid, stay close and calm. Eventually, based on your reaction and comfort, he or she will learn there’s nothing to be afraid of in these situations.

• • • • •

11th month milestones

During the 11th month, your baby is busy:

Mastering crawling

Standing with support

Pulling up to stand

Standing alone for a few seconds, perhaps, or even taking a few steps

Holding on to furniture to walk around (cruising)

Using thumb and first finger together (pincer grasp)

Manipulating toys appropriately

Learning to let go voluntarily

Using gestures to communicate

Feeding self

Recognizing and responding to familiar words

Babbling, stringing syllables together

Saying mama and dada

Verbalizing other familiar words

Looking for hidden toys

Imitating the activities of adults and older kids

Testing limits and observing parental reactions

Becoming more assertive

Avoiding strangers yet interacting more with family

• • • • •

CHAPTER 30 Month 12

This month marks the end of your baby’s first year. Your son or daughter has changed dramatically in the past 12 months. During those first days and weeks, you may have wondered if you would ever understand each other and work as a team. Now you can read your baby’s moods and cues and respond with exactly what he or she needs. Your baby also understands you and knows how to thrill you, make you smile and even exasperate you.

You’ve changed, too. While your baby has become more independent and communicative, you’ve become a more confident and interactive parent. Congratulations! It’s not easy becoming a parent, but it’s definitely doable. And although this is the last month of year one, it’s really only the beginning of many adventures to come.

The confidence you’ve developed and your ability to understand and communicate with your baby are your best tools in the months ahead. No one knows your son or daughter as well as you do. As your little one makes the transition from infant to toddler, your in-depth knowledge of your child will help you provide the challenges, support and assurance he or she needs.

Baby’s growth and appearance

What a difference 12 months can make! For most babies, birth weight has tripled by the end of the first year. So if your baby weighed 7.5 pounds at birth, he or she is likely to be between 21 and 23 pounds now.

During the first year, most babies grow about 10 inches from birth. The average baby is now between 28 and 32 inches tall. The typical head size at 12 months is about 18 inches, up 4 inches from a newborn size of approximately 14 inches. Some babies may have only one tooth at this stage; others may have up to 12 or more.

Childhood experts and medical providers use a baby’s first birthday as a natural benchmark for many milestones, but keep in mind that all babies will continue to grow and develop at their own unique rates. What’s important is not that your baby’s height and weight numbers match up with national averages, but that he or she is following his or her own steady growth curve.

In the same way, the normal range for many developmental milestones is quite wide, so don’t be concerned if your baby isn’t walking or talking yet, or is still very leery of strangers. The first birthday is magical only in the sense that loved ones make it so in celebration of reaching that one-year milestone. However, in terms of measuring development, it’s much less significant. Your baby will begin doing all of the things he or she is supposed to, whether it’s a few months before or a few months after the big birthday bash.

• • • • •

What’s going on this month

Here’s a snapshot of what your baby’s basic care looks like in the 12th month.

Eating By now, your baby’s diet probably includes foods with various textures and flavors. But the amount your baby eats at a meal may seem very small. Many parents become concerned that their babies aren’t eating enough. Keep in mind that portions for an 11- to 12-month-old are pretty small compared with an adult’s, perhaps a scant ¼ cup from each food group. And as babies transition into the second year, their appetite tends to drop and becomes more erratic. Altogether, this might translate into a meal of a few tablespoons of cooked carrots, two bites of rice, a taste of meat and several bites of pears. Focus on your baby’s signs of hunger and thirst rather than how much is left on the plate. Allow him or her to stop eating when he or she is full, rather than coaxing or playing tricks to get more food in. If you make a healthy selection of foods available, your child won’t starve or lose significant weight.

Keep giving your baby breast milk or formula. Both are important sources of nutrition. If you’ve decided to wean your baby from breast-feeding, replace the breast milk with iron-fortified formula. After the first birthday, you can gradually transition your baby to drinking whole milk with meals.

Sleeping Most 11- to 12-month-olds sleep as long as 10 to 12 hours at night and take a couple of naps during the day. Most babies still need two naps a day, but some start giving up their morning naps around this time. If that’s the case for your baby, try starting the afternoon nap a little earlier and make bedtime a little earlier, as well. This will help avoid overtiredness. Pay attention to your child’s cues, too, and adjust his or her sleeping schedule to accommodate his or her need for sleep.

By 11 to 12 months, nighttime feedings are generally a thing of the past. Nursing or taking a bottle is likely to be for reasons of comfort, not calories. If your baby is still waking up for feedings and you want to work toward sleeping through the night, try gradually shorter nursing sessions or smaller bottles. Eventually you can cut down to none at all. Also look at your child’s bedtime routine. Place your child in bed while tired but still awake so that he or she learns how to put himself or herself to sleep.

• • • • •

Baby’s movement

Your son or daughter has learned so much in the past year. In a matter of months, he or she has gone from struggling to hold up his or her head to learning how to sit, crawl, cruise and maybe even walk, all on his or her own. Where once your child was able only to bat at large objects with closed fists, he or she can now pick up an item as small as a crumb. This is all a result of the rapid development of your baby’s nervous system, which is now a much more efficient conductor of messages from brain to muscles and vice versa.

Sitting Not only can your baby sit for indefinite periods of time without toppling over, he or she can also pivot while seated to reach a toy or to turn toward you. He or she can also easily get in and out of a sitting position at will.

Standing and bending During this month, about half of babies gain enough balance to stand alone for a few seconds or even longer. This opens up a whole new level of vision and reach for your baby, as he or she can now play with toys above ground level. At the same time, about a quarter of infants are learning to bend down while standing to recover an item from the floor.

Walking Between months 11 and 12, about 1 out of 4 babies learns to walk well. Walking is a complex activity that requires coordination, balance and a good dose of confidence. A key stage in learning how to walk independently is learning to lift first one foot and then the other so that the baby is briefly standing on one leg. Your baby practices doing this while cruising around holding on to furniture for support.

When your baby first shows an interest in taking steps, walk with your baby, holding his or her hands and praising his or her efforts to move forward. Once baby signals that he or she is ready to walk alone, crouch down a short distance away with your arms out, and encourage him or her to walk toward you. Pretty soon, look out — there goes your toddler! First steps are always exciting. It’s good to stand back and let your baby practice, but continue to stay close, as it takes awhile to get the hang of walking without help.

Don’t fret if your baby doesn’t seem to be interested in walking just yet. A few babies start walking as early as 9 months, but others wait until 17 months to take the plunge. Both are perfectly normal.

Getting up and down stairs Even before a baby starts walking well, he or she will likely figure out how to get up a set of stairs, which involves a mix of crawling and walking maneuvers. In a few weeks, usually sometime between 12 and 15 months, children learn to go down the stairs, too, most often by sliding down feet first on their tummies.

Getting up and down stairs is an important skill to learn, but you’ll want to be close by whenever your child is working on it, to catch any slips and avoid tumbles that are bound to happen.

Hand and finger skills Your son’s or daughter’s refined pincer grasp at 12 months allows him or her to pick up objects with ease. When reading a book together, your child can turn the pages with a little bit of help. Later, he or she will use these same skills to learn to draw, paint, write, and work buttons and zippers.

Most babies can hold an object in each hand by this age and enjoy banging the objects together. Your baby may even have figured out how to hold two objects in one hand and how to put them into a container. He or she may also throw toys to the side when they lose appeal or to pick up something more interesting. But your fickle juggler won’t have much control over where he or she can throw.

Between 11 and 12 months old, many infants are getting a better grasp of their eating and drinking utensils, both literally and figuratively. Your baby may know how to pick up a cup and drink from it but may not be able to set it down just yet, and will probably drop it if you don’t take it. He or she is also getting better at using a spoon and has probably discovered that spoons make good toys (especially if they’re filled with food).

• • • • •

It’s a party!

At the end of this year, the whole family deserves a party — perhaps for the family more so than baby, who likely won’t grasp the significance of the event until around age 3. In any case, it’s a traditional time to celebrate, and why not? For many families, the baby’s first birthday marks the end of a period of labor-intensive parenting. There’s more to come, sure, but colicky evenings, breast-feeding struggles and chronic sleep deprivation are now largely behind you. It’s time for cake!

While it’s tempting to invite everyone you know to such a grand occasion, for baby’s sake you might consider having a small party with immediate family. At 1 year of age, your baby may not enjoy a large, noisy gathering of friends and neighbors. Even if your little one is the gregarious type, you might still want to limit the duration of the party to an hour or so, to avoid any baby-related meltdowns.

• • • • •

Baby’s sensory development

By the end of the first year, your child’s senses are working together in a coordinated fashion to make your child aware of the outside world. And as he or she becomes used to routine sights and sounds around the house, your son or daughter learns to filter out distractions and better focus on things of interest, such as eating a meal or listening to a favorite story.

• • • • •

Safety check

Every step your baby takes toward more independence and mobility is thrilling, but it also means an increased risk of injury. As your baby learns to stand, cruise and walk, the risk of injury increases. Being aware of your baby’s ability to move farther and faster is the first step in reducing this risk. It may seem surprising that your baby can get into something that a week earlier was out of reach.

Take time out every few days to get down to the baby’s level and look around each room. What new temptations do you see?

Injuries are most common at times when the family is occupied, such as dinnertime. Your baby is active and impulsive. When you’re busy and stressed, it’s easy to lose sight of the baby for just a second. Unfortunately, babies at this age don’t know how to adjust their need for attention and exploration just because you’re stressed. Sharing mealtime duties with another family member may allow one person to play with or feed the baby while the other tends to the rest of the family’s needs.

For more information on childproofing your home, See Chapter 17.

• • • • •

Looking and listening Your baby’s hearing is sharper now, and he or she listens with greater attention. In fact, he or she can look and listen at the same time, making reading books together that much more enjoyable. If you think your baby isn’t hearing well, talk to your baby’s medical provider about a hearing assessment.

Touch Even though your little guy or gal is benefiting from integrated sensory input, he or she still enjoys singular sensations, such as feeling different textures or pouring water from one container into another. For some adventure as your baby learns to walk, let him or her tread barefoot on different surfaces, such as on soft grass or in a puddle of water. Your baby also enjoys human touch and loves to return hugs and kisses, although not always on demand.

At age 1, your baby still explores using fingers and mouth together. Anything your baby picks up will be taste tested.

Baby’s mental development

Brain imaging studies of sleeping babies from infancy to 2 years old reveal that the total volume of a baby’s brain increases by over 100% during the first year of life. Pretty amazing, isn’t it? No wonder a baby’s head size grows so much — it has to accommodate all of that growth in gray and white matter.

The older your baby gets, the greater the myelination of your baby’s nerves — the process whereby nerves become encased in a fatty sheath called myelin, which makes them stronger and more efficient messengers. This myelination helps bring more and more areas of the brain into use.

Some areas of the brain don’t mature until much later — such as a part known as the reticular formation, which helps you maintain attention. This area doesn’t become fully myelinated until puberty or later. The frontal lobes, responsible for executive thinking and judgment, don’t become fully myelinated until adulthood (and you thought impulsive teenagers were just out to give a parent gray hair).

Increasingly complex thinking By age 1, your baby is starting to gain control of the limbic system — the area of the brain responsible for emotions, appetites and basic urges, but also responsible for information processing and directing incoming information from the outside world to the appropriate areas of the brain. Thus, a 1-year-old’s thinking gains in complexity and starts to contain longer chains of thoughts. If you offer two toys to a 1-year-old, for example, he or she will likely make a choice between the two rather than trying to grab both. Or if your baby sees a toy with a blanket on it, he or she may employ knowledge of cause and effect to pull the blanket to get to the toy.

Understanding The part of the brain involved with understanding is maturing as well. By the end of the first year, babies are beginning to respond to one-step commands. For example, your child may hold on to you on request when you pull his or her pants up to get dressed. Or your baby may give you a kiss when you ask.

Your son or daughter may also show understanding of simple questions, such as “Is that a puppy?” when pointing at a picture of a puppy in a familiar book.

Language Speaking develops more slowly than understanding, and it won’t be until the second or third year that your child’s vocabulary begins to expand dramatically. And it may take even longer for people outside of the family to understand what your child is saying.

Still, the beginnings of speech are at hand. More than half of babies know at least one word, such as uh-oh or doggie, by the age of 1 in addition to mama and dada. Some may even know two or three words. Continue to encourage your baby’s exploration of words by listening intently and responding to the baby’s jabbering. Repeat new words your baby is learning, and verbally name gestures that he or she already uses for communication.

If you’re concerned about your child’s speech development, try to discover what he or she is channeling his or her energies toward. Perhaps your son or daughter is spending more time standing, cruising and walking. Eventually, once these skills are mastered, speaking will become a priority. Allow your baby to learn these skills within his or her own time frame.

You should also know that how well your baby understands language is a better measure of language development than are the words he or she is able to say.

• • • • •

Toys and games

Through the end of the first year and beyond, your baby will still enjoy toys and games that use and build motor skills. Games that involve picking up and dropping objects will likely be entertaining. At 12 months, your baby’s play may range from exercising large muscles to working and mastering fine motor skills. He or she will likely think it’s fun to push, throw and knock down everything.

When walking down the toy aisle of your local retail store, it may be easy to get carried away because there’s so much to choose from. When purchasing a toy for your child, keep in mind the fun factor, as well as the fact that many objects will still go in your child’s mouth. Toys can certainly be educational, but try to stick with something appropriate for your child’s level of development. If a toy or game is too difficult for your child to comprehend, he or she will quickly lose interest. And while toy manufacturers may think of their products as the perfect developmental aid, there’s nothing that beats interaction with you when it comes to helping your baby grow and learn. Here are some ideas to get you started.

Find open space Often the best thing you can do for your baby when he or she is learning how to crawl and walk is to give him or her plenty of space to move around in. This could be at a park if the weather is nice or at a community recreation center or kids’ gym. If you have older children who are taking a class in a gym or other open area, such as ballet or karate, take your baby along, if it’s ok with the teacher and there’s enough room. This way your baby can benefit from the space, too.

Walk together Practice walking together with your baby by holding hands. Gradually, he or she will move to holding one hand only and then just a finger. Soon, you’ll be able to take a step back and let your baby walk toward you. Let your baby try out different surfaces, too, such as warm sand, soft grass or a wet puddle.

Crayons Some babies start to scribble around 12 months or so. Give your child a crayon and a piece of paper and see what happens. Show him or her how it works and see what your child does. He or she may be delighted at the results, and so will you.

Pull toys With your son’s or daughter’s increased dexterity, he or she can pull a toy along if it has a string or ribbon attached. Pulling a toy can be just as fun as pushing one around.

Water toys A book in the bath? Little ones love sitting in the tub and flipping through a waterproof picture book. Your little guy or gal also might enjoy bathtub paints and crayons that rinse right off with the bath water. Water is fascinating to kids, and many will be content to simply pour it from one cup to another. Just be sure to always supervise your child around water to avoid any possibility of drowning. Remember, if the phone rings or the doorbell sounds, don’t leave your baby in the bathtub alone.

• • • • •

Baby’s social development

Your baby may be on the road toward independence but still has lots to learn. Some of the fear that accompanies that early independence is starting to fade as your child becomes more sure of his or her place in the family. However, you and other family members will still be the ones your baby relies on for safety and security.

Veni, vidi, vici Your baby is starting to take up Julius Caesar’s famous motto, “I came, I saw, I conquered.” Everything is up for mastery. Early signs of your baby’s drive for independence include self-feeding, drinking from a cup, and being able to move about on his or her own. For most youngsters, the thrilling part of learning to walk is gaining more control over the world. The world is no longer limited to what comes to them; now they can go out and conquer it. This independence can be both exciting and intimidating.

Tantrums Although tantrums become more common during a child’s second year, you may be noticing the first signs of your baby’s temper. Your 1-year-old may get upset when something is taken away or when he or she doesn’t get what he or she wants. As your baby’s drive for independence and mastery run up against his or her still-limited abilities and your parental limits, he or she may feel frustrated and mad. Some babies express these feelings more loudly and intensely than do others, depending on their personalities (see Chapter 11 for more on a child’s temperament).

When you see your child becoming irritable, more often than not it’s a sign that he or she is tired or hungry. This is true even for older children and adults. If your baby is out of sorts or seems increasingly resistant to your efforts at soothing, your best bet may be to head for a nap rather than repeated attempts at discipline. Keep in mind that your baby may need to vent a little before actually falling asleep.

Saying no By now, your son or daughter understands what you mean when you say the word no. It’s just that everything in your home is so fascinating — including pot handles, fireplaces, holiday decorations, the way the water swirls in the toilet, and your pet’s whiskers, tail and food. Your child’s desire to explore is stronger than the desire to listen to your warnings. This isn’t a sign of defiance, just your baby’s natural, irrepressible curiosity.

As much as possible, remove valuable or dangerous objects that tempt your baby. For the remaining objects, keep a close watch and be prepared to move your persistent baby away from dangerous objects or offer a distraction. If the object remains in the room, expect that your child will likely go right back to what you just said no to. Try hard to reserve no for those things that can harm your baby. (Easier said than done!) You can also teach your baby the meanings of “be gentle” and “be soft” for situations that require caution, such as playing with a friend or the family pet.

Relating to others Most babies this age are very affectionate with family members and enjoy snuggling and cuddling up for lap time. But don’t be surprised if your baby’s wariness of strangers continues through these months. Many babies have a fear of strangers past their first birthdays. Others have shorter stages, and many even have on-and-off periods of stranger anxiety.

• • • • •

12th month milestones

During the 12th month, your baby is busy:

Standing alone

Cruising

Maybe taking first steps

Using pincer grasp accurately

Manipulating toys appropriately

Feeding self

Learning to let go voluntarily

Looking and listening simultaneously

Increasing attention span

Using gestures to communicate

Recognizing and responding to familiar words

Increasing vocabulary

Responding to one-step commands and simple questions

Imitating the activities of adults and older kids

Testing limits and expressing frustration

Still being wary of strangers but very affectionate with family

• • • • •

CHAPTER 31 Months 13 to 15

Welcome to the toddler years! No doubt you’re finding it a little bittersweet. You’re proud when your toddler reaches major milestones — taking first steps, building tall towers with favorite blocks, learning new words. But you also realize you’re watching him or her grow up and make those first moves toward needing you a little less. Over the coming months, he or she will also start losing that “baby look” and begin to take on a more “big kid” appearance.

For your toddler, this is a time when he or she is torn between two worlds: One in which he or she wants to test newfound skills such as walking, and be more independent; and one in which he or she clings to you, not quite ready to be on his or her own.

It can be frustrating for parents as toddlers move back and forth between independence and clinginess. One moment, your toddler’s whining and neediness tries your patience. The next, you find yourself with a little person who doesn’t want your help with eating, dressing or pretty much anything. Still, no matter how independent your toddler can be at times, you can bet that when the world feels a little scary, he or she will want to be safe in the comfort of your arms.

So when it feels like you’re back to square one in this whole parenthood journey, know that all of this is just a normal part of raising a toddler. The knowledge and skills you picked up in the first year of your child’s life will serve you well as you learn and grow as a parent during the next few years.

Toddler’s growth and appearance

Toddlerhood marks a time of major change in your child’s appearance. Between 13 and 15 months, most toddlers have a certain look: rounded facial features, short legs and arms that are soft rather than muscular, a long torso and a belly that sticks out when standing up. Over the months ahead, and as your toddler becomes more active, the baby fat will give way to a leaner, more muscular appearance and his or her limbs will gradually get longer. Brain growth is still substantial, and your toddler’s head will increase in size by about an inch over the course of the year ahead.

As you may have noticed, your toddler’s growth is much slower now than it was in the first year of life. Moving forward, growth occurs at a steadier pace. On average, toddlers gain 3 to 5 pounds total during the second year. By the end of this period, an average girl will weigh about 23 pounds and measure 30.5 inches in height, while average boys weigh 24.5 pounds and measure 31 inches tall.

Your child’s medical provider will keep track of your son’s or daughter’s growth and check that it’s following a normal growth curve. Compared to the earlier years, what constitutes a “normal” range is much broader in toddlers.

As always, keep in mind that height and weight numbers on growth charts are just averages. Your child may fall below or above these; what’s important is that he or she is thriving and following his or her own growth curve.

• • • • •

What’s going on

Here’s a snapshot of what your toddler’s basic care looks like at this age.

Eating Your toddler isn’t just becoming independent when it comes to movement. He or she is also becoming better at self-feeding, learning to use sippy cups, and deciding which foods he or she likes. Don’t be surprised if this increasing independence goes hand in hand with picky eating and refusal to eat certain foods. Though it can be frustrating, keep offering your toddler a variety of healthy options and let him or her decide which of the foods to eat and how much to eat. This can help him or her feel a bit more in control and prevent a mealtime power struggle. See Chapter 4 for more on feeding your toddler.

If you’re still breast-feeding and comfortable doing so, continue offering breast milk. Your child still gets the nutritional benefits. Make plans to eliminate bottle feeding by 18 months, since extended use of the bottle has been linked to obesity and dental cavities. When bidding farewell to the bottle, introduce your child to the use of a spoon at mealtime if you haven’t already done so. This can be an exciting step up into toddlerhood.

Sleeping How much sleep a toddler needs varies, depending on factors such as his or her temperament, health, activity level, and growth. However, most toddlers need between 10 and 14 hours of sleep each night, and many will still take a nap or sometimes two during the day. If your child decides not to nap, offer him or her quiet time to unwind instead.

• • • • •

Toddler’s movement

A toddler’s developing motor skills center on getting around and exploring his or her environment. He or she may crawl, climb, cruise alongside furniture or walk to accomplish this.

It can be nerve-wracking to watch your toddler attempting new feats, but they’re essential to his or her development. Restraining a child who wants to explore or test new skills can leave him or her doubting his or her abilities or feeling insecure or frustrated. Instead, recognize that as your child tries new things, there will be inevitable bumps in the road. Learning to walk will lead to a tumble here and there.

Over the course of the months ahead, your child will master the necessary skills to get around on his or her own. In the meantime, stay close by and build confidence by offering support and encouragement — and comfort if there are some bumps or scrapes.

Walking and climbing If your toddler hasn’t already started walking independently, you’re no doubt looking forward to the moment when he or she takes those first steps. On average, toddlers start walking between 12 and 15 months, but plenty of children start walking either sooner or later than this age range.

Walking early isn’t a yardstick for how intelligent a child is or a measure of future physical abilities, and learning to walk later typically doesn’t become a concern unless your child isn’t walking by 18 months old.

Early on, walking is often done with knees bent, feet set wide apart and toes pointed out. Your child may appear to walk “bowlegged.” Some toddlers, excited by their newfound abilities, appear to be in perpetual danger of plowing headfirst to the ground. This is common and your child will eventually transition to a more confident stride as his or her balance improves.

Until he or she is ready to walk, you’ll likely find your toddler crawling, cruising along furniture or reaching for your hand. Offering your fingertips to help your child will give him or her just enough support to stabilize those little legs.

Some toddlers get a little cranky as they concentrate on learning to walk independently. Learning a new skill can be stressful for a toddler! But you can generally expect a big improvement in mood once walking starts. Toddlers typically become very happy with their newfound mode of transportation and independence, and they’re mighty proud of what they’ve accomplished.

You’ll also need to be extra cautious around stairs — a keen source of interest for many toddlers. At this age, they’ll be climbing up them and trying to learn how to get back down. Be prepared to help out. And if you haven’t already, install safety gates and other child-proofing measures to help keep your toddler safe and give you peace of mind. See Chapter 17 for more on home and outdoor safety.

Skilled hands Those first steps tend to get all of the attention. However, your child is also learning to master hand skills that will allow him or her to better grasp and examine objects. The ability to grasp things between the thumb and index finger allows your child to build towers, better use a fork or spoon, and more easily turn the pages of a book — to name just a few skills. In fact, this is a good time to introduce a spoon to mealtimes, if you haven’t yet done so.

Toddler’s sensory development

Your child’s interest in exploring the world and playing is helping to fine-tune not only motor skills but also key vision and hearing abilities.

Vision By this age, your child has an improved sense of distance and can throw objects with a fair degree of accuracy. Activities such as rolling a ball, scribbling with crayons and putting together simple puzzles are laying the groundwork for improved hand-eye coordination later on.

Hearing At this stage, your child is able to listen and generally follow simple instructions, such as “Bring the ball to me.” He or she can also participate in conversations, answering simple yes or no questions. Your toddler will enjoy listening and following along as you read stories from a picture book, an activity that can help your little one expand his or her vocabulary.

If your child has difficulties following directions, appears to ignore you or isn’t using words in a meaningful way, talk with his or her medical provider. Your child may need to take a screening test for hearing or an audiology exam that checks your child’s response to sound.

• • • • •

It’s tantrum time

You’ve heard of the “terrible twos,” right? But what you may not have realized is that this period can start well before a second birthday. One minute you are standing in the frozen food aisle at the supermarket next to your calm child. The next minute your toddler is having a meltdown on the floor because you said no to a box of frozen waffles. And you’re standing there feeling more than a little frazzled and avoiding the stares of other shoppers.

Though it can be easier said than done, do your best to stay calm. Even the best-behaved kids have these moments, and they’re certainly not a reflection of your parenting skills. Most tantrums are the result of your child’s inability to effectively tell you what he or she needs or is feeling, or as a result of frustration or displaced anger. Being hungry, thirsty or tired can also be a catalyst for a tantrum.

In most cases, the best way to respond to a tantrum is to ignore it. That includes in public places, though that can be a challenge when others are watching. Often at this age, distracting your child or steering him or her to a different place effectively ends the tantrum. If your child is being particularly disruptive, you may need to move him or her to a private, safe spot for a chance to calm down. Then, when your child is calm, return to the activity. Doing this will let your child know that a tantrum is not an effective way to get what he or she wants.

Tantrums aren’t always preventable. However, there are some ways in which you can head them off before they begin:

Set a daily routine, including nap time and bedtime, and try to stick to it as much as possible. Routines are especially important for young toddlers.

Plan ahead, running errands after your child has eaten or taken a nap. Pack toys or other diversions if you expect to spend time waiting.

If your child isn’t communicating clearly yet, show him or her how to ask for things she needs—such as more water or food—or express feelings such as being tired through sign language.

Offer choices. Give your child a couple of options for snacks or what color of shirt to wear so he or she feels some sense of control.

Praise the behavior you want. If your child submits to being buckled into his or her car seat without a fight, smile and use a happy voice to tell him or her how proud you are that you’re working together as a team.

Avoid certain environments. If you know there may be a tantrum risk, avoid the cookie aisle in the grocery store or prioritize quick service when you want to eat out.

Tantrums usually start subsiding by the age of 3. However, if your child has violent tantrums or you think he or she may be a risk to himself, herself or others, bring it up with your child’s medical provider.

• • • • •

Toddler’s mental development

For toddlers, playing is learning, so expect to see your child concentrating on playing like it’s his or her job. Almost everything your child interacts with — whether it be a puzzle or plastic containers with lids — has the potential to sharpen your child’s problem-solving skills or help him or her gather more information about how things work in the world.

Imitation Your son or daughter is no longer content with using objects in random ways. Instead, you’ll see your child using them to imitate you — for example, pretending to cook by stirring a pot, imitating you drinking coffee using an empty cup or pretending to talk to a grandparent on a toy phone. Your child may invite you to play along. Sometimes he or she will want to help you with the household chores. Let your child help you do simple tasks, such as sweeping or wiping cabinets.

Of course, imitation also means your child is watching what you do and say. Take the opportunity to model behaviors you want to see in your child. Quite often, children learn better by example than by verbal instruction.

Separation Your toddler is beginning to understand that when you leave, it doesn’t mean you’re gone for good. Toddlers will still have some separation anxiety, but parents will notice that the amount of time they spend getting upset is decreasing. And most likely, you’re probably more upset about the separation than your child is. However, try not to let on how much it may bother you. Your son or daughter is young, but he or she is quickly understanding that perhaps a good protest might get you to stay. When you leave, offer an affectionate goodbye and tell him or her you’ll be returning. It’s best to avoid sneaking out, as this may make your child uncertain or anxious that you might disappear again without notice.

When you return home, provide your child with warm, undivided attention. This helps to cement the idea that though you have to leave sometimes, you’ll also return the same as you left.

Judgment The relationship between cause and effect is still beyond your toddler’s understanding. As a result, he or she will continue to depend on your steady guidance to keep him or her safe from harm. Your little one may begin to understand that an oven is where you put food to make it hot, but won’t necessarily make the connection that touching a hot oven can result in a burn.

Language Does it seem like your toddler understands most of what you say? That’s because your child does! His or her ability to comprehend language is improving every day, and you’ll notice a lot of interest in simple stories, songs and rhymes. It’s an exciting time, as a whole new world of communication with your child is opening up. Your child is also listening intently to your conversations, so you’ll probably find yourself employing that age-old tactic of spelling out words you don’t want your child to hear (“Should we order D-E-S-S-E-R-T?”)

Language is another area of child development where a lot of variation exists. Some children start talking and never seem to stop, while others may not seem to say a lot. In general, boys tend to develop language skills at a slower pace than girls. However, understanding what is being said typically outpaces being able to say words at this age. This disparity will improve in the year ahead.

By 15 months, your child may understand up to 70 or so words, but only use about six meaningfully. In addition to words like mama or dada that your child may have been saying for a while, your child may also try to identify household pets, relatives and items around the house. Even if your child can’t pronounce words and names accurately just yet, his or her brain is developing the ability to make connections between objects and their names. For example, many toddlers can point to parts of their body or an object in a book when asked.

At the same time, your child won’t always be able to let you know what he or she wants or needs through words. This won’t stop your child from trying to get his or her requests across in other, not-so-subtle ways, such as banging on the table as a bid for more food.

You can build your toddler’s vocabulary by helping him or her form sentences with the words he or she knows. For example, if your toddler points and says “car,” when a car drives down the street, add some detail, such as “We see a red car.” You can also explain everyday occurrences, such as “Here comes the mailman. He puts mail in our mailbox.” It’s also a good time to transition away from the singsong baby talk. Provide a good basis for learning how to speak well by using short sentences containing simple words that your child can understand. Some children will also begin asking very basic questions, such as “Out?” if they want to play outside.

It’s likely that you and other close family and friends are the only ones who understand your child right now — and even you may be struggling some of the time. At this age, about 25 percent of what your child says can be understood. As your child explores the use of language to convey his or her needs and make observations, the inevitable mispronunciations will happen. When your child mispronounces a word, it’s OK to correct him or her, but do so gently. For example, if your child says “tuck,” you can answer with, “Yes, that’s a big truck.”

• • • • •

Toys and games

Toys are a critical part of development as your child enters toddlerhood. What may look like a simple game of playing with dolls or stuffed animals is actually laying the foundation for communication skills. Encourage the use of words in pretend dialogue and scenarios that help your child practice social engagement. Toys play a significant role in social development, hone fine motor skills and help keep your child physically active.

But your child isn’t the only one who gets to have fun. Toys provide the perfect tools for you to bond with your child and his or her overall development through play and one-on-one interaction.

Reading You can help foster your child’s language skills by continuing to read to him or her every day. Choose books that encourage your child to touch and point to objects and that have an enjoyable writing style, such as rhyming.

Low-tech High-tech toys aren’t necessarily best, even if they say they’re “educational.” There’s currently no research that backs up the claims that toys such as tablets or apps are as beneficial for a child’s cognitive development as traditional toys. In fact, toys outfitted with too many features can distract a child and may leave little room for imagination. High-tech toys can also interfere with parent-child bonding, a drawback that’s particularly true for digital toys. More often than not, such toys are considered more entertaining than educational.

As a low-cost alternative, encourage your child to play with everyday things you can find around the house, such as wooden spoons, cardboard boxes and empty food containers, as well as board books, dolls and simple puzzles. Open-ended toys that have many uses, such as blocks, can test problem-solving skills, introduce math concepts, aid children in understanding how things fit together, and stimulate the imagination to conceive and build things such as bridges, palaces and fortresses. In general, choose toys for your child that help him or her hone new skills.

For all ages Objects that span the various stages of toddlerhood are a good investment, such as toy animals, action figures, dolls, and trucks and cars. As a very young toddler, your child may simply place plastic animals in a box and carry them around as part of his or her prized collection. When your toddler is older, the figures may be used as characters in an elaborate story he or she creates about being a zookeeper. Crayons, finger paints and paper are sure to provide fun for years to come.

Alphabet It’s not too early to introduce children to letters and written words. Books, magnetic letters and letter crafts can help develop early language skills.

• • • • •

Toddler’s social development

During these early years, a toddler’s point of view is primarily self-centered. A one-year-old’s world is instinctively focused on his or her own needs and wants. Sharing toys with another child at this age, for example, isn’t typically voluntary and can create friction if it’s forced.

Overriding this natural egoism with a growing awareness and accommodation of the thoughts and feelings of others is a key social skill that children develop over time — years in fact. Understanding this phase of development can help a parent gently guide a young child toward a healthy sense of empathy and the ability to interact with others.

Children this age don’t always enjoy playing together. They may observe each other or just like being around other children. However, playtime often involves more parallel play — playing near other children but not really interacting with them.

Keeping the peace When toddlers do interact with each other, it’s common for squabbles to break out. The combination of being self-centered and unable to share or take turns often leads to hitting or other aggression. This doesn’t mean that play dates are a waste of time, though. Young children need multiple opportunities to develop and practice social skills. You just might need to keep a variety of toys on hand to minimize potential conflicts and be ready to step in as referee.

Remind a child who is possessive with his or her toys that yes, these toys belong to him or her, and playmates are only looking at them or playing with them for a little while. It might help to set aside a few toys your child is particularly fond of for times when other children aren’t around. Your toddler may find this an agreeable compromise and be a little more lax with children playing with his or her other toys.

Physical responses Even though toddlers are little, they still experience big emotions and they don’t always know what to do with intense feelings. They may scream, hit or kick out of frustration or to get someone’s attention. When your child loses control, hold your child so he or she doesn’t harm others or himself or herself. Show your child how to name his or her emotions. This can help your child better understand what he or she is feeling inside and lay the groundwork for future communication and problem-solving skills. For example, you can say “I see that you’re angry because it’s time for someone else to take a turn.” Mirror your child’s facial expression. Then, follow up with “But we don’t hit.” In this way, you help your child identify his or her emotion but also show him or her how to handle it.

• • • • •

Milestones for months 13 to 15

By the end of this period, your toddler is busy:

Walking on his or her own, or by holding your hand

Crawling up stairs

Throwing a ball

Turning pages of a book

Stacking two or three blocks

Making a line with a crayon and scribbling

Following simple commands

Responding to his or her name

Pointing to show what he or she wants

Imitating your actions, such as stirring an empty bowl with a spoon

Giving hugs

Working on language skills, such as naming familiar objects (although it may still sound a little like gibberish) and saying “no” when he or she wants to be independent; may know four to six words

• • • • •

CHAPTER 32 Months 16 to 18

Toddlerhood is a simultaneously rewarding and challenging time. Your child’s language skills are blossoming, setting the stage for more interactive — and endearing — conversations. Each day, your toddler becomes a little more independent and eager to show you newfound skills that allow him or her to run, climb stairs and scribble a drawing without your help.

This is also a time when your child is likely becoming more assertive and isn’t afraid to make his or her feelings known — if only you had a dollar for every time you heard the word no come out of your little one’s mouth! And those temper tantrums mentioned in Chapter 31 may be on the rise. However, all of these are normal and expected developments at this age.

In most cases, it’s simply a matter of your child acting his or her age. Self-control is not something that’s developed till well after your child’s third birthday. Even then you’ll need to help your son or daughter cope with big emotions and reflexive impulses. Keeping expectations of your child’s behavior in line with his or her age can offer you some comfort when things get a little chaotic.

Toddler’s growth and appearance

Slower and steady growth, punctuated by growth spurts, continues during this period as your child slowly sheds the baby look.

On average, toddlers gain about 1½ pounds during this period and about an inch in height. You may notice that as your child’s medical provider plots growth on a chart, those lines that used to be straighter or curved now sometimes look more like steps, a pattern that reflects growth spurts.

By 16 months, most kids have their top and bottom front teeth (central incisors), as well as the teeth to the left and right of these (lateral incisors).

• • • • •

What’s going on this month

Here’s a snapshot of what your toddler’s basic care looks like this month.

Eating By 18 months, your child has the dexterity and coordination to use utensils and cups with no problem. Of course, that doesn’t mean he or she will always want to, and you’ll no doubt still find food that’s purposely thrown on the floor or used like finger paint on the table. This sort of exploratory food behavior is common and reflects your child’s curiosity about how things work.

At this age, picky eating is common. In fact, if you could use one word to describe a toddler’s eating habits, it would be erratic. Even those who were eager to try almost any food mere months ago may become very selective at mealtime.

Toddlerhood is a time when all of the developing senses converge. When it comes to food, that means that taste, appearance, smell and texture all play bigger roles in your child’s decision about what he or she is willing to eat. Patience in the process is crucial. Continue to offer a variety of healthy options and allow your child to choose which and how much of those options to eat. Anticipate that it may take at least eight to 10 tries to get your child to actually eat something new. Offering fun accompaniments, such as dipping sauces, may entice your child to take a bite. For more on toddler nutrition, see Chapter 4.

Sleeping With so much exploring going on during the day, it can be hard for a toddler to wind down at bedtime. Getting a young child to bed is often one of the most challenging parts of a parent’s day. Consistent bedtime routines — such as taking a bath, reading a book and going to bed at the same time every night — can help give your child the structure he or she needs to more easily go to sleep.

Some parents are surprised when their child, who has been sleeping through the night for some time, begins waking again during the night. This can occur for a number of reasons, including growth spurts, illnesses or changes in routine. However, a regular bedtime routine can help minimize this waking and return your child to a regular sleeping schedule. See Chapter 9 for more on setting up bedtime routines and troubleshooting sleep problems.

• • • • •

Toddler’s movement

Between the first and second years, your toddler is gaining physical and movement skills on the double — and learning how to use multiple skills at once!

Multitasking When your child first started walking, he or she needed to keep arms at shoulder level for balance, leaving little room to perform other tasks at the same time, such as carrying a toy. However, after children have been walking for a month or two, they will be able to squat to pick up an object and carry it, as well as push and pull toys, step backward and to the side, and throw a ball overhand without losing their balance. With increased confidence in the ability to get around, your child will begin using his or her physical skills to accomplish desired goals, such as stretching for an object that’s out of reach.

Need for speed Having improved in the mobility department, your child will likely be ready to try his or her hand at running. As with walking, this will take some time to master. Be prepared for a few falls. Early on, your toddler’s running style may look pretty stiff and will tend to follow a straight path.

Improved mobility, coupled with a child’s natural curiosity, also means your toddler will more easily encounter some unsafe situations. Though it can seem at times that your child is trying to purposely test your nerves, he or she is really just exploring the environment and needs your guidance to stay safe while doing it.

Fingers as tools At this point, your child is able to pick up very small objects between his or her thumb and forefinger with ease. Toddlers use this skill to carefully examine objects and perform everyday activities, such as turning doorknobs and book pages.

Getting dressed Putting on clothes becomes a team effort as your child shows off this newly acquired skill. Your child may assist you with pulling a shirt over his or her head or removing mittens, shoes and socks. With an improved thumb and forefinger grip, some toddlers may be able to unzip their coats.

• • • • •

Milk and iron deficiency

Whole milk is recommended for toddlers from 1 to 2 years old because it’s best for a child’s brain development. However, drinking too much milk may cause your child to be less interested in eating other nutritious foods, which, in turn, can lead to conditions such as iron deficiency and anemia. Anemia is a medical condition characterized by a low red blood cell count. It interferes with blood’s ability to carry oxygen. If your child is drinking 2 to 3 cups (16 to 24 ounces) of whole milk daily, there’s no need to be concerned. However, if your child consumes more than this or seems to forgo balanced meals in favor of drinking milk, consider talking with his or her medical provider about whether your child might benefit from an iron supplement. Children this age should be getting at least 7 milligrams of iron a day.

• • • • •

Toddler’s sensory development

Your child relies greatly on sounds, sights, smells, taste and touch to explore his or her surroundings. He or she may examine an object by turning it over, smelling it and trying to taste it to find out more about it. In addition, your toddler’s improving vision helps him or her move around, as well as grasp and carry toys, cups and other objects. In a few months, some kids may be ready to start thinking about using a potty chair or the toilet.

Taste test Understanding that taste is part of how toddlers explore the world is important when it comes to safety. Choking on small objects is a serious risk, and something to keep in mind at home and in new environments. Balloons, small toys or bits of food on the floor are some common choking hazards — and irresistible to toddlers. Make sure floors and easy-to-reach areas are free of choking hazards. This will give you peace of mind and your baby a safe place to explore.

Vision While your child’s eyesight is well developed in certain areas — such as the ability to use both eyes to focus on objects — other vision skills, such as depth perception, are still improving. Falls from elevated areas are possible, so keep safety a priority.

Bladder and bowel functions The muscles that help your child control his or her bowel movements are maturing. By 18 months old, your child can hold his or her urine for up to two hours or longer. It may be some time before you really start toilet training (see Chapter 6), but you can always introduce your child to a potty chair to get him or her accustomed to the concept.

• • • • •

Bye-bye bottle

Experts recommend eliminating bottle feeding after the first year — and no later than 18 months — because of the risk it poses for tooth decay and the potential for overeating and iron deficiency. Drinking from bottles at this age is very often a comfort measure for your child. This is particularly true at bedtime, when the bottle becomes something your child needs to fall sleep. For some children, ditching the bottle is easier said than done. If you’re still having difficulty getting your child to give up the bottle, try eliminating bottles one by one, starting with the afternoon bottle, then moving on to the evening and morning bottles. Save the bedtime bottle for last. You can also try putting only water in the bottle.

• • • • •

Toddler’s mental development

By 18 months, your child has a firm grasp of many key intellectual (cognitive) concepts — including object permanence, the understanding that things don’t cease to exist even if they’re out of sight. As a result, games of hide-and-seek — where you hide things under a blanket or pillow and encourage your child to find them — can be particularly exciting.

Learning through repetition Experimentation is a key learning tool at this age, helping toddlers better comprehend cause and effect in daily life. Don’t be surprised when your child performs the same task over and over — say, throwing a cup to the floor — to see how things turn out. This keen interest in experimentation can also lead to trouble, and any items you don’t want your child exploring, such as a garbage can, should be placed in an area that’s inaccessible. See Chapter 17 for more on child safety.

How does it work? Toddlers love using their fingers to manipulate objects, and you’ll probably see your child engaging in activities such as placing and removing tops on containers and placing objects in boxes. This is not only entertaining for your child but also an important part of the learning process. Such activities help toddlers learn about concepts such as under, in and on.

That’s me! Toddlers this age are becoming increasingly aware of themselves and by 18 months begin to recognize their own reflections in the mirror. Your child may provide ample self-amusement by making funny faces in the mirror or moving body parts to see if the image in the mirror follows suit.

Language This is an exciting time of rapid language growth, and you’re probably noticing that your child is better able to tell you about his or her wants and needs. By 18 months, your child will likely be able to say his or her own name. Your little one will also be able to combine verbs and gestures to ask you for things, such as extending his or her arms and saying, “Up,” to be picked up.

As you’ve probably discovered, the word no is also popular at this age. Saying no is a way for your child to differentiate himself or herself from you (see this discussion).

With language in particular, it’s important to remember that there are variations in when children develop skills. Talk to your child’s medical provider if your child doesn’t speak at least a dozen or so words by 18 months of age.

Possessiveness There are few things more important to your child than toys and, well, you. Right around this time you may notice that your child becomes more protective of his or her possessions and family members. Seeing you show attention to another child can lead to a tantrum from your own little one, as can losing a toy to a playmate.

• • • • •

Toys and games

It’s natural to gravitate toward certain toys when you shop for your child. Looking at the toy aisle, you might see trucks and cars marketed to boys and, to girls, dolls and pink toys. However, there’s no research that suggests that children prefer this categorical separation. In fact, toddlers are typically attracted to and enjoy all types of toys, if allowed to play with them. Giving your child freedom to play with whatever interests him or her is a great way to explore interests and build self-esteem.

Nesting toys and puzzles Children this age understand that there are different shapes and are often curious as to how shapes relate to one another. Nesting toys — for example, small boxes that fit inside each other — and puzzles that require your child to put shapes into matching holes help hone cognitive skills.

Pretend play Pretending to be the host of a fanciful tea party is just one example of how a toddler may create imaginary worlds in which he or she rules the roost. Pretend play is a great way to develop certain skills, such as ordering events to form a narrative or taking part in conversation. While items such as dress-up clothes can add another layer to your child’s play, you don’t necessarily need to invest much money in the tools of playtime. A large shipping box, for example, can quickly become a house or a race car with just the right amount of imagination.

Hide-and-seek Your child now gets the concept of object permanence. A great way to reinforce this is by playing hide-and-seek games, such as hiding a toy under a blanket or pillow and encouraging your child to find it.

Slippery textures Mediums such as water, paint, clay, soap bubbles and sand are fascinating to toddlers. Exploring them offers children the opportunity to engage in beneficial unstructured play.

• • • • •

Toddler’s social development

Play, an important learning and socializing process, is still very much a parallel activity, with children playing near each other, but not necessarily together. Sharing remains a foreign concept. Still, there are some notable changes.

Everyone has feelings By 18 months, toddlers are becoming more tuned in to the feelings and reactions of others, and are beginning to develop the foundation for a conscience. In fact, don’t be surprised if your child comes over to pat your arm in a comforting way when you’re upset, or purposely blows raspberries with his or her mouth to make you laugh. Reading books that talk about feelings can help your child explore his or her own. You can also help your child understand feelings by naming them, such as feeling sad or happy. See Chapter 11 for more on emotional development in young children.

Renewed separation anxiety Your child was eager to do his or her own thing at the beginning of this period. Now, you may find your child going back to being clingy. This results from your child’s growing awareness that he or she is very much a separate person from you. When you go away, or when life throws your child a curveball — for example, going to a new child care center or having a medical test — transitional objects such as blankets and stuffed animals can provide much-needed comfort. Such objects serve an important function, so don’t be concerned that your child is becoming too dependent on them.

Negative Nellies For many toddlers, no is a common answer to most questions. This is called negativism and in this case doesn’t mean that your child is being particularly stubborn or disrespectful. It’s more your child’s way of exhibiting control and asserting independence. Either way, it can be frustrating. Instead of letting your child know how exasperating it feels, stay calm and avoid asking questions that can be answered with a simple no. Offer choices when possible. For example, if you need to run errands, refrain from asking your toddler if he or she would like to come along. Instead, ask your child if he or she would like to listen to music or look at a book along the way.

• • • • •

Milestones for months 16 to 18

By the end of month 18, your toddler is busy:

Walking

Starting to run (falling down is common)

Jumping in place with both feet

Sitting down on a chair by himself or herself

Exploring inside things, such as drawers or containers

Pulling and pushing toys

Stacking as many as four blocks

Scribbling with a crayon

Using 10 to 20 words

Naming body parts and pictures

Feeding himself or herself

Looking for help when in trouble

Being vocal if diaper is soiled or wet

Understanding simple one-step commands or questions

Venturing away from you for longer periods

• • • • •

CHAPTER 33 Months 19 to 24

Kids approaching age 2 are highly curious about the world around them, and this can mean your child tests you at every turn with the goal of determining just how much he or she can get away with. You may hear the word no said to you quite frequently, particularly when you say it’s time for bed, and you’ll probably find yourself uttering it many times to your child as he or she pushes against the limits you’ve set.

But it’s also an amazing time of blossoming language skills. Your child is better able to harness words to tell you what he or she needs or wants and to engage you in more coherent conversation. Though temper tantrums certainly still occur with regularity at this age, improved communication skills will eventually help lessen them.

And you’ll have a front-row seat to your child’s many accomplishments coming soon, such as becoming a master builder of increasingly taller block towers, having the ability to maneuver stairs without holding your hand, and perhaps conquering toilet training and leaving diapers in the dust.

So when you have one of those trying days, remember: You and your child are traveling into unfamiliar territory together. It’s an exciting growth process for both of you.

Toddler’s growth and appearance

When it comes to growth, boys and girls are fairly even at this stage. By 24 months, girls average 34 inches in height and weigh 27 pounds, while boys average 341/2 inches in height and almost 28 pounds. At 24 months, your child’s medical provider will also begin keeping track of your son’s or daughter’s body mass index (BMI), which is a measurement of weight in relation to height.

By the time your child is 2 years old, 75% of your child’s brain growth is completed and his or her head is about 85% to 90% of its adult size. Your child’s height is about half of what it will be as an adult.

Gender and sexuality At 24 months, toddlers start to recognize the difference between boys and girls, though it will take a while longer for your child to develop a true sense of gender identity. Toddlers also discover that touching their genitalia results in pleasurable feelings. This is normal behavior, and as a parent, you don’t need to call attention to it. Use correct terms for genitalia and avoid using negative descriptions, such as dirty, for masturbation, which can give your child a faulty impression of sexuality and create unnecessary feelings of shame. If your toddler is masturbating in public, redirect your child to another activity. When your child is older, you can explain about the importance of doing such activities in private.

• • • • •

Is it potty time?

Aside from first steps and first words, there’s probably little that’s more highly anticipated — from a parent’s perspective — than the day your child no longer needs diapers. But as many parents realize early on, it’s often a marathon process. Though the maturing of muscles necessary to control bowel movements and urination gradually occurs by 18 to 24 months, there are also developmental and behavioral elements that are important for toilet training success. Some signs that your child may be ready to use the toilet include when your child:

Stays dry for two hours, has a decreasing number of wet diapers or wakes up dry from naps

Wants to be changed immediately when his or her diaper is soiled

Has regular bowel movements

Recognizes he or she has to go to the bathroom and is able to tell you

Is able to sit on the toilet for several minutes

Can perform certain tasks, such as removing pants

Children aren’t the only ones who need to be ready. Parents must be, too, by having the time and willingness to invest in toilet training. If things are a little stressful in your child’s life at the moment, perhaps due to moving to a new home or having a baby brother or sister on the way, it may not be the best time to attempt training. For more on toilet training, see Chapter 6.

• • • • •

Toilet training There’s no set age for toilet training, but on average, many parents start when their child is between 18 and 24 months old. Learning to use the toilet to have a bowel movement is usually easier for children, as bowel movements tend to follow more of a schedule. Still, it’s not always a straightforward process. About 20% of kids will resist having a bowel movement in the toilet initially. Eventually, they get the hang of it.

Staying dry at night typically takes longer than mastering daytime control. That’s because sleep cycle signals that alert children to wake up and go to the bathroom take a while longer to mature. Bed-wetting isn’t unusual in girls up to age 4 and boys up to age 5, and is within the range of normal up to age 7. For more on toilet training — when to start and how to do it — see Chapter 6.

• • • • •

What’s going on

Here’s a snapshot of what your toddler’s basic care looks like at this age.

Eating By 24 months, children can use a cup with ease, chew with their mouths closed, and are pretty good at deciding which foods might require a spoon to eat and which ones can be eaten by picking them up. However, their chewing skills are still rough, so keep looking out for choking hazards.

At this age children generally like to keep their plates simple, usually favoring a few select foods and refusing to try others. Make sure you’re not overwhelming your child with oversized portions. Because this is also a time of growth spurts, be prepared for your child to go through days when he or she acts famished, and other times when he or she shows little interest in food. See Chapter 4 for more on feeding your toddler.

Sleep It’s not uncommon for children to start to give up napping around this time. Refusing to go to bed and waking up during the night are also hallmarks of toddlerhood — even in children who were previously good sleepers. Factors such as changes in routine, an illness or learning a new skill can cause your child to awaken at night, as can a scary dream. For more information on sleep, see Chapter 9.

• • • • •

Toddler’s movement

Your child’s mobility is rapidly improving, so much so that the uncertain steps taken just a few months ago have probably taken on a whole new level of confidence. By 24 months, most children are able to run fairly well and walk up and down stairs without help. Toddlers typically climb steps by getting both feet on one step and then attempting the next one.

Children at this age are also usually able to stop and pick up an object or kick a ball without toppling over. A whole new world of exploration — and, often, accompanying hazards — opens up as your child is able to turn doorknobs and navigate steps. Make sure you have childproofing measures in place and that your little explorer is always supervised. See Chapter 17 for more on childproofing and home safety.

Sophisticated skills Children at this age are able to handle increasingly complex tasks, such as folding paper, placing puzzle blocks into matching openings, stacking increasingly taller towers of blocks, and dismantling simple toys and putting them back together. You may notice that your child favors one hand over the other when he or she scribbles. Other children can use both hands equally well or may not show an inclination to right- or left-handedness till much later. With your guidance, your child may be able to brush his or her own teeth and wash his or her own hands.

‘I got this!’ With your child’s developing fine motor skills, he or she is likely able to remove most clothing items independently. Children this age may also be able to put on socks and shoes. However, don’t be surprised if your child’s attire displays a lack of understanding of right, left and backward. At this age, shoes are likely to be put on the wrong foot, and pants pulled up backward. No worries — your child will figure it out soon enough.

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Is it time for a bed?

There’s no set age when a child should switch from his or her crib to a bed. For safety’s sake, it would be nice to keep your child in a crib until he or she is more developmentally ready to stay in bed at bedtime, which keeps him or her from wandering the house and potentially finding danger. However, many kids are climbers, and you may find that your child is a regular escape artist, able to get out of the crib even with the mattress set at the lowest possible level. This presents a serious safety hazard, and marks a good time to make the switch.

Some kids transition very early on in toddlerhood, while others may not move to a bed until age 3 or older. Some parents will begin putting their toddlers in beds out of necessity — for example, the crib is needed for a baby brother or sister on the way.

When you decide to make the switch, your child will likely be pretty excited at this newfound freedom. No more crib walls means he or she can get up at will. For you, this may mean seeing your child frequently for just one more “good night.” When you put your child in bed, be firm about the rules for staying in bed. Also, be prepared to repeat instructions over and over again. Staying consistent now will mean less trouble with bedtime in the years ahead. For more on switching from crib to bed, see this discussion.

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Toddler’s mental development

One of the trickiest things about raising children this age is that while they understand the concept of no, they don’t yet grasp the why behind the no. For example, they usually don’t understand that jumping repeatedly off the couch not only can damage the furniture but may cause bodily harm. Even if they get hurt, they may not remember the association between cause and effect the next time the couch beckons. The forethought and judgment required for this type of thinking isn’t quite developed yet. It’s not that your child is being willfully disobedient so much as it’s his or her way of testing the boundaries of what’s acceptable and what’s not.

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A word about spanking

Who hasn’t been there: It’s been a long day and your toddler is being extra stubborn and acting out. It’s tempting to want to give him or her a smack on the bottom to stop the negative behavior. However, experts agree: There are really no pros to spanking a child. The American Academy of Pediatrics makes the case against spanking by pointing out that spanking can cause injury, even if unintentional, and sets an unhealthy example for dealing with conflict. Instead, take a moment to breathe deep and bring yourself under control first. Remember that at this age, redirecting your child’s attention to another activity or removing your child from the triggering situation is generally the most effective way to dissuade disruptive behavior.

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Setting limits Though your little one is intent on testing boundaries, it’s important to be consistent in the limits you’ve set for your child — for the sake of safety and as a way to establish family rules. As your child grows, consider having an ongoing discussion with your spouse, partner or coparent as to what’s acceptable behavior for your child. Strive to enforce the rules together. Quite often, when your toddler is pushing against limits, distraction and redirection to another activity will resolve the matter. For example, instead of letting him or her bang a breakable cup he or she pulled off the table, offer a plastic one instead or a different toy.

Importantly, offer praise and attention as reinforcement for behaviors you want to see in your child. For example, if you see your child cheerfully getting ready for bed, heap praise on your child for the positive behavior. Encouraging desired behavior with your attention is generally more effective than focusing on trying to correct negative behavior (see Chapter 11). Here are some other tips to keep in mind.

Don’t make too many rules. Instead, stick to and enforce what is essential. Another way to look at it: Pick your battles.

Enable your child to be good. Provide an environment where your child is free to play, not a place filled with items he or she isn’t allowed to touch.

Ignore negative behaviors that aren’t potentially harmful or hazardous, such as whining. This is generally the most effective way to eliminate the behavior.

Expanding vocabulary By age 2 years, most children have a vocabulary of about 50 to 100 words, and can generally understand two-step commands, such as “Put down the puzzle and come get your coat on.” Me, you and mine are popular words at this age, as are simple phrases, such as “Daddy go” or “What that?” About two-thirds of a child’s speech can be understood at this age. Toddlers will still use gestures to accompany speech and get their points across.

These are rough guides, of course, and the number of words your child uses may be above or below these numbers. Most importantly, keep making conversation with your child and reading together. This is the best way to expand your child’s vocabulary.

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Toddlers and screens

For many families, digital devices and electronic entertainment are a part of daily life. But that doesn’t mean that screen time is necessary or even helpful to a young child’s development. The best kind of entertainment remains the kind that lets a child use his or her imagination and facilitates interaction between parent and child.

Experts agree on the importance of active play and limiting sedentary screen time for kids. The American Academy of Pediatrics (AAP) recommends using digital devices only for video chats — with grandparents, for example — for children under 18 months. Both the AAP and World Health Organization recommend against sedentary screen time for all kids under age 2. There’s no benefit to introducing electronic devices early, and some studies demonstrate risk, especially if devices take the place of active play.

Around 2 years of age, kids are more developmentally ready to engage with digital media. If you like, high-quality television programming may be introduced during family time together. Check out PBS Kids, Sesame Workshop or Common Sense Media for suggestions. Limit screen time to an hour or less. To get the most benefit, watch the show with your child and use it as a springboard for further discussion. In general, keep bedrooms, mealtimes and playtimes screen-free for everyone. Turn off screens at least an hour before bedtime and avoid having the television on when not in use. As a parent, you can model healthy moderation in your use of digital devices and show your child how much you value face-to-face interaction.

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Concept of time Telling time from a clock is a concept that’s yet to be learned at this age. But your little one may be getting better at waiting for short periods of time. Attention spans are still brief, however, so don’t expect your child to focus on any one activity too long.

Bilingual toddlers If your family speaks more than one language, you may be hesitant to introduce another language into the mix for fear that this may somehow cause delays in learning the predominant language. Rest assured that this is a myth. Children in bilingual households acquire the same language skills as children who grow up learning one language. If your child truly has language delays, these will appear in both languages.

Your child may sometimes use words from both languages in the same sentence; this is normal. In fact, now is actually the best time to introduce children to other languages, as they are often quick to pick them up at this age. However, children of any age can certainly learn. Books, music and school programs can help your child become a better bilingual speaker.

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What’s going on

Here’s a snapshot of what your toddler’s basic care looks like at this age.

Eating By 24 months, children can use a cup with ease, chew with their mouths closed, and are pretty good at deciding which foods might require a spoon to eat and which ones can be eaten by picking them up. However, their chewing skills are still rough, so keep looking out for choking hazards.

At this age children generally like to keep their plates simple, usually favoring a few select foods and refusing to try others. Make sure you’re not overwhelming your child with oversized portions. Because this is also a time of growth spurts, be prepared for your child to go through days when he or she acts famished, and other times when he or she shows little interest in food. See Chapter 4 for more on feeding your toddler.

Sleep It’s not uncommon for children to start to give up napping around this time. Refusing to go to bed and waking up during the night are also hallmarks of toddlerhood — even in children who were previously good sleepers. Factors such as changes in routine, an illness or learning a new skill can cause your child to awaken at night, as can a scary dream. For more information on sleep, see Chapter 9.

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Toddler’s social development

Toddlers love to imitate those around them, from the way their siblings play pirates to the way parents sip their coffee. It’s fun to watch your little one show you how to do something, using your same mannerisms and tone. But it’s also a great reminder that imitation is the way your toddler learns to interact with the world around him or her. As a result, it’s never too early to model the behaviors and attitudes you would like to see in your child. How you react to a spilled cup of milk, for example, will set the stage for how your child learns to handle unexpected stress. Your child’s also absorbing how you treat your partner or your pets. Such keen observation directed your way may feel like a lot of pressure. But keep in mind you’re also demonstrating that people aren’t flawless — that when mistakes are made, there are often ways to fix them and that love and warmth persist despite imperfections.

Little helpers By 2 years old, mealtime is not only nutritional in nature but also a fun time to socialize with the rest of the family. Your child will have the dexterity to use a spoon and feed himself or herself well, and may show more interest in helping you set the table or put away dishes. Though having your toddler help you with such chores may not save you time, it provides your child with valuable lessons in helping others and being part of a team.

Playtime Playtime is serious business for children and is the laboratory where they can give curiosity full rein, experiment with how things work and begin to develop problem-solving skills. Being able to play without a lot of rules or structure is key to a child’s developing brain and creates rich pathways for mental and social development. Around 18 months, toddlers are generally able to engage in symbolic play, where a doll may symbolize a baby or a stuffed animal a pet. Over these next few months, your child may also identify how to solve certain problems, having seen you or another caregiver do it before. For example, your toddler might pretend to soothe a doll by offering a bottle or place a toy dog in front of the family dog’s food bowl.

At this age, kids typically still prefer to play independently alongside each other rather than in a coordinated fashion. Sharing is likely to be reluctant at best.

Shy children may cry when encouraged to try a new activity involving people they don’t know. At a time when most children are testing out independence, your child may seem to want nothing more than to cling to you. Allow your child to go at his or her own pace. Don’t pull away when he or she looks to you for reassurance in a trying situation. Your support can help your child gain the necessary confidence to venture out.

Handling aggression While no one wants to be the parent whose child kicks or hits other children, this sort of behavior isn’t uncommon at this age and it doesn’t necessarily mean there’s a problem. Some children naturally are more intense and may lash out when events don’t go their way.

Setting limits is crucial. Let your child know that you expect him or her to be respectful of peers, and praise your child when he or she does what you ask. Offer plenty of ways to burn off energy, but keep a close eye on him or her when playing with other children. If your child starts acting out, firmly tell him or her that hitting others is never OK and redirect him or her to another activity or leave the area. If this doesn’t work or the situation escalates, consider introducing timeouts (see this discussion). A timely break from the action offers a way for your child to cool off and start over.

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Milestones for months 19 to 24

By the end of this period, your toddler is busy:

Building a tower of six to seven cubes

Imitating vertical and circular lines when drawing

Unscrewing a lid

Developing a vocabulary of 50 to 100 words

Using simple phrases

Understanding multiple-step commands

Knowing his or her own name and using it

Verbally telling you what he or she needs

Having fewer temper tantrums

Becoming more independent

Beginning to understand that other people have their own feelings

Telling you about something that just happened

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• • • • •

Toys and games

Purchasing a new toy or game is often a fun anticipatory experience, for child and parent alike. When selecting a toy, keep in mind your child’s age and developmental stage. Look carefully at the packaging to see if it’s appropriate for your child. Some toys have a warning label that the toy may be hazardous to young children — for example, it contains small parts and poses a choking risk to children younger than 3. Others may display a label that recommends a certain developmental age for use. If there are reports that a toy is hazardous, the Consumer Product Safety Commission (CPSC) may issue a recall. For more information about current recalls, visit the CPSC and Safe Kids Worldwide websites.

Keep in mind that you don’t always need the latest toys to provide your child with a safe and fun experience. Often, you can find household items that fit the bill. Here are some ideas for age-appropriate toys and activities.

Sorting Toddlers love to sort objects. Have your child help you with the clean laundry by putting socks in one pile and pants in another, or have him or her group together plastic containers based on size.

Puzzles At this age, children are usually capable of matching up shapes. Try a shape-sorting game where your child can put different shapes into matching holes.

Arts and crafts As your child is better able to manipulate his or her fingers, try complementing your budding artist’s talents by adding painting tools, such as brushes and easels.

Hide-and-seek This classic game is taken up a notch at this age. Now, if you hide something, your child will look in several potential hiding spots to find it.

Reading By 24 months, your child is developing logic and reasoning. Help develop these skills by asking your child questions such as “Why did the boy do that?” or “What do you think the girl will do?” You may need to answer your own questions, but practicing now helps your child learn to ask these questions going forward.

Water play While splashing in water is still likely to be your child’s favorite activity, you can also use it to introduce science concepts, such as displacement (dropping a toy into a container filled with water may cause the water to go over the edge) or density (will the rock sink or float?). Water also lends itself to many imaginary activities, such as pretending to wash dishes or sail a boat.

Red light, green light This and other games that require children to follow directions and “stop and go” are good ways to teach your child about self-control.

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CHAPTER 34 Months 25 to 30

“No, I do it!” As the parent of a toddler, you may hear this phrase or one like it from your child on a daily basis. Maybe you made the “mistake” of trying to pick out your daughter’s clothes to help speed along the morning routine or help your son put food on his dinner plate to avoid creating a mess on the table.

Sometimes toddlers insist on doing tasks they’re not quite capable of performing (yet), and their refusal to let you help can be frustrating. But it’s important to let your child practice these developing skills, even if it involves some mistakes and a lot of repetition. Increasing independence is the theme for this stage in your child’s life, and anything your child sees as hampering it is likely to be met with resistance and some tantrums here and there.

Tantrums are one of the biggest challenges of raising a toddler. Children this age have trouble dealing with limits, compromise and disappointment, which often results in angry outbursts and tears. But with time, patience and consistent limits, you’ll see tantrums decreasing. In the meantime, however, your child still has a great need to see, hear and feel you nearby. You can help your child navigate his or her frustration with plenty of hugs, kisses, praise and attention. Feeling loved and well cared for can help motivate toddlers to behave better.

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When a new baby arrives

Just when your toddler thought he or she was getting a pretty good idea of how things run in the household, here comes a new brother or sister. This can be upsetting to a toddler, who’s probably seeing his or her entire routine turned upside down. Parental attention is now split, and your child may be upset about losing his or her crib to the new addition. So it’s understandable when children act out at having to welcome a sibling. Keep in mind that there’s no malice in this, just anger about deviating from the normal routines.

If mom is expecting, the best time to talk about coming changes with a child is when he or she is becoming aware of the pregnancy — for example, your child starts asking questions about a growing belly. Explain what to expect in the coming months, such as decorating a room for the new baby and perhaps staying with another family member when it’s time for the baby to be born. Also provide reassurance, such as “I’ll need to feed and put diapers on the baby a lot, but I will still read you a bedtime story.”

Once the new baby arrives, allow your older child to help out when possible. For example, your child can hand you diapers while you change the baby or help you pick out clothes after the baby’s bath. If your child isn’t interested in interacting with his or her new sibling, there’s no need to force it. How you word a request may help, too — try asking your older child to help you rather than the baby. With time, the relationship between new siblings will grow. Always supervise a toddler with a young baby.

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Toddler’s growth and appearance

By 30 months, your little one is looking less and less like a baby and more and more like a big kid. Legs are now getting longer and head growth has slowed. As your child grows and becomes more physically active, muscle tone is improving, which means that so is your child’s posture. Better posture helps give children a longer, leaner appearance.

Your toddler’s grin is also likely to reveal many more teeth. Most children have about 20 teeth at this age.

Height and weight By age 2 or so, many toddlers have quadrupled their birth weight while losing baby fat. In fact, by the time your child is 5, he or she will only have about half the percentage of body fat he or she did at age 1. Some of the areas where this will be the most noticeable are in the face, arms and thighs. With the loss of fat pads in the arches of the feet, children will no longer appear to be flat-footed.

In general, you can expect your child to grow about 2½ inches and gain about 4 pounds annually as the preschool years approach. However, if your child’s growth seems to have stalled, talk to his or her medical provider to rule out any underlying health issues.

Toilet training Continue encouraging and supporting your child as he or she works on his or her toileting skills. Even toddlers who are adept at using the toilet on their own may still need your help with related tasks, such as wiping and dressing.

If your child isn’t toilet trained yet, don’t worry. Avoid pushing your child into a situation for which he or she isn’t ready. Forcing your child to use the toilet can complicate and lengthen the process. Research has found that starting around the age of 2 typically results in a child who is trained by age 3. In contrast, starting earlier may actually lengthen the process in some kids. For more information on toilet training, see Chapter 6.

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What’s going on

Here’s a snapshot of what your toddler’s basic care looks like at this age.

Eating At this point your child will likely be following a more adult feeding schedule, or three meals a day with two or three snack times sprinkled in. Although your toddler’s attention span is limited, it’s reasonable to expect your child to sit with the family during meals. Include your child even if he or she isn’t interested in eating. This is a formative time when your child learns and benefits from the socialization that occurs at mealtime. During family meals, your child learns good eating habits, such as trying foods that are nutritionally beneficial, and portion control.

Sleeping Two-year-olds need anywhere from 11 to 14 hours of sleep a day, which includes nighttime sleep and naps. Some children may be giving up naps during this time; others may still be napping for a couple of hours each day.

It’s important to keep bedtime the same time every night, and for children to wake up at their regular time — whether it’s a weeknight or the weekend. A consistent sleep schedule helps them get enough good quality sleep.

Regular bedtime routines make it easier to put your child to bed. If bedtime has slipped later than you’d like and you need to hit the reset button, do so gradually. Try setting your child’s current bedtime earlier by 15 minutes, then push it up by the same amount again every few days till you reach the ideal bedtime. For more on sleep and sleep issues, see Chapter 9.

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Toddler’s movement

Children this age are balls of energy, in constant motion from sunup to sundown. It can be tough to keep up, but think of it this way: All this activity is helping your child strengthen muscles and fine-tune coordination skills.

By the time your child is 2½, he or she may be able to jump using both feet, balance on one foot for a second or two at a time, start taking some tentative steps on tippy-toes, and walk backward. That unsure walk he or she had earlier is being replaced by a more mature heel-to-toe stride. Stairs are less challenging, as children this age are starting to use alternating feet to climb without holding a grown-up’s hand. In the coming months, they’ll gain the necessary skills to pedal a tricycle.

Sometimes parents of toddlers worry that their children may be too active (hyperactive). Usually, there’s nothing to worry about. Most toddlers are constantly on the go, running and climbing from one activity to another in the span of mere minutes. A long attention span is in short supply at this age so it’s generally best to adjust your expectations accordingly. For example, you might want to avoid having an extended meal at a restaurant or engaging in other activities that require staying still and quiet for long periods.

If you think your child has distinct problems with attention span or hyperactivity, especially compared with his or her peers, bring up your concerns with your child’s medical provider. He or she can reassure you about what’s typical for this age and help you determine if further evaluation is needed.

Skilled fingers and hands Toddlers love to steer objects, and their ability to push things, such as strollers or carts, in the direction they want is improving. Your child is also able to hold a pencil or paintbrush properly and make circular, horizontal and vertical strokes. The more modest block towers of early toddlerhood are giving way to taller, more ambitious projects.

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Giving a timeout

You may, on occasion, need to separate your child from an activity when a behavior isn’t acceptable — such as for hitting or biting. Toddlers have little self-control and have yet to learn how to effectively regulate their emotions. A timeout can be a timely tool to help your child learn to become calm and accept limits, especially when used calmly and lovingly by the parent or caregiver.

Timeouts shouldn’t be used too frequently or they may become ineffective. To give a timeout, seat your child in an unstimulating (boring) spot, such as a chair in the hallway. The amount of time for a young child to remain in a timeout is about one minute for each year of age or until your child is calm. If your child gets up beforehand, return your son or daughter to the designated seat. Don’t respond to things your child says while he or she is in timeout. When the timeout is complete, talk to your child about what happened to cause the timeout.

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Toddler’s mental development

To cement patterns of positive behavior, toddlers need lots of praise. Whether your child is well behaved at a play date, using the toilet consistently or going to bed without a struggle, he or she will need to hear how proud you are. Praise for positive behavior helps to build competence and confidence, and, in turn, independence and a good foundation for problem-solving and decision-making.

And speaking of independence, you may notice — with perhaps a hint of melancholy — that your child is more open to being separated from you. It’s yet another sign of your child’s growing independence.

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Why does my child only act up with me?

Your child has been having a lot of tantrums lately, so you’re understandably nervous about leaving him or her with a baby sitter while you go out. When you get back, however, the sitter reports that your child behaved admirably. Though you may want to keep this sitter’s number on speed dial, this contrast with caregivers is normal and the explanation is pretty simple: Tantrums are a way of testing limits, and your child feels most comfortable testing limits with you. The same goes for daredevils. Your little risk taker may attempt potentially dangerous things with you that wouldn’t be attempted with another caregiver because he or she feels secure enough with you to try new things.

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Language and association Gradually, your child is gaining the ability to associate objects with their uses. Your son or daughter may recognize that a skillet is used for cooking or that swimsuits are used for swimming. You can see this reflected in imaginative play or excited anticipation when swimsuits and sunscreen come out for a day at the pool.

Most children this age will proudly be able to say their first and last name and refer to themselves by the correct pronoun. Children also are learning to use plural nouns and can usually name at least one color. Sentences are becoming more complex. A request to play outdoors may be phrased as “Me and Daddy go to the park?”

Language is an area where children may differ from each other the most. If your child isn’t as talkative as a friend, don’t lose too much sleep over it. Some children just talk more than others. It isn’t really a reflection of how smart a child is or how well he or she is mastering thinking skills. But if your child isn’t starting to put words together or can’t point to familiar objects or pictures, or if you feel there may be a problem with your child’s language development, make sure to let his or her medical provider know.

Read and sing to your child, and with your child, every day. Talk with your child, using simple sentences to describe what you’re doing. Introduce new words or names to your child in a familiar setting, and repeat them often. Your child’s vocabulary increases when he or she hears familiar sounds and words repeated. This prepares your child for more-complex speech and reading.

What’s that under the bed? What happened to that very brave toddler of just a few months ago? As you’re probably already realizing, some toddlers can develop new anxieties and fears as they get older. Your child may suddenly be afraid of a monster under the bed or in the closet. He or she may insist on sleep ing with every light on. Though this may seem to come out of nowhere, this is normal as toddlers develop better imaginations and memories. You can help your child by explaining what is real and what is pretend, and helping to ease the stress of bad memories. Be mindful of media violence. Even if children are not watching television, the noise that comes from the television can have an impact on children.

Ace problem-solver When your child was younger, he or she no doubt had to use trial and error to figure out how things worked. Now, children are developing the ability to work through a problem they’re trying to solve in their heads, rather than by acting it out. For example, instead of pulling out a whole drawerful of socks to get to a pair in the back, your child may reach around for the pair. This is good news for parents, as it will likely mean fewer messes in the discovery process!

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Toys and games

Playing isn’t just a way to help your child master important physical skills. It’s also a way for him or her to develop social skills, expand vocabulary and use critical thinking to solve problems.

Pretend play Your child may go to the imaginary grocery store or feed his or her baby doll food from an empty plate. Don’t be surprised to see your child’s daily routine re-created in this pretend play.

Joke books Children this age love books that contain jokes or repetition using silly phrases.

Puzzles Your child is already getting adept at naming familiar objects. Choose puzzles that contain different colors, shapes or animals, and help your child identify these characteristics as he or she places the pieces.

Playing ball Go out in the back yard or the park and have your child kick a ball with you to practice aim. When he or she masters that, have your child run and kick the ball to work on coordination and balance.

Dance party Toddlers love nothing more than to move. Put on some fast-paced music and let your child wow you with his or her dancing and jumping skills. Join in — he or she will feed off of your enthusiasm!

Blocks Building objects with blocks is a great way to encourage cooperative play in children who are just starting to play together. Put out plenty of blocks at the next play date and invite your child and his or her friends to work together building a tall tower.

Walks Taking a stroll can be stimulating for a child. There’s a lot to see, smell, touch and hear. A walk to the park can help your child get to know his or her neighborhood. Hiking on a nature trail allows your child to explore in a relaxing setting and, if he or she is lucky, identify a critter or two.

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Toddler’s social development

Two-year-olds often get excited to see other children, and may even have a couple of friends they prefer to be with. This is a great time to meet up with other parents and their kids and give your child a chance to socialize.

What was once a play date that included a few children playing near but not with each other is starting to give way to brief interaction. In some cases, this may be no more than children chasing each other around the room. In others, it may be cooperative play, where one child helps the other complete a block tower. Or it may focus on the developing imagination and involve pretend playing, such as taking care of a stuffed animal or driving a pretend car.

For a majority of the time, children this age will still fly solo at playtime, and sharing is still difficult for them.

Emerging emotions Your child’s feelings are growing more complex and he or she may express pride, guilt, embarrassment or shame. Guilt in particular comes into play as events happen that, while beyond your child’s control, he or she may still feel responsible for, such as divorce or the death of a loved one. On the flip side, your child’s sense of humor is also beginning to emerge. Saying silly things to your child will no doubt elicit big laughs.

Handling stress Though it’s sometimes hard for an adult to understand what could be so stressful in a toddler’s life, kids this age can and do experience stress. A new child care center, a new sibling or a move to a different home are some of the curveballs life can throw at a young child. While a little bit of stress can help your child learn how to cope with it later on in life, make sure your young child isn’t overwhelmed. Look for signs that your child is stressed, such as increased thumb sucking or being aggressive. Ease stress by giving your child quiet periods to recover, particularly periods involving free play, which can help release some pent-up emotions.

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Milestones for months 25 to 30

By the end of this period, your 2-year-old is busy:

Walking up the stairs, using one foot at a time

Walking backward

Fine-tuning balance, such as standing on one foot

Climbing

Turning handles to open doors

Playing pretend in more-elaborate ways

Learning to make friends

Unscrewing jar lids

Following commands with two or three parts

Identifying common objects

Saying name, age and sex

Using pronouns and learning plurals

Speaking in a way even strangers can understand

Learning to take turns

Showing affection for people he or she knows

• • • • •

CHAPTER 35 Months 31 to 36

As your child approaches age 3, he or she is steadily gaining an increased understanding of the world that surrounds him or her. Your little one is learning new words daily and using them effectively to carry on more in-depth conversations with you. This improved communication is a big part of the reason you’ll see tantrums gradually declining. Your child is also figuring out how to better manage his or her behavior and respond to situations appropriately. You’ll need to repeat the rules frequently and maintain consistent limits, but your child’s brain is rapidly absorbing the lessons of cause and effect.

Your soon-to-be preschooler is also becoming more independent. He or she probably can pedal a tricycle, draw increasingly complex figures, and create and visit imaginary worlds where he or she is the hero, saving the family from a ferocious fire-breathing dragon.

Although you’re moving away from the baby years, there are a whole lot of milestones and good times ahead — think fishing trips, impromptu T-ball games in the park, and helping your child build his or her own little toy race car. And, of course, there are many things that won’t change just yet. Your child, while not requiring the same level of supervision as when he or she was younger, will still need you close by to offer lots of loving attention and make sure he or she stays out of harm’s way.

Toddler’s growth and appearance

Your child’s arms, legs and upper body are becoming longer and leaner as his or her body grows and adds more muscle. Slowly, your child’s face will mature, too. In the preschool years ahead, his or her jaw will widen to make room for the eventual arrival of adult teeth.

By the end of this period, the average weight for a toddler is 32 pounds and the average height is 37½ inches. Weight gain slows gradually, with most kids gaining about 5 pounds a year. As tempting as it may be to compare your son or daughter to other children, keep in mind that height and weight can vary greatly among children.

The numbers above provide averages, but plotting your child’s height and weight over time is the best way to see if your child is following his or her own individual growth pattern. If you notice that weight is outpacing height, or that your child’s height seems stalled, bring it up with your child’s medical provider.

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What’s going on

Here’s a snapshot of what your toddler’s basic care looks like at this age.

Eating Nowadays, your toddler may enjoy the social aspects of meals, such as sitting around the dinner table and talking with family, in addition to the nutritional aspects. Your little one’s overall attitude toward food is evolving, which may translate into a certain degree of pickiness about what is eaten. Food preferences can vary day to day.

At times, it may seem that your child hardly eats at all. Often, toddlers will eat well at one meal, and only take a few bites at others. The most important marker of whether a child eats enough is his or her growth. If you notice weight loss, take your child in to see his or her medical provider right away. If growth seems slow, schedule a weight check at the provider’s office.

Sleeping Children this age still need about 10 to 12 hours of sleep a day. If your child is still taking naps, these may last 1 to 2 hours. Most children this age are ready for bed between 7 and 9 p.m.

Be consistent with bedtime routines. This helps establish healthy sleeping habits and encourages enough rest for your child. Allow your child some time to fall asleep on his or her own. If your child is having trouble falling or staying asleep without your help, read through Chapter 9 for some troubleshooting advice. It’s not uncommon for children this age to have nightmares thanks to their developing imaginations. If your child awakens upset from a nightmare, provide comfort and reassure your child that dreams aren’t real.

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Toddler’s movement

Running, climbing and jumping are all second nature by now. By the age of 3, toddlers are walking heel to toe with ease and most can pedal a tricycle well.

Children this age are working on mastering other skills, too, such as standing on tippy-toe or balancing on one foot. Two- to 3-year-olds are also working on changing positions more smoothly, such as standing up from a squatting position or catching a ball.

Circles and squares, oh my An exciting new development in fine motor skills is gaining the ability to draw shapes. By the age of 3, children can typically draw squares and circles, as well as a rough outline of a person — minus a few body parts. Your child’s drawing technique is becoming very deliberate as he or she approaches the preschool years, with the ability to create crosses and vertical and horizontal lines. Some children this age may attempt to copy capital letters. Using instruments such as scissors and mastering use of a fork at mealtime are additional accomplishments that your child may achieve.

Toddler’s mental development

Toddlers have infinite curiosity and “Why?” is bound to be a favorite question. Short, simple answers generally work best, especially for questions such as “Why can’t I have the knife?” or “Why do I have to go to bed?” Sometimes a question can be a good segue for a learning opportunity or further discovery. If your child asks “What do bugs eat?” for example, take a field trip to the backyard and find a bug to observe, or look up a book on bugs the next time you go to the library.

Self-control By the end of this period, the “terrible twos” are technically behind you. But for some children, terrible twos may give way to “terrible threes.” That’s when it can feel like your child is 3 going on 13, with teenager-like mood swings. He or she may be ecstatic to help you bake chocolate chip cookies one minute, then burst into tears when the cookies look a little bit browner than he or she expected. Such outbursts will be gradually winding down in the months and years ahead, but you may be wondering how you’ll deal with the behavior until then.

Understanding where the behavior is coming from is a good first step. It’s a complicated time, emotionally, for children. For the first time, their repertoire of feelings has expanded to include embarrassment, guilt and shame — among others — and they’re just beginning to learn how to cope with them. “Coping” at this age may include yelling, crying, stomping or throwing things.

You can help your child gradually develop the self-control necessary to manage these emotions and impulses by identifying and naming these new emotions, and offering better ways to handle them. For example, if your child feels disappointed that the cookies didn’t turn out as expected, sympathize by saying, “It’s disappointing that they didn’t turn out like we thought.” Make a plan to change what you can: “Let’s not keep them in the oven as long next time.”

In the meantime, be realistic about which situations your child can and can’t handle, and establish consequences for when negative behavior does crop up — for example, taking away a toy for a set number of minutes if your child throws it. It’s also important to make sure you’re modeling appropriate behavior for your child. While it’s understandable to lose your cool when your child repeatedly tests the limits, reacting calmly to the situation sets an example that your child can observe and follow.

As your child moves further along into the third year, better language skills and more experience in dealing with peers, following rules and encountering disappointment will strengthen coping skills. Offering your child other, more appropriate outlets to release frustration or anger also can help, such as playing outside in an area where your child can run freely or dancing to music. Sometimes just moving on to other routine activities such as taking a bath or prepping dinner is enough to distract a toddler from disruptive behavior.

Language skills Chatterbox may only scratch the surface when it comes to describing your child and how much he or she may like to talk these days. By 3 years of age, most children can tell you their full names and typically have a vocabulary of 900 words or more. Sometimes it can feel like they’re trying to use them all at once! Though your child’s vocabulary is expanding, that doesn’t mean that he or she always understands every word.This can make for some interesting and amusing conversations.

Your child may be eager to tell you stories, and generally speaks clearly enough for even strangers to understand. Sentences expand to about five or six words and include nouns and verbs. Some children this age still have difficulty with pronouns. Mispronunciation of certain letter sounds is common — for example, replacing “th” with “f,” saying “free” instead of “three.”

To help your child expand his or her vocabulary, encourage him or her to give more details about what he or she experiences. For example, when your child tells you he or she saw the neighbor’s dog outside, ask about its color and size, and whether it was barking or quiet.

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Stuttering

It’s not unusual for children to trip over their words as their vocabulary expands faster than the words can come out. This is common until age 5 and tends to affect boys more than girls. If your child is stuttering, the best thing to do is to speak slowly yourself, and avoid interrupting your child or trying to complete his or her sentences. Listen attentively. Pointing out your child’s stutter may only make him or her self-conscious and worsen the problem.

If you’re concerned that your child may have a speech problem, talk to his or her medical provider about an evaluation. While most children outgrow stuttering by age 5, an evaluation may be recommended sooner if the stuttering has persisted for longer than three to six months, there is a family history of stuttering, or a child is upset about his or her stuttering. Stuttering can be caused by any number of factors, including hearing problems and developmental delays.

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Pretend play With a burgeoning imagination, the line between the world of fantasy and reality is frequently blurred for toddlers. Objects such as trees, rocks and cars may take on a life of their own in your child’s world of make-believe, a world often populated by imaginary friends.

In fact, your child may float between the real world and pretend play quite frequently. Sometimes it can be hard for your child to tell the difference between the two. This can make it easy for a child to become upset by scary stories, such as tales of monsters or vampires. In these situations, don’t poke fun at his or her fears. Instead, provide comfort and reassure your child that these fictional characters aren’t real.

Make-believe is an essential part of developing emotions. If your child invites you to play along, do so! You can help your child see new perspectives and ways to deal with emotions. If you don’t get invited, don’t worry. Your child wants to run the show, and that’s perfectly normal.

Concept of time Though a minute will still feel like an eternity to a child, he or she is becoming much more aware of what time involves — particularly as it relates to routines. For example, your child may get excited at a specific time in the afternoon because he or she knows that it’s time to go to the library for reading hour.

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Sex ed

Think questions about sex are reserved for older children? Think again! Children this age are curious and always looking to their parents and caregivers for answers to their questions. So don’t be surprised when your child seeks answers to where he or she came from or why girls are different from boys. Answer these queries in a simple and straightforward way. Use the correct terms for parts of the body — such as breasts, genitalia, vagina and penis — and take your child’s questions seriously. Too much detail or an answer that’s too complicated may be more than your child bargained for. But if he or she wants more details, provide age-appropriate information.

If you’re looking for age-appropriate responses to sex-related questions, consider these examples:

How do babies get inside a mommy’s tummy? You might say, “A mom and a dad decide to put a baby in mommy’s tummy.” If asked how, you can say “By holding each other in a special way.”

How are babies born? For some kids, it might be enough to say, “Doctors and nurses help babies who are ready to be born.” If your child wants more details, you might say, “Usually a mom pushes the baby out of her vagina.”

Why doesn’t everyone have a penis? Try a simple explanation, such as, “Boys’ bodies and girls’ bodies are made differently.”

Why do you have hair down there? You might say, “Our bodies change as we get older.” If your child wants more details, add, “Boys grow hair near their penises, and girls grow hair near their vaginas.”

As your child matures and asks more-detailed questions, you can provide more-detailed responses. Even if you’re uncomfortable, forge ahead. Remember, you’re setting the stage for open, honest discussions in the years to come.

Sometimes, curious children will do some exploring on their own. While masturbation is common at this age, so, too, is wanting to examine the genitals of another child. There’s generally nothing sexual about this, and it’s typically harmless. However, you may want to set limits on such exploration and provide simple rules on privacy. It’s also not too early to teach your child about safety. Explain that vaginas and penises are private and that only mommy, daddy or sometimes a doctor should ask to look at these private parts.

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Imaginary friends You’re making dinner when your daughter asks you to make a little extra food for Sarah. You’re taken aback because you have no clue who Sarah is — until your child explains that Sarah is the friend you can’t see.

Imaginary friends tend to pop up between the ages of 2½ and 3 years. A child may have only one or many, and these friends may stick around till your child starts school. Pretend playmates serve many critical functions: They can help your child work through emotions, practice their conversation skills, or learn how to make the distinction between fantasy and reality. They may also help your child envision reaching a certain goal. For example, an imaginary friend may reach goals your child dreams about but may not yet be able to achieve, such as riding a horse. It’s also OK for a child to not have an imaginary friend. This doesn’t mean your child lacks imagination or won’t develop certain skills.

So how do you handle Sarah? Go ahead and acknowledge her. Address her by her name and set a plate with a little bit of food for her. However, don’t allow your child to blame Sarah for misdeeds. If your child throws a sibling’s toy down the stairs and blames Sarah, for example, firmly tell your child that he or she is responsible for Sarah’s actions.

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Toys and games

“Not for children under the age of 3” is a common warning label found on toys. These labels alert parents that the toy contains small parts — parts less than 1¼ inches in diameter and 2¼ inches long — and poses a choking risk. So when your child turns 3, is he or she ready for these toys? You know your child best, and if he or she doesn’t seem developmentally ready, it’s OK to hold off. In the meantime, there are inexpensive ways to encourage your child’s sense of curiosity and learning, including:

Make-believe. Pretend play with siblings or other children tends to be more cooperative, meaning it’s great for keeping the peace. Children learn how to take turns, communicate and respond appropriately to peers.

Craft boxes. Fill a shoe box with craft items such as popsicle sticks, pipe cleaners, foam shapes, glue sticks and construction paper (if you’re feeling brave, add glitter). These simple but great tools help your child develop fine motor skills, as well as provide a vehicle for your little one’s imagination.

Matching games. Give your child an object, such as a rectangular box, and have your child find matching shapes throughout your house.

Unstructured play. Having time to play freely, without structure, has been shown to boost cognitive development and social and emotional health in young children.

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Toddler’s social development

By age 3, children are becoming less focused on themselves and more interested in playing and interacting with other children. An increase in empathy and a desire to socialize often lead to more peaceful interactive play and the forging of friendships. Friendships are a great way to help children embrace the differences in playmates, as well as see their own unique qualities and how other children appreciate those qualities. (“Brayden says I’m fun!”)

Developing empathy Cooperation with peers is an important theme moving forward. Children may begin moderating their behavior to achieve desired outcomes, such as playing with a toy but also sharing to make a friend happy. Of course, learning to moderate behavior takes time, and unkindness or aggression may flare up every now and again. You’ll still need to step in to redirect your child when necessary. Over the next few years, your son or daughter will learn to consider others’ emotions, although they may not put others’ feelings first just yet. Importantly, make sure to notice and compliment empathetic behavior to help build your child’s confidence and encourage him or her to use that behavior again. In addition, keep in mind that you are your child’s primary example of how to behave and relate to others.

Exploring gender roles It’s common for children this age to begin to explore the concept of gender and where they fit in. Don’t worry if your child’s exploration goes against the grain — for example, if your daughter refuses to wear anything but boy clothes, or your son wants to play princess. Experimenting with different roles helps your child define his or her own role. Avoid using stereotypes to govern your child’s play. Focus instead on highlighting positive character traits found in all girls and boys, such as generosity and determination. Plus, you still have the final say on what’s appropriate for your child to wear to a special occasion, such as attending a wedding (although there may be protests).

Gearing up for preschool In the blink of an eye, your baby has gone from diapers and stacking a block or two to speaking a mile a minute and maybe even preparing for preschool.

Many children attend preschool for a year or two before entering kindergarten. There are a variety of programs available, ranging from public to private options. Public school districts often have preschool programs, some of them free of charge, open to local residents. Preschool programs may also be available through parochial school systems or private organizations. Some child care programs have a built-in preschool curriculum.

Preschool not only helps children prepare for more formal learning but also helps them get used to other school routines. These might include longer separations from you, socialization with classmates and abiding by set rules in a school setting. A good preschool program can help create a smoother transition to kindergarten for your child.

When looking for a preschool, search for certain characteristics, such as:

Goals and rules that align with yours. The focus at this age should be helping children find self-confidence and build independence. It shouldn’t be to fast-track academics, such as learning how to read or do advanced math. Also important is making sure discipline is handled in a way you agree with.

Small class size. Children up to 3 years old tend to do better with about eight to 10 classmates.

Low turnover. A high turnover of teachers and other staff can be indicative of a problem keeping good teachers. Teachers and other staff should be trained in early childhood development or education.

If you and your child haven’t been separated before, you’ll likely have some feelings of sadness or guilt. This is understandable. On the positive side, preschool can help your child become more independent and teach him or her valuable socialization skills. It can also give you and your child some time apart so you can focus on yourself. These are things that can deepen your parent-child relationship.

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Milestones for months 31 to 36

By the end of this period, your toddler is busy:

Pedaling a tricycle

Moving with more ease forward and backward, hopping briefly on one foot, and using alternating feet to go up stairs

Getting dressed, with assistance

Drawing lines, crosses, shapes; starting to draw people

Building a tower of nine or 10 cubes; building bridges

Using as many as 900 words

Understanding more complex sentences (such as, We’ll go to the park after you eat breakfast.)

Talking and asking questions

Beginning to understand concepts such as numbers and comparisons

Recalling events that happened the day before

Thinking up his or her own stories

Playing with other children and beginning to forge friendships

Being aware that people look different

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Part 4 Common illnesses and concerns

Among the many challenges you face as a parent is caring for your child during illnesses or medical emergencies. This can be scary, but thank goodness true medical emergencies in infants and toddlers are fairly rare. Still, because your son or daughter can’t always verbally tell you when something hurts, it can be difficult to sort out more-serious illnesses from those that are common and easily managed at home.

Illnesses in general are more frequent in the first years of life, simply because your new baby is young and still developing in many ways. He or she is also confronting a whole new environment filled with people, pets and germs. But as your child matures and his or her immune system becomes stronger and better adapted to the environment, illnesses will become less frequent.

As you get to know your son or daughter better, it will become easier for you to know when your child has a minor illness and when you need medical help. You know your child better than anyone else — including details about his or her current and previous illnesses. You will notice, for example, if your little one is suddenly more fussy than usual, or has changed eating or sleeping patterns. You’ll also be able to tell if your child is less active or clinging to you more.

You’re an essential part of the team that cares for your sick child. In most cases, you’ll determine when you can handle an illness at home or when it’s time to call your child’s medical provider or visit an emergency department. You can help your provider determine if a problem is present when things just don’t seem right with your child.

You also play a key role in caring for your sick child: knowing when to give medication, understanding what changes to watch for and foods to avoid, and determining when your child can return to child care. Remember, parents’ instincts about sick children are usually very good — trust yours.

Infants and medications

A question new parents often have when faced with a sick child is whether it’s OK to give medication. When you have a headache, for example, the easiest and most effective solution is to take a pain reliever. But what about for a child?

When it comes to medications, the benefits must always be weighed against the risks. While some medications play a role in helping infants and children get better, many others do not. Plus, almost all drugs have potential side effects. So choose wisely when deciding what type of medication to give and when to give it.

The general approach to over-the-counter medications in an otherwise healthy child is that they’re rarely needed. If you do use them, use only those that are designed for infants or children. Use them only when necessary and as indicated by your child’s medical provider.

Fever and pain If your baby is under 2 months and has a rectal temperature of 100.4 F or higher (fever), call your child’s medical provider promptly. Don’t give your baby any medications unless recommended by the provider. Because a young baby’s immune system is still developing, a fever in an infant this age generally requires a medical evaluation.

If your older baby has a fever but seems to feel fine, medication isn’t necessary. If your child seems uncomfortable, acetaminophen (Tylenol, others) can help ease pain and reduce a fever and is safe for babies over 2 months old. Ibuprofen (Advil, Motrin, others), another pain reliever, is safe for babies older than 6 months, although it can aggravate illnesses affecting the digestive tract. Check with a medical provider before giving medication to a child with a chronic illness, such as kidney disease or asthma.

Cough and congestion When your child is coughing or congested, it’s tempting to pick up one of the many cough and cold medications available at your local drugstore. But research indicates that these aren’t safe or effective in improving colds. The Food and Drug Administration warns that these drugs can have rare but serious side effects. A safer and more effective alternative for a stuffy nose may be to use saline nasal drops to thin the mucus or a suction bulb to remove secretions from your child’s nose. For children who are over a year old, a teaspoon of honey can help soothe a cough (see “Cold” here and “Cough and cold medications” here).

Precautions When giving your child medicine, follow these precautions:

Give the right dose Infant medicines usually come in liquid form but in different strengths based on the individual medicine. Use only the dispenser that came with the medication, and follow the directions on the label carefully. Often, for children under age 2 years, the medicine label will tell you to ask a medical provider for instructions on dosing. If you know your child’s weight, use that as a guide (see this table).

Avoid overdosing Don’t give your child multiple medicines with the same active ingredient at the same time, such as a pain reliever and a decongestant, which can lead to an accidental overdose. Some parents alternate between pain relievers such as acetaminophen and ibuprofen, but be cautious about doing this. Each medicine requires a specific time interval between doses (see this table). Trying to keep the two straight may become confusing, and you may unintentionally overdose your child.

Avoid aspirin Aspirin is not approved for children under 2 years. It’s generally not recommended for children under age 18 because of its association with a serious illness called Reye’s syndrome, which can damage the brain and liver. The risk is mostly associated with using aspirin to treat symptoms of a viral illness, such as the flu or chickenpox. But since it’s not always easy to accurately distinguish between a viral and a nonviral type of illness, experts recommend avoiding aspirin altogether in children under 18, unless specifically prescribed by a medical provider.

If you have any questions about giving your child a medication, call your child’s medical provider. This will help you avoid unnecessary risks. If your child vomits or develops a rash after taking a medicine, call the provider promptly.

How to give medicine When your child does need to take a medicine, here are some tips to make the job easier:

A baby is usually more willing to take medicine by mouth before a feeding.

Place a small amount of medicine inside the child’s cheek, where it’s not as easy to spit out.

Don’t refill bottles or use measured droppers for anything other than the original medicine.

Avoid chewable medications in infants younger than age 2 years.

Follow the directions of your child’s medical provider for continuing to use a medication, even if it doesn’t taste good or your child’s symptoms are getting better. A course of antibiotics, for example, needs to be taken in full for it to work as it should and to prevent bacteria from developing resistance to the antibiotic.

Taking your child’s temperature

If your child feels warm or seems sick, taking his or her temperature can help you tell if he or she has a fever. In very young infants — under 2 months — a fever is cause to see your child’s medical provider right away. This is because your new baby’s immune system is still developing. In older infants and children, however, a fever in and of itself generally isn’t cause for alarm, unless it’s combined with other signs and symptoms of illness (see “Fever” here).

Taking your child’s temperature sounds simple enough, but if you’re new to it, you may have questions. Here’s what you need to know to take your child’s temperature.

Thermometer options There are several types you can choose from:

Digital thermometers. These thermometers use electronic heat sensors to record body temperature. They can be used in the rectum (rectal), mouth (oral) or armpit (axillary). Rectal temperatures provide the best readings for infants and toddlers. Armpit temperatures are typically the least accurate of the three measures. Digital pacifier thermometers and fever strips aren’t recommended.

Digital ear thermometers (tympanic membrane). These thermometers use an infrared scanner to measure the temperature inside the ear canal. Keep in mind that earwax or a small, curved ear canal can interfere with the accuracy of an ear thermometer temperature.

Temporal artery thermometers. These thermometers use an infrared scanner to measure the temperature of the temporal artery in the forehead. This type of thermometer can be used even while a child is asleep.

Whatever the method, make sure you carefully read the instructions that came with your thermometer. After each use, clean the tip of the thermometer with rubbing alcohol or soap and lukewarm water.

For safety — and to make sure the thermometer stays in place — never leave your child unattended while you’re taking his or her temperature.

Taking a baby’s temperature rectally

Age matters The best type of thermometer — or the best place to insert the thermometer, in some cases — depends on your child’s age.

Birth to 2 months. Use a standard digital thermometer to take your baby’s rectal temperature.

2 months to 4 years. In this age range you can use a digital thermometer to take a rectal or an armpit temperature or you can use a temporal artery thermometer. However, wait until your child is at least 6 months old to use a digital ear thermometer. If you use another type of thermometer to take a young child’s temperature and you’re in doubt about the results, take a rectal temperature.

4 years and older. By age 4, most kids can hold a digital thermometer under the tongue for the short time it takes to get an oral temperature reading. You can also use a digital thermometer to take an armpit temperature, or use a temporal artery thermometer or a digital ear thermometer.

How it’s done Here’s how to take a temperature using the different methods. Be sure to turn on the thermometer before you start.

Rectal temperature. Turn on the digital thermometer and lubricate the tip of the thermometer with petroleum jelly. Lay your child on his or her back, lift his or her thighs, and insert the lubricated thermometer 1/2 to 1 inch into the rectum. Insert the thermometer slowly, and stop if you feel any resistance. Hold the thermometer in place until the thermometer signals that it’s done. Remove the thermometer and read the number.

Armpit temperature. When you place the thermometer under your child’s armpit, make sure it touches skin — not clothing. While the device reads your child’s temperature, hug your child, keeping the side holding the thermometer against your chest. Keep the thermometer tightly in place until the thermometer signals that it’s done. Remove the thermometer and read the number.

Ear temperature. Gently place the thermometer in your child’s ear. Follow the directions that come with the thermometer to ensure that you insert the thermometer the proper distance into the ear canal. Hold the thermometer tightly in place until the thermometer signals that it’s done. Remove the thermometer and read the number.

Temporal artery temperature. Gently sweep the thermometer across your child’s forehead. Remove the thermometer and read the number.

Oral temperature. Place the tip of the thermometer under your child’s tongue toward the back of the mouth and ask your child to keep his or her lips closed. Remove the thermometer when it signals that it’s done and read the number. If your child has been eating or drinking, wait 15 minutes to take his or her temperature by mouth.

When reporting a temperature to your child’s medical provider, give the reading you took and explain which thermometer you used and how the temperature was taken.

Caring for a sick child

Many common childhood illnesses can be treated at home. If you have any questions, seek the help and advice of your child’s medical provider. When you have a sick child at home, a little extra loving care is always in order. To help your child recover quickly and fully, there are some simple steps you can follow.

Encourage rest Make sure your child has plenty of opportunity to rest. Getting enough sleep will help ease crankiness and smooth over irritability and discomfort. Take the opportunity to snuggle up and relax together. A mild illness is often just the excuse you need to pause the family’s hectic schedule and spend quality time with your child.

Offer plenty of fluids One of the biggest risks associated with infections and other common childhood illnesses is dehydration. Dehydration occurs when your child loses more fluids than he or she is taking in — because of vomiting, diarrhea, difficulty feeding or just the increased demands on your child’s metabolism. If your child is having difficulty eating or keeping fluids down, offer small, frequent sips of breast milk, formula, water or oral rehydration solution (see “Vomiting” for more details on getting your child to take in enough fluids). Older babies and toddlers may enjoy sucking on an ice pop or crushed ice.

Make your child comfortable If your child is congested, adding extra moisture to the air by running a humidifier or vaporizer may help soothe your child’s nose. Or have your child breathe the warm, moist air in a steamy bathroom. Saline drops or spray into the nose can help with congestion. If your child’s room feels hot and stuffy, circulate the air with a fan. Also make sure your child isn’t dressed too warmly.

Use medications wisely If your child is more than 2 months old and has a fever but is eating and sleeping well and playing normally, medication may not be necessary. But if your son or daughter is fussy and uncomfortable, it’s fine to give him or her acetaminophen (Tylenol, others) to relieve the discomfort. Ibuprofen (Advil, Motrin, others) should only be given to babies older than 6 months. Follow the directions on the label, the dosage charts here or the advice of your child’s medical provider. Be sure to wait for the appropriate amount of time before giving your child another dose. If your child’s medical provider has prescribed antibiotics or another medication, follow the instructions exactly to maximize the drug’s benefits and reduce possible risks.

Call your child’s medical provider When dealing with a sick child, trust your intuition as a parent. If you feel that you should call your child’s medical provider — call. Describe what’s worrying you and what you’ve tried so far. A phone call to a medical provider often can solve a lot of problems and give you reassurance that the steps you’ve already taken are the right ones. If you feel that you should have your child seen in either the doctor’s office or the emergency department — go in.

Prevent the spread of germs Young babies are especially vulnerable to viruses and bacteria. Take commonsense steps to keep germs from spreading. Sneeze or cough into a clean tissue or into your elbow if tissues are unavailable. Toss used tissues promptly. Don’t share eating and drinking utensils. Keep surfaces clean, including pacifiers and toys that your child likes to chew on. Refrain from kissing a young infant if you have an active cold sore. Cold sores are caused by a type of herpes virus, which can cause serious problems for babies.

In general, avoid people who are sick, and stay away from crowded areas in the fall and winter, when more people are indoors and the chances of infection are higher. Above all, wash your hands frequently and thoroughly and make sure other family members do the same. You may want to keep bottles of hand sanitizer in various places around the house.

A to Z Illness Guide

Following are some illnesses most common to newborns and young children and tips on how to treat them.

Allergies

Allergies occur when your body’s natural defense system incorrectly identifies a typically harmless substance as harmful. The body then overreacts in an attempt to protect itself, and the result is an allergic reaction. A tendency to develop allergies is usually inherited.

Food allergies are most common in children, especially toddlers and infants. Over time, your child’s digestive system matures and his or her body is less likely to absorb food or food components that trigger allergies.

The top food allergens include eggs, milk, wheat, soy, tree nuts, peanuts, fish and shellfish. Fortunately, children typically outgrow allergies to milk, soy, wheat and eggs. Severe allergies and allergies to nuts and shellfish are more likely to be lifelong.

Reactions to pollen and other environmental triggers are less common in infants and toddlers. Pollen allergies, for example, usually don’t start until around age 4 years.

How to recognize it An allergic reaction to a food typically occurs shortly after eating it. Food allergies often cause signs and symptoms such as:

Itchy skin

Rash

Hives

Swelling

Cough, wheezing or shortness of breath

Diarrhea

Vomiting

Food allergies can be confused with an intolerance or sensitivity to certain foods. Intolerance of a certain food can cause digestive problems — such as a stomachache, gas and diarrhea — but isn’t related to the immune system. For example, some children don’t have enough of the enzyme required to digest milk sugar (lactose), making them lactose intolerant. Also, sometimes the acid found in certain foods, such as tomatoes or oranges, can cause a red rash around the mouth that parents mistake for allergies.

How serious is it? Food allergies must be taken seriously as they can cause a life-threatening allergic reaction (anaphylaxis) that requires emergency treatment. Allergic reactions to pollen, soaps or rough fabric (see this discussion), and other environmental factors are more annoying than serious.

Anaphylaxis A serious allergic reaction often happens quickly. Signs and symptoms to watch out for include:

Difficulty breathing

Facial swelling

Hives

Bluish skin color

Loss of consciousness

When to call If your child has signs or symptoms of anaphylaxis, call 911 or your local emergency number. After emergency treatment, see your child’s medical provider to determine what caused the reaction and to figure out how to avoid another one. Doctors will often prescribe an emergency epinephrine autoinjector (EpiPen or Twinject) that you can keep with you at all times. This medication will provide your child relief until you’re able to reach the emergency department.

If your child has allergy signs or symptoms such as a constant runny nose, chronic cough or dry, itchy skin, make an appointment with his or her medical provider to discuss what’s causing it and to learn how to treat it.

What you can do The best way to prevent any allergy is to avoid the substance that’s triggering the reaction. If you’re in the midst of introducing new foods to your child, and he or she shows signs of a possible food allergy, your child’s medical provider may advise going back to foods you know are safe and holding off on new foods for a week or two. Then introduce new foods one at a time, so you can monitor which food might be causing problems. Your provider may refer you to an allergy specialist who can conduct tests to identify potential allergens.

It was common practice to wait to introduce allergenic foods such as peanuts and eggs, often until after 2 years of age. But based on newer evidence, experts now advise introducing these foods around 4 to 6 months to help prevent the development of food allergies. If your child is at increased risk of allergies — such as having eczema, an egg allergy or a family history of food allergies — talk to your child’s medical provider. An early introduction to peanut-containing foods may be helpful (see this discussion).

Anemia

Anemia is a condition in which blood lacks a sufficient number of healthy red blood cells. Red blood cells carry oxygen to the brain and other organs and tissues, providing energy and giving skin a healthy color. They’re also essential to a child’s growth and development.

The most common cause of anemia in infants is a lack of iron (iron deficiency). Iron is necessary for the creation of hemoglobin, the substance that enables red blood cells to deliver oxygen to the body. Iron deficiency can also occur as a result of premature birth or excessive blood loss.

In full-term infants, iron deficiency usually results from a lack of iron in the child’s diet. Babies who drink cow’s or goat’s milk too early, for instance, miss out on iron because these kinds of milk are a poor source of iron. Cow’s milk, goat’s milk and soy milk can also interfere with iron absorption. Excessive milk intake — especially more than 24 ounces a day — is a common cause of iron deficiency in toddlers.

Most full-term babies are born with a supply of iron that lasts about four months. After that, the supply diminishes and needs to be supplemented with other sources of iron, such as iron-rich foods or an iron supplement. Supplements aren’t needed in infants fed fortified formula, as it provides adequate iron.

How to recognize it Mild signs and symptoms of anemia aren’t always easy to recognize. Often, children are diagnosed with anemia as a result of a blood test done for a separate reason. In general, though, a child with more severe iron deficiency anemia may:

Appear pale or ashen

Tire easily

Be persistently irritable

Have a poor appetite

Have restless sleep

How serious is it? If untreated, iron deficiency in children can cause delays in normal growth and development. Some studies show a long-term association between iron deficiency anemia in infancy and later deficits in intellectual capacity.

Don’t try to treat your child on your own. Always talk to your child’s medical provider before giving your child any type of vitamins or supplements.

When to call If your child seems unusually pale, tired, irritable or uninterested in eating, or if you’re concerned about the amount of iron in your child’s diet, talk to your child’s medical provider. In most cases, a simple blood test is all that’s needed to diagnose anemia. In many areas, babies are routinely screened for anemia before reaching 2 years of age.

Iron deficiency anemia is treated with iron supplements, usually in a liquid form for infants. Generally, you administer the supplements for about seven to nine weeks until your child’s iron supply is at a healthy level. Iron medications can change your child’s stool to a dark color, so don’t be concerned if this happens. Once your child’s iron levels are back to normal, you’ll want to make sure he or she continues to get enough dietary iron, through food or supplements.

It’s possible to overdose on iron supplements — too much iron is poisonous — so be sure to give supplements to your child exactly as the medical provider recommends. Also, keep this and any other medications away from small children.

What you can do Iron deficiency anemia can be prevented by making sure your child gets an adequate supply of iron in his or her diet. Here are some simple steps you can take:

Offer milk appropriately. Wait to give your child milk until he or she is at least 1 year old. Until then, give your child breast milk or formula. After that, limit milk to 2 or 3 cups a day (16 to 24 ounces).

Introduce iron at the right time. If you’re breast-feeding, give your child iron-fortified cereal when you start to introduce solid foods. If you’re breast-feeding exclusively beyond age 4 months, talk to your child’s medical provider about giving your child an iron supplement.

Use iron-fortified formula. If your child drinks formula, make sure it has iron added (4 to 12 milligrams of iron per liter). Most standard formulas on the U.S. market contain iron.

Offer a balanced diet. As your son or daughter gets older, you can include iron-rich foods in his or her diet, such as pureed meat, egg yolks, green beans, peas, squash, spinach, sweet potatoes, tuna, ripe apricots and stewed prunes.

Enhance iron absorption. Offer your child foods rich in vitamin C, which helps the body to absorb iron. Examples include strawberries, cantaloupe, kiwi, raspberries, broccoli, tomatoes and cauliflower.

Asthma

In some people, the lungs and airways become easily inflamed or constricted — more easily than in other people — when exposed to certain conditions called triggers. The inflammation narrows the airways and leads to difficulty breathing. Exposure to triggers — such as a cold — can cause the airways to tighten up or constrict (bronchospasm). This is referred to as asthma, or an older term, reactive airway disease. In young children, the first sign of asthma may be wheezing that’s triggered by a cold, goes away and then recurs with the next cold.

Asthma can be difficult to diagnose, especially in younger kids because it’s hard to get accurate results on lung function tests. Also, a number of childhood conditions — bronchiolitis and pneumonia as examples — can have symptoms similar to those caused by asthma. If your child has repeated episodes of wheezing, your medical provider is likely to consider asthma as a possible underlying problem.

Asthma is more common in children who have a family history of asthma, allergies or eczema.

How to recognize it Rapid, labored breathing, especially with a cold, is a common symptom. Wheezing — a high-pitched whistling sound produced when your child breathes out (exhales) — is another sign of asthma, but isn’t always audible. Other signs and symptoms include a cough that gets worse at night, tightness in the chest and shortness of breath. With asthma, wheezing or coughing episodes tend to recur. Some kids may have only one sign or symptom, such as a lingering cough or chest congestion.

How serious is it? Asthma signs and symptoms vary from child to child and may get worse or better over time. Some kids outgrow recurrent wheezing when they reach 5 or 6 years old. For others, wheezing episodes may stop and then recur again later in life. Still others have chronic, persistent wheezing that requires daily management.

When to call Seek emergency medical care if your child has severe trouble breathing, or his or her mouth or fingertips are turning dusky or blue.

Make an appointment right away with your child’s medical provider if you notice a fever with persistent coughing or wheezing, or if your child has difficulty sleeping or eating because of wheezing, coughing or troubled breathing.

Asthma is treated with prescription medications. Quick-relief medications work by opening up the airways and making breathing easier right away. Controller medications work to reduce inflammation. They’re used every day by children who have been diagnosed with asthma and have regular symptoms or who have symptoms with colds or other upper respiratory infections.

If your child has symptoms of asthma, your child’s medical provider may use a wait-and-see approach before prescribing medications, depending on the severity of symptoms. If your child has severe wheezing episodes, a medical provider may prescribe a quick-relief medication to help ease your child’s symptoms. This medication comes in the form of an inhaler or a nebulizer.

With an inhaler, medical staff can show you how to use a spacer, a plastic tube — usually with a mask attached — that makes it easier to deliver the medication to your child. For younger children, you may also use a nebulizer, a machine that vaporizes liquid medication into fine droplets that your child breathes in. Sometimes, an oral medication may be prescribed. Asthma medications are very safe. All medications carry risks if used inappropriately, but when asthma medications are used correctly, their benefits far outweigh the small risks.

If your son’s or daughter’s wheezing persists over time, his or her medical provider will likely recommend a full evaluation for asthma. If your child does have asthma, your medical provider can prescribe medications that control your child’s symptoms and help to prevent severe attacks.

Daily asthma medications can sometimes be difficult to remember to use because when your child’s asthma is well controlled, he or she has no symptoms. As a parent, it may not seem necessary to give your child a medication if he or she isn’t ill. But it’s very important not to stop asthma medication. Left untreated or undertreated, childhood asthma can lead to permanent lung changes that can result in poor lung function in adulthood.

What you can do Keep track of your child’s wheezing episodes, preferably in a journal if you can, and don’t be afraid to call your child’s medical provider when symptoms warrant it. If you’re not sure when to call, ask the provider to tell you.

If you notice that certain things tend to trigger your child’s wheezing, such as dust or pollen, try your best to avoid them. Clean regularly to eliminate dust, and use air conditioning during pollen season to keep out airborne allergens. If your child’s wheezing is worsened by cold air, bundle your child in a blanket to keep the air around his or her face warm and moist. Not all studies show that allergen-avoidance measures are effective in controlling asthma, though, so don’t feel that you need to surround your child in a protective bubble at all times.

Bronchiolitis

Bronchiolitis is a common lung infection in babies and young children. It’s caused by a virus, often the respiratory syncytial virus (RSV). In adults, RSV infection typically causes only mild upper respiratory tract symptoms. In infants, however, the infection sometimes spreads to smaller lung airways (bronchioles), leading to inflamed, narrowed airways (bronchiolitis). RSV infection is very contagious and is most common during the winter months. Other less common viral causes of bronchiolitis include influenza, parainfluenza, measles and adenovirus.

How to recognize it Bronchiolitis typically starts out like the common cold with a runny nose, mild fever and a cough. Over several days, the cough becomes more pronounced and you may hear your child wheezing. Babies are nose breathers. When too much mucus is stuffing a child’s nose or trickling down his or her throat, sucking and swallowing become more difficult. Because of this, he or she may not be interested in eating.

How serious is it? Signs and symptoms of bronchiolitis can range from mild to severe. Wheezing and coughing typically last for a week to a month or more and then go away on their own.

In some cases, especially if your child has an underlying health problem or is a significantly premature newborn, bronchiolitis can become very severe and require hospitalization.

During the illness, it’s important to encourage your child to drink frequently. Not getting enough fluids creates a risk of dehydration, which itself can be serious.

When to call If your child’s symptoms are severe — such as marked difficulty breathing or skin that’s turning blue from lack of oxygen (especially around the mouth and fingertips) — call 911 or your local emergency number.

Call your child’s medical provider right away (or seek urgent care if after office hours) if your child:

Is making a high-pitched, whistling sound (wheezing) each time he or she breathes out

Is having trouble eating

Develops signs of dehydration (infrequent urination — fewer than three wet diapers in 24 hours, dry mouth, crying without tears, taking less fluid)

Is under 2 months and has a fever, is listless or not waking as you’d expect, or has a fever that lasts more than three days

Also, call your child’s medical provider without delay if you suspect bronchiolitis and your child was born prematurely or has an underlying health problem.

If the severity of your child’s symptoms requires a hospital stay, your child may need humidified oxygen to maintain sufficient oxygen in the blood, and perhaps fluids through a vein (intravenously) to prevent dehydration.

What you can do You can treat most cases of mild bronchiolitis at home with self-care steps. Treat the cold symptoms with a humidifier and perhaps saline nasal drops if your child is very congested (see here for tips on relieving cold symptoms). Encourage plenty of fluids, as breathing difficulties often cause your child to eat or drink less and more slowly.

Wash your hands frequently to prevent the spread of viruses. When your child is a newborn, avoid close contact with children or adults who have any type of respiratory infections — even if the symptoms seem mild.

Colds

Babies and toddlers are especially susceptible to the common cold — a viral infection of the nose and throat — in part because they’re often around other children with colds. In fact, young children have an average of 6 to 8 colds a year. Colds generally last a week or two, but occasionally they persist longer. Sometimes it may seem as if your child has a runny nose all winter! This is especially true if a child has older siblings or he or she attends child care.

Colds are most commonly spread when someone who is sick coughs, sneezes or talks, spraying virus-carrying droplets into the air that others inhale. Colds can also be spread through hand-to-hand contact. Some viruses can live on surfaces for a few hours, so contaminated toys may be another source of infection.

Once your child has been infected by a virus, he or she generally becomes immune to that specific virus. But because there are so many viruses that cause colds, your child may experience several colds a year and many throughout his or her lifetime.

How to recognize it When your child has a cold, he or she will likely develop a congested or runny nose. Nasal discharge is typically clear at first, then turns yellow, thicker and even green. After a few days, the discharge again becomes clear and runny.

Colds may produce a fever (see this discussion) in your child for the first few days. Your child may also sneeze and have a cough, a hoarse voice or red eyes.

Some colds seem to settle mainly in a child’s nose, and others settle in the chest. If your infant seems to have a lot of sneezing or snorting and is frequently congested, he or she may not always have a cold. Because a baby’s nasal passages are quite small, it doesn’t take much mucus to cause congestion. Congestion may also result from dry air or from irritants such as cigarette smoke.

How serious is it? Colds are mostly a nuisance and usually don’t require a visit to a medical provider. If your child has a cold with no complications, it should resolve within about seven to 14 days.

Keep an eye on your child’s symptoms, though, because sometimes colds can progress into more-serious problems, especially in smaller or younger infants. If your child’s symptoms seem to be worsening, call your child’s medical provider promptly.

When to call If your child is younger than 2 to 3 months of age, call the medical provider early in the illness. For newborns, a common cold can quickly develop into croup, pneumonia or another more serious illness. Even without such complications, a stuffy nose can make it difficult for your child to nurse or drink from a bottle. This can lead to dehydration. As your child gets older, his or her medical provider can guide you on when your child needs medical care and when you can treat a cold at home.

If your child is under 2 months and has a temperature of 100.4 F or higher, see your child’s medical provider right away. If your child is over 2 or 3 months, call your medical provider if he or she:

Has a fever that lasts more than three days

Seems to have ear pain

Has red eyes or develops yellow eye discharge (also see “Pink eye” here )

Has a cough that improves then worsens, interferes with ease of breathing or lasts longer than one month

Experiences signs or symptoms that worry you

Seek medical help immediately if your child:

Refuses to nurse or accept fluids and has fewer than three wet diapers in 24 hours or reduced urine output

Coughs hard enough to cause persistent vomiting or changes in skin color

Coughs up blood-tinged sputum

Has difficulty breathing or is bluish around the lips and mouth

What you can do Unfortunately, there’s no cure for the common cold. Antibiotics kill bacteria but don’t work against viruses. Over-the-counter medications should generally be avoided in infants. However, pain relievers may be used — provided you carefully follow dosing directions — if a fever is making your child uncomfortable (see this table). Acetaminophen (Tylenol, others) is safe in babies age 2 months or older. Ibuprofen (Advil, Motrin, others) is OK to use if your child is age 6 months or older. Cough and cold medications are not safe for young children. In the meantime, consider the following suggestions for making your child more comfortable.

Offer plenty of fluids Liquids are important to avoid dehydration. Encourage your child to take in his or her normal amount of fluids. Extra fluids aren’t necessary. If you’re breast-feeding your child, keep it up.

Thin the mucus If your child’s nasal discharge is thick, saline nose drops or salt-water nasal sprays may help loosen the mucus. Saline nose drops and sprays are made with the optimal amount of salt and water. They’re inexpensive and available without a prescription. To help your son or daughter eat better, place a couple of drops in each nostril. In infants, this can be especially helpful if done 15 to 20 minutes before a feeding. This can be followed by suction with a nose bulb, if desired. Other suctioning devices such as NoseFrida are also popular and effective.

Moisten the air Running a cool-mist humidifier in your child’s room can help improve a runny nose and nasal congestion. Aim the mist away from your child’s crib to keep the bedding from becoming damp. To prevent mold growth, change the water daily and follow the manufacturer’s instructions for cleaning the unit. It might also help to sit with your child in a steamy bathroom for a few minutes before bedtime. Avoid the use of hot steam vaporizers because of the risk of burns to infants and children from their use.

Avoid sick people Keep your child away from anyone who’s sick, especially during the first few days of an illness. Remind family and friends that the most loving thing they can do when sick is to stay away from young children, especially a new baby. If possible, avoid public transportation and public gatherings with your newborn.

Keep hands clean Wash your hands before feeding or caring for your child. Use hand gels, wipes or soap and water. Ask that everyone who cares for or visits your child do the same.

Don’t share Don’t share bottles, utensils or sippy cups. If your child attends a child care facility, make sure his or her items are clearly labeled. Clean your child’s toys and pacifiers often.

Use tissues Teach family members to cough or sneeze into a tissue — and then toss it. If you can’t reach a tissue in time, cough or sneeze into the crook of your arm.

• • • • •

Cough and cold medications

The Food and Drug Administration (FDA) strongly recommends against giving over-the-counter cough and cold medicines to children younger than age 4. Over-the-counter cough and cold medicines don’t effectively treat the underlying cause of a child’s cold and won’t cure a child’s cold or make it go away any sooner. These medications also have potential side effects, including a rapid heart rate and convulsions.

Other remedies may be more effective and have fewer risks:

Warm fluids. A little soup or broth can have a soothing effect and help loosen nasal congestion.

Honey. For children over 12 months old, a teaspoon or so of honey — either given straight or diluted, such as in milk — is safe to consume and can soothe a cough. Due to the risk of infant botulism, a rare but serious form of food poisoning, never give honey to a child younger than age 1.

Moist air. Moistening the air with a cool mist humidifier can help your child breathe easier. So can sitting with your child in a steamy bathroom (see this discussion).

Coughing isn’t all bad. It helps clear mucus from your child’s airway. If your child is otherwise healthy, there’s usually no reason to suppress a cough.

• • • • •

Cough

A cough is common in infants and toddlers. It’s also a common cause of anxiety in parents. Your child usually coughs because something is irritating his or her air passages. A child’s cough most often is caused by a cold or other upper respiratory tract illness. But it can also result from the irritation caused by an aspirated chunk of food, a toy or other small object that has “gone down the wrong pipe” and settled in an airway. A chronic cough that’s triggered by exercise, cold air, sleep or allergens may be a sign of asthma.

How to recognize it Coughs may vary according to the part of the respiratory tract affected. An irritation near the vocal cords may cause a barking, croupy cough, and an irritation of your child’s trachea may cause a raspy cough. Allergies or asthma may cause a dry, unproductive cough that often occurs during the night. Pneumonia may cause your child to have a deep chest cough that occurs both day and night. Young children with pneumonia usually have a fever and look sick.

How serious is it? Your child’s cough, by itself, may be bothersome but usually isn’t serious. The seriousness of the cough depends on the condition that’s causing the cough. Treating the underlying problem usually helps the cough.

When to call Contact your child’s medical provider promptly if your child develops a cough and:

Is younger than 2 months and has a rectal temperature of 100.4 F or higher

The cough lasts longer than four weeks or worsens after beginning to improve

Seems to be in pain

Call 911 or your local emergency number if your child:

Begins turning blue

Has problems swallowing or difficulty making sounds

Stops breathing

What you can do You may be able to ease your child’s cough by providing extra fluids and adding moisture to the air with a humidifier. Sitting with your child in a steamy bathroom may help, too. For children who are over a year old, a teaspoon of honey, diluted in some water or milk if desired, can help soothe a cough.

If your child’s cough is interfering considerably with eating and sleeping, check with your child’s medical provider about measures to take. Cough medicines aren’t recommended for young children because of potential side effects and because they’re generally not effective in this age group (see “Cough and cold medications” here).

Constipation

Parents sometimes worry that their child is constipated because several days go by without a bowel movement. But it’s not unusual for an infant who is exclusively breast-fed to go for several days — even a week or longer — without a bowel movement. Constipation refers to dry, hard stools that are difficult to pass. As long as the stool is soft and easily passed, constipation likely isn’t a problem.

Constipation tends to be more common in toddlers than in infants, especially during toilet training or with changes in diet.

How to recognize it Constipation may be a problem if your child:

Is a newborn and hasn’t passed his or her first meconium stool one to two days after birth

Has stools that are hard and dry

Has painful bowel movements (grunts and grimaces, discomfort, fussiness)

Has stools streaked with blood

Appears to have abdominal pain that seems to be relieved after a large bowel movement

How serious is it? Most infant constipation is mild, a result of a change in the child’s diet, and resolves within a short time. In older children, it can usually be managed by providing extra fluids and more high-fiber foods.

Constipation can interfere with toilet training, especially when bowel movements are difficult or uncomfortable. Treating the constipation can help make toilet training easier.

When to call Call your child’s medical provider if your child seems chronically constipated or if your efforts at home aren’t providing any relief. Don’t give laxatives, enemas or medication without consulting your medical provider first.

What you can do Breast-fed babies are seldom constipated from changes in the mother’s diet. If a change of diet seemed to start the problem, it will likely improve with time. For kids who are eating solid foods, these measures may help:

Offer plenty of fluids.

Limit your child’s intake of milk.

Offer more fruits and vegetables.

Gradually add high-fiber foods to your child’s diet. This might include prunes (or up to 4 ounces of prune juice a day), apricots, plums, peas and beans.

Crossed eyes

Crossed eyes (strabismus) is one of the most common eye problems in babies. It occurs as a result of an imbalance in the muscles controlling the eye.

It’s normal for a newborn’s eyes to wander or appear cross-eyed because his or her brain cells haven’t yet learned how to control eye movements. But by 4 months of age your child’s nervous system should be developed enough that his or her eyes work together to focus on the same point at the same time. If they continue to cross or wander, then it’s time to see your child’s medical provider.

How to recognize it You may notice that one of your child’s eyes turns in, out, up or down. This misalignment may be present all the time, or it may come and go.

Some babies have what’s referred to as false strabismus (pseudostrabismus). Although their eyes are perfectly aligned, they appear cross-eyed because of the way their face is shaped. They might have extra skin around the inner folds of the eyes or a wide bridge of the nose. As your child gets older, the appearance of being cross-eyed should fade.

How serious is it? A child can’t outgrow true strabismus, and the condition typically gets worse if left untreated. At first, a misaligned eye can lead to double vision. But eventually the brain will learn to ignore the image from the turned eye, and the eye may become “lazy” (amblyopic). This may result in permanently reduced vision.

When to call If by 4 months of age your baby’s eyes appear crossed, even if only sometimes, make an appointment with your child’s medical provider. He or she may refer you to a pediatric eye doctor for an evaluation. It’s important to get an accurate diagnosis as soon as possible. The earlier treatment is started, the better the outcome for your child.

Rarely, a child’s eyes may suddenly become misaligned after having been straight. If this happens, call your child’s medical provider right away, as it may signal a more serious problem.

To treat strabismus, your child’s eye doctor may recommend prescription eyeglasses, eyedrops, eye patches or surgery on the eye muscle. Surgery is usually reserved for when other treatments aren’t working. It’s safe and effective, but a second procedure is sometimes required to get the eyes exactly aligned.

What you can do You can’t treat strabismus at home, but you can monitor your child’s eyes. Request an evaluation as soon as you suspect any problems with your son’s or daughter’s eyes. If your child requires treatment, do your best to make sure your child complies by wearing his or her glasses or by administering eyedrops exactly as your doctor recommends. If necessary, surgery is usually performed between 6 and 18 months of age. An eye surgeon will help you learn exactly what you need to know about the procedure.

Croup

The most common characteristic of croup, a viral infection of the upper respiratory tract, is a harsh, repetitive cough that’s often likened to a seal barking. Because the cough is so harsh, it can be scary for children and their parents. But croup usually isn’t serious, and most cases can be treated at home.

The barking cough of croup is the result of inflammation around the vocal cords and windpipe. When the cough reflex forces air through this narrowed passage, the vocal cords vibrate with a barking noise. Because young children have small airways to begin with, they tend to have more marked symptoms.

As with a cold, croup is contagious until the fever is gone, or a few days into the illness. The virus is passed by respiratory secretions or droplets in the air.

How to recognize it The classic sign of croup is a loud, harsh, barking cough — which often comes in bursts at night. Your child’s breathing may be labored or noisy. Other cold-like symptoms — such as a runny nose, fever and hoarse voice — are common, too.

How serious is it? Most cases of croup are mild, and your child likely won’t need to see a medical provider unless symptoms are severe. Croup generally lasts three to seven days (plan on at least a couple of “bad” nights) and then resolves on its own.

Rarely, the airway swells enough to interfere with breathing, warranting a trip to an urgent care clinic or emergency department. Pneumonia is a rare but potentially serious complication.

When to call If your child’s skin is turning blue or grayish around the nose, mouth or fingernails, or he or she is struggling to breathe, dial 911 or your local emergency number.

Call immediately or seek medical care if your child:

Makes noisy, high-pitched breathing sounds when inhaling or exhaling (stridor)

Begins drooling or has difficulty swallowing

Seems agitated or extremely irritable

Becomes unusually sleepy or lethargic

Has a fever of 103.5 F or higher

Call as soon as you’re able if you’re concerned that your child:

Can’t sleep, and your efforts won’t settle him or her

Is getting worse night after night, despite home treatment

Isn’t taking fluids well for 24 hours

What you can do While your child’s sick, try to:

Stay calm Comfort or distract your child — cuddle him or her, read a book, or play a quiet game. Crying makes breathing more difficult.

Moisten or cool the air Although there’s no evidence of benefit from these practices, many parents believe that humid air or cool air helps a child’s breathing. Use a cool-air humidifier in your child’s bedroom or bring your child into a steamy bathroom so he or she can breathe the warm, moist air.

If it’s cool outdoors, you can open a window to allow fresh air in or wrap your child in a blanket and walk outside for a few minutes (although if your child is wheezing, cold air may make the wheezing worse).

Hold your child in an upright position Sitting upright can help make breathing easier. Hold your child on your lap, or place your child in a favorite chair or infant seat.

Offer fluids For babies, breast milk or formula is fine. For older children, soup or frozen ice pops may be soothing.

Encourage rest Sleep can help your child fight the infection.

Diarrhea

Diarrhea is a common concern for new parents. Since bowel movement patterns can vary widely among young infants — from a single bowel movement once a week or so to over 10 a day, especially in breast-fed babies — it can be tricky to tell when diarrhea is a problem. A “blowout” every so often is nothing to worry about, but if you notice stools that are more frequent than usual and have a watery consistency, your child may have diarrhea.

Diarrhea is most often caused by an infection of your child’s stomach and intestines (gastroenteritis), usually by a virus. Sometimes bacteria or parasites may cause diarrhea. Although your child will seldom have diarrhea from a specific food allergy, it can be caused by certain dietary factors, such as increased juice intake, lactose intolerance or the addition of new foods. Antibiotics also may cause diarrhea.

How to recognize it If you’re changing more dirty diapers than usual and the contents in the diaper (or the potty) are consistently thin and watery, your child likely has diarrhea. Diarrhea caused by an infection may also be accompanied by vomiting and fever. Bacterial infections may cause blood in the stool and abdominal pain, as well. Occasionally, children have small streaks of blood in their stool, caused by skin irritation from frequent passing of stool or by irritation of the intestinal lining.

How serious is it? Dehydration is the main complication that can result from your child’s diarrhea, especially if your child has also been vomiting. Your child has a much smaller reserve of fluids than you do because his or her body’s volume is much less. Milk or lactose intolerance can cause explosive diarrhea that persists for more than two weeks. Diarrhea in toddlers can also result from excessive juice or fruit intake.

When to call Contact your child’s medical provider immediately if your child:

Passes more than eight diarrheal stools in eight hours or has blood in the stool.

Seems to have abdominal pain and a temperature of more than 102 F, or other obvious signs of illness (or just a temperature of 100.4 F or higher for a child less than 2 months old).

Can’t keep any fluids down.

Shows signs of dehydration. This includes reduced urination or three or fewer wet diapers in 24 hours, no tears when crying, dry mouth, or sunken eyes or fontanels (the soft spots in the head).

Seems unusually sleepy or noticeably less active than usual.

If your child has mild diarrhea for more than a week and you’re concerned, you might also contact your child’s medical provider.

What you can do To avoid dehydration, offer your child plenty of fluids that are easily absorbed.

If your child has mild diarrhea and is hungry, there’s no need to restrict his or her diet. Continue feeding your baby as you normally would with breast milk or formula. If your child is eating solid foods, offer bland foods if that’s what your child prefers. Offering yogurt may help, but there’s no consensus that probiotics — found in foods such as yogurt — can help with diarrhea. Offer frequent, small feedings, meals or snacks rather than large ones. Aim to get your child back to his or her normal diet within a few days to ensure adequate nutrition.

If your child has moderate diarrhea, use a commercially prepared oral rehydration solution (Pedialyte, others) to replace the sodium and electrolytes lost in your child’s stool. These solutions are available over-the-counter and can be used until your child’s symptoms improve. Your child’s medical provider or a pharmacist can answer questions you may have.

Call your child’s medical provider if diarrhea is severe or symptoms get worse. Call right away if you notice signs of dehydration (see When to call.)

Ear infection

An ear infection (acute otitis media) is a common reason children visit their medical providers. An ear infection is caused by a bacteria or virus that affects the middle ear, the air-filled space behind the eardrum that contains the tiny vibrating bones of the ear. Children are more likely than are adults to get ear infections.

Ear infections often occur after a cold or other respiratory infection. These illnesses set the stage for inflammation and buildup of fluids in the middle ear.

Ear infections often clear up on their own. For infants, or in severe cases, however, your child’s medical provider may recommend antibiotic medications.

How to recognize it Infants with an ear infection usually develop the infection after an upper respiratory tract infection, such as a cold. Here are some signs and symptoms to look for.

Ear pain, especially when lying down

Difficulty sleeping

Unusual crying or fussiness

Difficulty hearing or responding to sounds

Drainage of fluid from the ear

Loss of appetite

Tugging or pulling at an ear

How serious is it? Mild ear infections usually improve within the first couple of days. Symptoms that are severe or persist are often treated with antibiotics.

Long-term problems related to chronic ear infections — persistent fluids in the ear, persistent infections or frequent infections — can cause hearing problems and other serious complications. So it’s important to bring ear infections, especially recurring ones, to the attention of your child’s medical provider.

When to call Contact your child’s medical provider if:

Symptoms last for more than a day

Ear pain is severe

Your infant or toddler is sleepless or irritable after a cold or other upper respiratory infection

You observe a discharge of fluid, pus or bloody fluid from the ear

In babies, most ear infections are treated with antibiotics. Among older children, a doctor may wait to see if the condition improves on its own before prescribing antibiotics.

Ear tubes — tiny tubes that are surgically placed through the eardrum to help ventilate the middle ear and prevent the accumulation of fluid — are usually reserved for children who have recurrent ear infections and persistent fluid behind the eardrum, or hearing problems.

What you can do Placing a warm (not hot), moist washcloth over the affected ear may lessen pain. If your child’s medical provider recommends a pain reliever, use it exactly as the provider instructs.

To reduce your child’s risk of ear infections, practice good infection prevention skills by washing hands frequently, not sharing eating and drinking utensils, and avoiding contact with others who are sick. Secondhand smoke also may contribute to frequent ear infections. In addition, hold your child upright when feeding him or her a bottle, to avoid blocking the passage between the middle ear and throat (eustachian tube).

Earwax blockage

Earwax blockage occurs when earwax (cerumen) accumulates in the ear or becomes too hard to wash away naturally.

Earwax is a helpful and natural part of the body’s defenses. It protects the ear canal by trapping dirt and slowing the growth of bacteria. Normally, it will dry up and tumble out of the ear on its own. But occasionally, wax buildup occurs, perhaps because of a narrower than usual ear canal, an excess production of earwax or even well-meaning attempts to clean out the ear, which can push the wax further into the ear and cause a blockage.

How to recognize it Although it may not be easy to identify in your child, signs and symptoms of earwax blockage are likely to resemble some of those related to an ear infection. Your child may pull or tug at his or her ear, cough, or be unusually fussy or irritable. You may also notice that your child doesn’t hear quite as well or doesn’t respond to sounds.

How serious is it? A buildup of earwax is unlikely to cause serious problems, unless you try to dig it out yourself. Trying to remove earwax with a cotton swab or other instrument may push the wax further into your child’s ear and cause serious damage to the lining of the ear canal or eardrum.

When to call Make an appointment to have your child’s ears checked if your child is tugging at his or her ears or you notice hearing problems.

Your child’s medical provider can determine if there’s an excess of earwax by looking in your child’s ear with an otoscope, a special instrument that lights and magnifies the eardrum. The provider can often remove excess wax using a small instrument called a curet or by using suction. He or she may also flush out the wax using a water pick or a rubber-bulb syringe filled with warm water.

What you can do Avoid cleaning your child’s ears with cotton swabs, your finger or anything else. If your child doesn’t have tubes or holes in his or her eardrum, his or her medical provider may recommend eardrops to soften the wax. The provider can show you how to irrigate the outer ear with warm water and a rubber-bulb syringe to wash out the softened wax.

Fever

Normal temperatures vary for different people. Your newborn’s temperature will vary by about 1 degree throughout the day. It’s usually lowest in the morning and highest late in the afternoon. In general, infants and young children have a higher normal body temperature than do older children and adults.

When faced with an infection or other illness, however, your child’s central nervous system cranks up his or her internal “thermostat” to help fight the infection. This results in a fever. In newborns and infants less than 2 months of age, a fever warrants an immediate call to your child’s medical provider. In older infants and children, the need for medical evaluation of a fever depends more on how your child is behaving and whether there are other accompanying signs or symptoms of illness.

How to recognize it If your child feels unusually warm to you, take his or her temperature with a thermometer (see this discussion). Although laying your hand or your cheek on your child’s forehead may give you a suspicion of fever, it won’t tell you the difference between 99 F and 101 F. A temperature of 100.4 F or higher constitutes a fever.

How serious is it? A fever itself isn’t harmful. Any potential harm would come from the infection that’s causing the fever. Usually, when a child has a fever, he or she is fighting an infection; a fever is a sign of the immune system at work.

In young infants, especially those under 2 months, an infection signaled by a fever can quickly become serious. Their immune systems are not yet up to the task of fighting off bacteria and other germs, making them particularly vulnerable to an infection that can easily spread throughout the body.

An elevated temperature after being in a hot environment is different from a fever caused by an infection. A temperature driven by the body’s thermostat in response to an infection rarely climbs high enough to be dangerous. But a high temperature from being in a hot car, for example, can be deadly.

When to call Call your child’s medical provider right away if your child is under 2 months of age and has a rectal temperature of 100.4 F or higher. This is important because your child’s immune system is still developing and may not be able to fight off an infection as well as an older child. So call, even if you’re feeling reluctant to bother your child’s medical provider.

For older infants and children, call if you have concerns or if your child’s fever lasts more than three days. Seek urgent care if your child experiences:

Repeated vomiting or diarrhea

Unusual fussiness or irritability

Dehydration — fewer than three wet diapers in 24 hours, dry mouth, crying without tears, sunken eyes and, in young babies, sunken fontanels (the soft spots in the head)

Lethargy and unresponsiveness

If your child seems feverish after spending time in an overheated area, such as on a hot beach or in a hot car, seek medical help immediately. Overheating (heatstroke) is an emergency and needs to be treated quickly.

What you can do If your child has a fever, monitor his or her behavior closely. Look for other signs or symptoms of illness, such as loss of appetite, vomiting, irritability or unusual sleepiness. Call your child’s medical provider if you have any concerns. Most of the time, mild fevers don’t need treatment and resolve along with the associated cold or other infection that brought it on. In the meantime, you can:

Provide plenty of fluids Continue breast-feeding or formula-feeding as usual. For infants over 6 months, you can also offer water or an oral rehydration solution (Pedialyte, others). For toddlers, offer water, Pedialyte or frozen ice pops. Prioritize fluid intake over solid foods. Sick toddlers often don’t eat well. Let your child decide whether and how much solid food to eat.

Encourage adequate rest Provide extra opportunities for rest and quiet play until the fever is improved or over.

Keep cool If your child seems hot, keep his or her room comfortably cool and dress him or her lightly.

Use medication for discomfort If your child seems uncomfortable, is older than 2 months and weighs 6 pounds or more, you can give him or her acetaminophen (Tylenol, others). If your child is 6 months or older, ibuprofen (Advil, Motrin, others) is OK. Read the label carefully for proper dosage (see this table). Don’t use aspirin to treat a fever in anyone age 18 years or younger, as it can cause a rare but serious disorder called Reye’s syndrome. Keep in mind that it’s generally not a good idea to give fever-reducing medication for more than three days without consulting your child’s medical provider.

• • • • •

Febrile seizures

Some babies experience convulsions as a result of a rapid rise in body temperature, often from an infection. Watching your baby have a febrile seizure can be alarming, but the good news is that it’s usually harmless and typically doesn’t indicate a long-term or ongoing problem. Studies suggest there also isn’t much that can be done to prevent a febrile seizure.

You can tell your baby is having a febrile seizure if he or she has repeated rhythmic jerking of arms and legs and is not responsive to you or aware of his or her surroundings. (Occasional odd twitchy or jerky movements are common, especially in sleepy infants — these are rarely due to seizures.)

Most of the time, a febrile seizure occurs the first day of an illness, sometimes even before parents realize that their child is ill.

If your child has a febrile seizure, stay calm and follow these tips to help your child during the seizure:

Place your child on his or her side, somewhere where he or she won’t fall.

Stay close to watch and comfort your child.

Remove any hard or sharp objects near your child.

Loosen any tight or restrictive clothing.

Don’t restrain your child or interfere with your child’s movements.

Don’t attempt to put anything in your child’s mouth.

Have a first-time febrile seizure evaluated by your child’s medical provider as soon as possible, even if it lasts only a few seconds. If the seizure ends quickly, call the provider as soon as it’s over and ask when and where your child can be examined. Do your best to take note of how long the seizure lasted, and what the movements looked like. If the seizure lasts longer than five minutes or is accompanied by vomiting, a stiff neck, problems with breathing or extreme sleepiness, call for an ambulance to take your child to the emergency department.

By staying calm, observing your child and knowing when to call for medical help, you’re doing everything that’s needed to take care of your child.

• • • • •

Fifth disease

Fifth disease is a highly contagious and common childhood ailment caused by parvovirus — you may also hear it referred to as parvovirus infection or slapped-cheek disease because of the rosy rash that appears on the cheeks. In most children, the infection is mild and requires little treatment.

How to recognize it You may suspect that your child has fifth disease if he or she develops bright red, warm patches on both cheeks. During the next few days, a child with fifth disease will develop a pink, lacy, slightly raised rash on the arms, trunk, thighs and buttocks.

Generally, the lacy rash occurs near the end of the illness when the child is no longer contagious. Some children develop mild cold-like symptoms before the rash, such as a sore throat, fever, headache and fatigue. Itchiness also may be an early symptom.

It’s possible to mistake the rash for other viral rashes or a medicine-related rash. The rash may come and go for up to three weeks, becoming more visible when your child is exposed to extreme temperatures or spends time in the sun.

How serious is it? Generally, infants feel fairly well when they have fifth disease. For most, it’s a mild illness unless your child has sickle cell anemia or a weak immune system, in which case it may cause more-serious problems.

Parvovirus can be a concern for pregnant women, though, so keep a sick child away from anyone who’s pregnant, particularly in the first trimester. If a woman develops a parvovirus infection during pregnancy, her child may be affected.

When to call Call your child’s medical provider if your child is under 2 months old and has a rectal temperature of 100.4 F or higher. The provider may want to examine your child to rule out more-serious causes of fever (see this discussion).

Typically, once the rash appears, the illness has mostly run its course and no treatment is needed. However, call the medical provider if your child has a fifth disease-like rash and another condition such as sickle cell anemia or a weak immune system.

What you can do Make sure your child gets plenty of rest and drinks lots of fluids. You can use acetaminophen (Tylenol, others) if appropriate to relieve fever or minor aches and pains (see this table).

It’s not always practical or necessary to isolate a child with fifth disease. You won’t know your son or daughter has parvovirus infection until the rash appears, and by that time, he or she is no longer contagious.

Flu (influenza)

Influenza, routinely known as the flu, is a common fall and wintertime viral illness that affects the upper respiratory system. It’s often confused with the common cold, although the flu usually leaves your child feeling more achy and miserable than does a cold.

Several types of viruses can cause influenza (A and B are the most common), with each type having several strains. Influenza viruses are constantly changing, with new strains appearing regularly. This is why it’s important to receive an annual flu vaccine — each year’s vaccine is developed to prevent the three or four strains most likely to appear that year. The Centers for Disease Control and Prevention (CDC) recommends annual flu vaccination for everyone age 6 months or older (see this discussion). It’s typically available as an injection. Some years, it’s available as a nasal spray. Ask your child’s medical provider about the best form for your child.

How to recognize it Having the flu usually causes:

A sudden onset of fever, typically more than 101 F, although not everyone gets a fever

Chills

Achy muscles

Extreme tiredness

Dry cough

How serious is it? Influenza can be a serious illness for your otherwise healthy child, although most babies recover without major problems. The main complications of influenza are ear infections and pneumonia; both require treatment from your child’s medical provider. Children with underlying health problems are at greater risk of complications.

Influenza infections are contagious a day or so before your child becomes sick and while he or she is sick.

When to call Children under age 2 are at higher risk of complications from the flu. Call your child’s medical provider for advice if you notice flu-like signs or symptoms. Call right away if you suspect your child is getting worse or if coughing or fever persists. If your child has flu-like symptoms and trouble breathing, seek medical care immediately. If you know your infant has been exposed to influenza, contact your child’s medical provider.

What you can do The best way to prevent the flu is to receive the flu vaccine, recommended to everyone 6 months of age or older. If your whole family receives the vaccine, you’re less likely to get the flu and pass it to each other. If your child is under 6 months of age, it’s especially important to take commonsense precautions against infections:

Wash your hands frequently.

Keep heavily used surfaces clean.

Cough or sneeze into a tissue or the crook of your elbow (discard used tissues promptly).

Don’t share eating or drinking utensils or toothbrushes.

Avoid cross-contamination between sick family members by not kissing each other on the hands or mouth.

Avoid people who have the flu.

Avoid crowds at peak flu season, where the chances of coming into contact with influenza viruses are greater.

If your child does develop influenza, encourage plenty of rest, fluids and hugs. If your child seems fussy and uncomfortable, acetaminophen or ibuprofen, depending on your child’s age, can help ease aches and pains, as well as reduce fever (see this table). Don’t give aspirin, which can cause serious side effects in children. Keep your child out of child care for at least 24 hours after the fever has passed.

Hand-foot-and-mouth disease

Hand-foot-and-mouth disease is a usually mild, contagious viral infection. Characterized by sores in the mouth and a rash on the hands and feet, it’s common in young children. Hand-foot-and-mouth disease is most commonly caused by coxsackievirus.

The infection isn’t related to an infectious viral disease found in farm animals (foot-and-mouth disease, or hoof-and-mouth disease). You can’t get hand-foot-and-mouth disease from pets or other animals, and you can’t transmit it to them.

Once your child is exposed to the virus that caused the hand-foot-and-mouth disease, he or she will build up immunity to it in the future.

How to recognize it A fever is often the first sign of hand-foot-and-mouth disease, followed by a sore throat, irritability and sometimes a poor appetite. One or two days after the fever begins, painful sores may develop in the mouth or throat. A rash on the hands and feet and possibly on the buttocks can follow within one or two days.

How serious is it? Hand-foot-and-mouth disease is usually a minor illness causing only a few days of fever and relatively mild signs and symptoms.

The sores in the mouth and throat can make swallowing painful and difficult for your child, however, increasing his or her risk of dehydration. Watch closely to make sure your child frequently sips fluid during the course of the illness.

Infected people are most contagious during the first week of illness.

When to call Contact your child’s medical provider if mouth sores or a sore throat keeps your child from drinking fluids. Call also if after a few days, your child’s signs and symptoms worsen.

What you can do As with most viral illnesses, there’s not much you can do but encourage plenty of fluids and plenty of rest. Acetaminophen or ibuprofen, depening on your child’s age, can help relieve discomfort from fever or aches and pains (see this discussion for more on medications).

For kids eating solid foods, certain foods may irritate blisters on the tongue or in the mouth or throat. You can help make blisters less bothersome and eating more tolerable by:

Offering frequent feedings of breast milk or formula. Drinking is more important than eating solids.

Offering ice pops or a small amount of sherbet to soothe the throat.

Avoiding acidic foods and beverages, such as citrus fruits and fruit drinks.

Offering soft foods that don’t require much chewing.

Hives

Hives is the name for a skin reaction that produces patches of red, raised, itchy skin. The medical term for the condition is urticaria. Often there’s no clear explanation for what triggers hives, but viral infections are a common cause. Hives can also occur as an allergic reaction to a food, drug, airborne allergen, insect bite or sting.

This photo shows an infant with hives, characterized by patches of red, raised skin.

How to recognize it Hives is characterized by splotchy, red, raised areas of skin, often with pale centers. The rash usually itches and can become uncomfortable. Hives can appear all over your child’s body or be concentrated in one area. The rash is irregularly shaped and can change locations. Some areas may enlarge and merge into each other. Hives may come and go for a few days or a few weeks.

How serious is it? Hives usually isn’t serious unless swelling develops around your child’s throat area and windpipe. If this occurs, it can make it difficult for your child to breathe and swallow.

When to call If your child develops hives, ask his or her medical provider about the proper treatment. Call the provider right away if your child:

Has difficulty breathing or swallowing or develops a swollen tongue

Develops hives while taking medication

Seems to have sore joints

Has hives for more than a few days

What you can do Kids with hives often look much worse than they feel. To keep your child as comfortable as possible, administer an antihistamine as indicated by your child’s medical provider. Keep your child dressed in light clothing and avoid bathing him or her in hot water. Lukewarm water is less likely to aggravate the itching. Trim your child’s fingernails to minimize irritation from scratching.

If you notice a pattern to the appearance of hives, try to determine what may be triggering it. Avoiding the trigger will help prevent a recurrence of hives.

Impetigo

Impetigo is a common and highly contagious skin infection that mainly affects infants and young children. It usually appears as a round, red rash covered in a flaking, honey-colored crust (see the photo here). It tends to develop on the face, especially around the nose and mouth. It often occurs when bacteria enter the skin through cuts or insect bites, though it can develop in skin that’s intact.

Keeping the skin clean is the best way to prevent infection. Treat cuts, scrapes, insect bites and other wounds right away by washing the affected areas and applying antibiotic ointment to prevent infection.

How to recognize it Your child might have impetigo if you notice:

Red sores that quickly rupture, ooze for a few days and then form a yellowish-brown crust

Itching

Painless, fluid-filled blisters, usually on the trunk, arms and legs (more common in children under 2 years old)

Painful fluid- or pus-filled sores that turn into deep ulcers (the more serious form)

How serious is it? Mild impetigo is seldom serious and usually clears on its own in two to three weeks. But because impetigo can sometimes lead to more severe infection, your child’s doctor may choose to treat impetigo with an antibiotic ointment or oral antibiotics. To prevent the infection from spreading, keep your child home from child care or preschool until he or she is no longer contagious — usually 24 hours after beginning treatment with an antibiotic.

When to call If you suspect that you or your child has impetigo, ask your child’s medical provider for advice on treatment. Sometimes he or she may choose to treat minor cases of impetigo with only hygienic measures. Keeping the skin clean can help mild infections heal on their own. In other cases, the provider may recommend an antibiotic ointment to apply to the affected areas.

If your child is uncomfortable, or the sores are oozing or widespread, make an appointment to have the sores examined. Severe or widespread cases may be treated with oral antibiotics taken by mouth. Be sure you child finishes the entire course of medication, even if the sores are healed. This helps prevent the infection from recurring and makes antibiotic resistance less likely.

What you can do For minor infections that haven’t spread, an over-the-counter antibiotic cream or ointment may help. Try the following steps.

Wash or soak the affected areas of skin with warm, soapy water. This helps the crust detach so that the antibiotic can penetrate the skin.

After washing the area, apply an over-the-counter antibiotic ointment three times daily. Wash the skin before each application, and pat it dry.

To help keep the infection from spreading to others:

Wash your hands frequently, especially after treating the sore.

Trim your child’s nails to prevent scratching and spreading the infection. Applying a nonstick dressing to the infected area can help, too.

Avoid touching the sores as much as possible until they heal.

Wash your child’s towels and washcloths every day, and don’t share them or other items, such as blankets or toys, with family members.

Your son or daughter can usually return to child care after his or her medical provider says he or she is no longer contagious — often within 48 to 72 hours of starting antibiotic therapy.

Insect bites and stings

Stings from bees, wasps, hornets, yellow jackets and bites from fire ants are typically the most troublesome. Bites from mosquitoes, ticks, biting flies and some spiders also can cause reactions, but these are generally milder.

How to recognize it Bites and stings may come from:

Bees, yellow jackets and hornets. In most children, stings cause initial pain and become red and swollen within the first several hours. But in a few kids, stings can cause severe symptoms of anaphylaxis, including vomiting, diarrhea, dizziness and sometimes trouble breathing (see When to call).

Mosquitoes. Usually the site simply itches and swells. In some children, the swelling can be substantial.

Deerflies, horseflies, fire ants, harvester ants, beetles and centipedes. These may cause painful red bumps that may blister.

How serious is it? Most children will have only a mild reaction to bites and stings. But a few children are more sensitive than are others to insect venom, especially from stinging insects, and can have a severe allergic reaction (anaphylaxis) that requires emergency treatment.

When to call Call your child’s medical provider immediately if your child:

Has difficulty breathing

Vomits

Shows signs of shock (rapid breathing, dizziness, clammy skin)

Has received multiple bee, wasp or hornet stings

Develops extreme facial swelling

Develops hives all over the body or in an area separate from the sting itself

Has increased swelling and redness around the sting or bite after the first six to eight hours

What you can do If a stinger is noticeable, remove it from your child’s skin as soon as possible. Use a fingernail, credit card or other thin dull edge to scrape the stinger away. Avoid pinching or squeezing the stinger, as this may release more venom into the skin. Once the stinger is gone, apply a cool washcloth or ice pack to relieve pain and swelling. Cool compresses can also help relieve itching associated with other insect bites.

Ask your child’s medical provider about applying ointments or creams to relieve itching, such as calamine lotion, hydrocortisone cream or baking soda paste. If itching is severe, the provider may recommend giving your child an oral antihistamine. To decrease the likelihood of bites, take these steps:

Cover your child’s skin with lightweight clothing when you take him or her outdoors.

Avoid areas where insects are commonly found, such as garbage cans, stagnant water (breeding ground for mosquitoes) and blooming flowers.

Don’t use strong perfumes or scented soaps and lotions on yourself or your child.

Cover all picnic food, and seal picnic garbage in plastic bags.

Keep garbage cans securely covered.

Don’t allow pools of stagnant water in your backyard.

DEET is the most widely used chemical found in insect repellents. Products that contain DEET aren’t recommended for babies under 2 months old. In older infants, the American Academy of Pediatrics (AAP) recommends choosing a 10% to 30% concentration of DEET.

Apply DEET only once a day and wash it off at the end of the day to avoid toxicity. The higher the concentration of DEET in a product, the longer the duration of protection it supplies. The AAP recommends using the lowest effective concentration for the amount of time your child spends outside. A 10% DEET product provides about two hours of protection; a 30% DEET product protects for about five hours.

To apply repellent to your child, put it on your hands first and then rub it on your child’s skin. Avoid your child’s eyes and hands, which he or she is likely to put in his or her mouth.

There are alternatives to DEET products. Picaridin in 5% to 10% concentrations is safe for young children. Oil of lemon eucalyptus is a plant-based repellent, but it’s not recommended for children under 3 years of age.

Jaundice

Jaundice is a yellow discoloration of a newborn child’s skin and eyes. Newborn jaundice is a common condition, particularly in babies born before 38 weeks gestation and breast-fed babies. It develops when a child’s liver isn’t mature enough to filter out a yellow-colored pigment of red blood cells called bilirubin from the bloodstream.

How to recognize it The main signs of newborn jaundice are yellowing of the skin and eyes. These usually appear between the second and fourth day after birth. You’ll usually notice jaundice first in your child’s face. If the condition gets worse, you may notice the yellow color in his or her eyes and on the chest, abdomen, arms, and legs.

The best way to check for newborn jaundice is to press your finger gently on your child’s forehead or nose. If the skin looks yellow where you pressed, it’s likely that your child has jaundice. If your child doesn’t have jaundice, the skin color should simply look slightly lighter than its normal color for a moment.

It’s best to examine your child in good lighting conditions, preferably in natural daylight.

How serious is it? Mild newborn jaundice often disappears on its own within two or three weeks. If your child has moderate or severe jaundice, he or she may need to stay longer in the newborn nursery or be readmitted to the hospital for phototherapy. This is a special blue light that helps the body clear the bilirubin.

Although complications are rare, severe infant jaundice can lead to cerebral palsy, deafness and brain damage.

When to call Most hospitals have a policy of checking babies regularly for jaundice while they are hospitalized and before they’re discharged. The American Academy of Pediatrics recommends that your newborn be examined for jaundice whenever a routine medical check is done.

Your child should be checked for jaundice when he or she is between 3 and 7 days old, when bilirubin levels usually peak. If your child is discharged earlier than 72 hours after birth, schedule a follow-up appointment with your child’s medical provider within two days of discharge to check for jaundice.

The following signs or symptoms may indicate severe jaundice or complications from jaundice. Call your doctor if:

Your child’s skin looks yellow on the chest, abdomen, arms or legs

The whites of your child’s eyes look yellow

Your child seems listless, sick or difficult to wake

Your child isn’t gaining weight or is feeding poorly

Your child makes high-pitched cries

Your child develops any other signs or symptoms that concern you

Diagnosed jaundice lasts more than three weeks

What you can do Feeding more frequently will provide your child with more milk and cause more bowel movements, increasing the amount of bilirubin eliminated in your child’s stool. Breast-fed infants should have eight to 12 feedings a day for the first several days of life. Formula-fed infants usually should have 1 to 2 ounces of formula every two to three hours for the first week.

If your child is having trouble breast-feeding, is losing weight or is dehydrated, your child’s medical provider may suggest giving your child infant formula or expressed milk in addition to his or her breast-feedings. In some cases, a provider may recommend giving only infant formula for a couple of days and then resuming breast-feeding. Ask your child’s medical provider what feeding options are right for your child.

Lazy eye

Lazy eye (amblyopia) develops when nerve pathways between the brain and the eye aren’t properly stimulated. This can lead to a condition in which the brain favors one eye, usually due to poor vision in the other eye. The weaker eye tends not to track with the stronger eye, commonly referred to as “wandering.” Eventually, the brain may ignore the signals received from the weaker — or lazy — eye.

Treatments such as corrective eyewear or eye patches can often correct lazy eye. Sometimes, lazy eye requires surgical treatment.

How to recognize it Lazy eye usually affects just one eye, but it may affect both eyes. With lazy eye, there’s no apparent damage or abnormality to the eye. Signs and symptoms to look for include:

An eye that wanders inward or outward

Eyes that may not appear to work together

Poor depth perception

How serious is it? Left untreated, lazy eye can cause permanent vision loss. In fact, lazy eye is the most common cause of single-eye vision impairment in young and middle-aged adults, according to the National Eye Institute.

Depending on the cause and the degree to which your child’s vision is affected, treatment options may include:

Corrective eyewear If a condition such as nearsightedness, farsightedness or astigmatism is contributing to lazy eye, an eye doctor will likely prescribe corrective glasses. Sometimes corrective eyewear is all that’s needed.

Eye patches To stimulate vision in the weaker eye, your child may wear an eye patch over the stronger eye — possibly for two or more hours a day, depending on the severity of the condition. This helps the part of the brain that manages vision develop more completely.

Eyedrops A daily or twice-weekly drop of a medication that temporarily blurs vision in the stronger eye is used to encourage use of the weaker eye. It offers an alternative to wearing a patch.

Surgery If your child has crossed or outwardly deviating eyes (strabismus), the eye muscles may benefit from surgical repair. Droopy eyelids or cataracts also may need surgical intervention.

For most children with lazy eye, proper treatment improves vision within weeks to several months — and the earlier treatment begins, the better. Although research suggests that the treatment window extends through at least age 17, results are better when treatment begins in early childhood.

When to call If you notice your child’s eye wandering at any time beyond the first few weeks of life, consult your child’s medical provider for an evaluation. Depending on the circumstances, he or she may refer your child to a doctor who specializes in eye conditions (ophthalmologist or optometrist).

What you can do There’s really nothing you can do at home to treat lazy eye. However, you can monitor your child’s eyes closely in the first few months of life to make sure they are in proper alignment and to make sure your child’s vision seems to be consistently improving. The sooner treatment for lazy eye begins, generally the better the outcome for your child.

Pink eye (conjunctivitis)

Pink eye is an inflammation or infection of the transparent membrane (conjunctiva) that lines your eyelid and part of your eyeball. It’s frequently caused by a viral infection — usually the same virus that causes the common cold. In fact, pink eye may develop after a cold. But conjunctivitis can also result from bacteria or allergies.

How to recognize it You might suspect that your child has pink eye if you notice that the white part of the eye and the eyelid are reddened in one or both eyes. Allergic conjunctivitis — pink eye due to allergies — typically affects both eyes at once.

Pink eye can also cause mucus, or “matter,” to form in your child’s eye, varying from thin and watery to thick and yellowish green. With viral conjunctivitis, eye matter is usually worse in the morning. You may find your child’s eyelids stuck together on awakening, requiring you to wash them clean.

Also suspect pink eye if your child experiences discomfort with exposure to bright lights or if he or she does a lot of blinking.

How serious is it? Pink eye generally lasts about as long as a cold, usually a week or so, but sometimes up to two or three weeks. If infectious, pink eye is contagious by contact.

Viral infections, which account for most cases of pink eye, just need time to run their course. Bacterial infections may or may not be treated with antibiotic drops. Mild bacterial conjunctivitis often gets better on its own in a few days.

If pink eye is due to allergies, your child’s medical provider may recommend specific eyedrops for people with allergies.

When to call Make a call if your child:

Develops a red and swollen eyelid

Develops a fever or starts acting ill

Has the symptoms of an ear infection

Doesn’t seem to improve after starting treatment

What you can do Wash the outside of your child’s eyelid, using clean cotton balls (a new one for each eye) and warm water. Or you can use washcloths and warm water. Wipe from the inner to the outer part of the eye to prevent spreading infection to the uninfected eye. Because pink eye is usually contagious, you and others who care for your child should take precautions to avoid spreading it. A child with pink eye should have his or her own towel and washcloth, both at home and away. Wash your hands carefully after you come into contact with secretions from your child’s eyes.

In some cases of bacterial infection, your child’s medical provider may recommend antibiotic drops or ointment. Some parents find ointment easier to use than eyedrops, although ointment can blur your child’s vision for up to 20 minutes or so after application. In either case, the discharge should improve within a day or two, although the redness may persist a few days more. Follow the instructions of your child’s medical provider and use the antibiotics until the prescription runs out to prevent recurrence of the infection.

Applying the drops or ointment in your child’s eye is sometimes easier with two people. Wash your hands before applying ointment or drops. (The other person should do the same.) To prevent contamination of the medication, don’t let the applicator tip touch any surface, including the child’s eye. When you finish, wipe the tip of the tube with a clean tissue and tightly close it. Wash your hands after touching your child’s eyes. Follow these application tips.

Eyedrops. Lay your child on his or her back. Gently pull the lower eyelid down to form a little pouch, and place the drops in the pouch. The drops will disperse over the eye as your child blinks.

Ointment. Pull your child’s lower eyelid away from the affected eye to form a pouch. Unless your child’s medical provider tells you otherwise, squeeze a thin strip of ointment into the pouch. Release your child’s lower eyelid, and then ease the upper eyelid down to cover your child’s eye. Hold the lid closed for just a moment or two.

Pneumonia

Young children who get pneumonia are usually sick first with a cold or other viral upper respiratory tract infection. Some viral infections can then affect the lungs, resulting in viral pneumonia. Pneumonia can also stem from a bacterial infection, perhaps after a cold.

In children under 2 years of age, bacterial pneumonia is less common than the viral kind. Bacterial pneumonia may be helped by antibiotics.

How to recognize it Pneumonia is usually worse than a bad cold. A child with pneumonia may cough and have a fever. Breathing may become fast and labored. You might notice that your child’s lips or nails have a bluish tint. Your child may also appear pale, develop a fever, lose his or her appetite, and become either more listless or fussier than usual.

How serious is it? In the past, pneumonia could be a dangerous illness. Now, most babies recover well if they receive prompt medical attention.

When to call Call immediately if you suspect that your child may have pneumonia or your child is less than 2 months old and has a rectal temperature of 100.4 F or higher. Be sure to check back with your medical provider if:

Your child’s fever continues more than two or three days, despite taking an antibiotic

Your child has difficulty breathing

What you can do If your child’s medical provider suspects bacterial pneumonia, he or she may prescribe a course of antibiotics for your child. Antibiotics don’t help viral infections, but sometimes it’s difficult to distinguish between viral and bacterial pneumonia. Be sure to give your child the full course of antibiotics, even if he or she starts to feel better. This helps reduce recurrence of the infection and minimizes the chances that the bacteria will become resistant to the drug.

Viral pneumonia typically doesn’t require anything other than home treatment. Encourage quiet activities so that your child gets plenty of rest. Your child may need extra holding and cuddling. He or she also needs plenty of fluids. Coughing is usually beneficial for children with pneumonia because it helps to clear the mucus and secretions associated with the infection. You can help prevent bacterial pneumonia in many cases by making sure your son or daughter is up to date with all of his or her vaccinations.

Reflux

Spitting up is common in new babies. Often, the condition goes away after the first few months. But in some babies, spitting up continues throughout the first year or so. The medical term for this condition is gastroesophageal reflux.

The causes of infant reflux are generally simple. Normally, the ring of muscle between the esophagus and the stomach (lower esophageal sphincter) relaxes and opens only when you swallow. Otherwise, it’s tightly closed — keeping stomach contents where they belong. Until this muscle matures, stomach contents may sometimes flow up the esophagus and out of your child’s mouth. Sometimes air bubbles in the esophagus may push liquid out of your child’s mouth. In other cases, your child may simply drink too much, too fast.

How to recognize it Although infant reflux most often occurs after a feeding, your child also may spit up when he or she coughs, cries or strains. You also may notice your child becomes more irritable during or after feedings, or coughs, wheezes or cries when you lay him or her on his or her back, especially after feeding.

How serious is it? Infant reflux typically resolves on its own when your child is around 12 to 18 months old. Unless it’s severe, infant reflux doesn’t interfere with a child’s growth or well-being. Gastroesophageal reflux disease (GERD) is a severe version of reflux that can cause pain, vomiting and poor weight gain.

When to call Call your child’s medical provider if your child:

Isn’t gaining weight

Spits up so forcefully that vomit shoots out (projectile vomiting)

Spits up green fluid, blood or a material that looks like coffee grounds (Call immediately if this happens.)

Resists feedings

Has blood in his or her stool

Has other signs of illness, such as fever, diarrhea or difficulty breathing

Begins persistent vomiting at age 6 months or older

What you can do Infant reflux is usually little cause for concern, but you may have to keep an extra supply of spit-up cloths on hand until your child outgrows the condition. To minimize reflux in the meantime:

Try smaller, more-frequent feedings Feed your child slightly less than usual if you’re bottle-feeding, or cut back a little on the amount of time you breast-feed. Feed more often.

Burp your child Frequent burps during and after each feeding can keep air from building up in your child’s stomach. Sit your child upright, supporting his or her head with your hand, and rub his or her back (see the illustrations here). Avoid burping your child over your shoulder, which puts pressure on your child’s abdomen.

Check the nipple If you’re using a bottle, make sure the hole in the nipple is the right size. If it’s too large, the milk will flow too fast. If it’s too small, your child may get frustrated and gulp air. A nipple hole that’s the right size will allow about a drop of milk to fall per second when you hold the bottle upside down.

Thicken the formula or breast milk If your child’s medical provider approves, add a small amount, such as a teaspoon, of rice cereal to your child’s formula or expressed breast milk. You may need to enlarge the hole in the nipple to make sure your child can drink the thickened liquid.

Make a change Occasionally, some babies develop an allergy to cow’s milk protein. If you’re breast-feeding, that means you may have to eliminate milk products from your diet. If you’re formula-feeding your child and there’s a concern your baby may have a milk allergy, your child’s medical provider may suggest switching to a different formula that doesn’t contain cow’s milk.

RSV

Respiratory syncytial virus (RSV) is a virus that can cause infections of the upper respiratory tract, such as a cold, or the lower respiratory tract, such as bronchiolitis and pneumonia. It’s so common that most children get RSV before age 2 years. Reinfections with RSV are common, but as a child gets older, symptoms usually become less severe.

In many cases, the symptoms of an RSV infection resolve on their own. Self-care measures are usually all that’s needed to relieve any discomfort.

In a few cases, the infection can be severe enough to require a stay at the hospital. Premature babies and infants with underlying health conditions are at greater risk of severe illness.

How to recognize it Initially, infection with RSV may cause a runny nose, decrease in appetite and perhaps a fever. Over the next few days, the infection may spread to the lower airways and lungs and your child may start coughing, wheezing and breathing fast. Ear infections are occasionally associated with RSV infections.

In babies who are only a few weeks old, infection with RSV may cause moregeneral symptoms, such as coughing, wheezing, extreme tiredness, irritability and poor feeding.

How serious is it? Children who are otherwise healthy generally recover from the illness in one to two weeks without the need for medical treatment.

Young babies are at greater risk of serious infection. Babies who are finding it difficult to breathe may need to stay at a hospital to receive supportive care, such as supplemental oxygen and suctioning of mucus from their airways. Even among babies who need to be hospitalized, most have a full recovery within a few weeks.

When to call Seek urgent care if your child:

Is less than 2 months old and has a fever (100.4 F or above), even if no other symptoms

Is struggling to breathe (your child’s chest muscles and skin pull inward with each breath)

Turns blue, particularly on the lips and in the nail beds

Shows signs of dehydration (dry mouth, reduced urination, sunken eyes and fontanels, extreme fussiness, or sleepiness)

Breathing or poor eating seems to be getting worse

What you can do Mild symptoms can be treated at home, although be ready to call your child’s medical provider promptly if symptoms worsen. Keeping your child upright and the air moist with a humidifier may help ease congestion.

Have your child drink plenty of fluids to prevent dehydration. Continue breast-feeding or bottle-feeding your infant as you would normally. Wash hands frequently and avoid sharing eating and drinking utensils to prevent spreading the infection.

If your child’s older than 2 months, you can give him or her acetaminophen (Tylenol, others) if needed to soothe discomfort. Children 6 months or older also can take ibuprofen (Advil, Motrin, others). See this discussion for more on medications.

The medication palivizumab (Synagis) can help protect children under age 2 years who are at high risk of serious complications from RSV, such as premature babies or those who have an underlying lung or heart problem. The medicine is started prior to the RSV peak season. If you think your child may qualify for this treatment, talk to your child’s medical provider. The medication isn’t helpful once the infection has developed.

Roseola

Roseola is a generally mild infection that commonly affects children by 2 years of age. Two strains of herpes viruses cause roseola (but not the same ones that cause sexually transmitted herpes or cold sores). The condition usually causes several days of fever followed by a rash.

How to recognize it Roseola typically starts with a sudden, high fever — often greater than 103 F. Some children have a slightly sore throat, runny nose or cough along with or preceding the fever. Your child may also develop swollen lymph nodes in his or her neck along with the fever. The fever lasts for three to five days.

Once the fever subsides, a rash typically appears — but not always. The rash consists of many small pink spots or patches, mainly on the child’s trunk. Although not itchy or uncomfortable, the rash can last from several hours to several days before fading.

How serious is it? Roseola typically isn’t serious. If your child is otherwise healthy, he or she will most likely recover quickly and completely. Treatment includes rest, fluids and, if your child is uncomfortable, medications to reduce fever.

When to call Call your child’s medical provider if your child is under 2 months old and has a rectal temperature of 100.4 F or higher, or if your child has a fever and appears sick or unusually fussy (see “Fever” here). The medical provider may want to examine your child to rule out more-serious causes of fever.

If your child is diagnosed with roseola, call if the fever lasts more than seven days or if the rash doesn’t improve after three days.

What you can do Like most viral illnesses, roseola needs to run its course. Encourage plenty of rest and plenty of fluids. A cool washcloth applied to your child’s head can soothe the discomfort of a fever. Once the fever subsides, your child should feel better soon. Most children recover fully from roseola within a week of the onset of the fever. The rash should fade on its own in a short time.

If the fever is making your child uncomfortable, you can give him or her acetaminophen (Tylenol, others) if he or she is over 2 months old. Once your child is older than 6 months, you can give him or her ibuprofen (Advil, Motrin, others). See this discussion for more on giving medications. Don’t give aspirin to a child who has a viral illness because aspirin has been associated with the development of Reye’s syndrome, which can be serious.

If your child is sick with roseola, keep him or her home and away from other children until the fever has broken.

Stomach flu (gastroenteritis)

Although it’s commonly called stomach flu, gastroenteritis isn’t the same as the flu. Influenza affects your child’s nose, throat and lungs. Gastroenteritis, on the other hand, attacks the intestines.

Rotavirus and noroviruses are two common causes of gastroenteritis. Children usually become infected when they put their fingers or other objects contaminated with a virus into their mouths.

A vaccine against rotaviral gastroenteritis is available in some countries, including the U.S., and has dramatically reduced the rate of rotavirus infection and its complications.

How to recognize it Gastroenteritis often causes these signs and symptoms:

Watery, usually nonbloody diarrhea — bloody diarrhea typically means a different, more severe infection

Abdominal cramps and pain

Vomiting

Loss of appetite

Irritability

Low-grade fever

Depending on the cause, viral gastroenteritis symptoms may appear within one to three days after your child is infected and can range from mild to severe. Symptoms usually last just a day or two, but occasionally they may persist as long as 10 days.

How serious is it? A bout of viral gastroenteritis usually resolves on its own within a week or two (although it can often include a miserable few days). Antibiotics offer no help for viral infections.

The main complication of viral gastroenteritis is dehydration. If your child can’t take in enough fluids — through breast milk, formula or an oral rehydration solution — to replace the fluids being lost through diarrhea or vomiting, he or she will become dehydrated and may need to go to a hospital to receive fluids through a vein (intravenously).

If your child has severe or prolonged diarrhea, especially if accompanied by vomiting, watch carefully for signs of dehydration — extreme thirst, dry mouth, crying without tears and reduced urination compared with your child’s usual output. Babies who are dehydrated often change from fussy to quiet to lethargic. Call your child’s medical provider promptly if you notice signs of dehydration.

When to call Call right away if your child:

Is less than 2 months old and has a fever (100.4 F or above)

Seems lethargic or very irritable

Is in a lot of discomfort or pain

Has bloody diarrhea

Has vomiting that lasts more than several hours

Can’t keep fluids down

Hasn’t had a wet diaper in six to 12 hours or fewer than three in 24 hours

Has a sunken fontanel — the soft spot on the top of your child’s head

Has a dry mouth or cries without tears

Is unusually sleepy, drowsy or unresponsive

What you can do When your child has an intestinal infection, the most important goal is to replace lost fluids and salts. After vomiting or a bout of diarrhea, let your child’s stomach rest for 30 to 60 minutes, then offer small amounts of liquid, 1 to 2 teaspoonfuls at a time.

Infants If you’re breast-feeding, offer just one breast and let your child nurse for five minutes. If you’re bottle-feeding, offer small amounts of regular formula. Don’t dilute your child’s already-prepared formula. After 15 to 30 minutes, if the liquid stays down, offer it again. If you’re concerned about possible dehydration, ask your child’s medical provider about giving your child a small amount of an oral rehydration solution.

Toddlers If your child is eating solids, these tips may help ease discomfort and avoid complications of dehydration:

Help your child rehydrate. Give your child an oral rehydration solution (Pedialyte, others). Don’t give him or her only water. In children with gastroenteritis, water isn’t absorbed well and it won’t adequately replace lost electrolytes. You can find oral rehydration solutions in most grocery stores. Talk to your medical provider if you have questions about how to use them.

Return to a normal diet slowly. Drinking is more important than eating. When your child seems ready to eat, there’s generally no need to restrict his or her diet, but bland foods — such as toast, rice, bananas and potatoes — may be easier to digest than foods that are high in fat. Milk and sugary foods or beverages can make diarrhea worse.

Make sure your child rests. The illness and dehydration may have made your child weak and tired.

Avoid certain products. Don’t give children aspirin. It may cause Reye’s syndrome, a rare, potentially fatal disease. Also don’t give your child antidiarrheal medications, unless advised to do so by your child’s medical provider. These medications can make it more difficult for your child’s body to eliminate the virus.

Sty

If you notice a red, painful-looking lump appear fairly rapidly near the edge of your child’s eyelid, he or she may have a bacterial eyelid infection called a sty. A sty may develop when your child rubs or scratches his or her eyes with dirty hands or fingernails, transferring bacteria to the eyelids.

In most cases, a sty will disappear on its own in a few days to a week. In the meantime, you may be able to relieve the pain or discomfort of a sty by applying a warm washcloth to the eyelid.

How to recognize it A red lump on your child’s eyelid that looks similar to a boil or a pimple is usually an indication of a sty. A sty often contains pus. Your child’s eyelid may also be swollen and the eye may be teary.

How serious is it? Most sties are harmless and don’t require treatment. A sty typically resolves on its own in a few days to a week.

When to call Contact your child’s medical provider if the sty doesn’t go away in a week, or the redness and swelling extend beyond your child’s eyelid, involving his or her cheek or other parts of the face.For a sty that persists, your child’s medical provider may recommend antibiotic ointment or drops to help clear the infection.

What you can do Don’t try to pop the sty or squeeze the pus from a sty, and keep your child’s face and hands clean. To relieve discomfort, apply warm compresses to your child’s eyelid. Run warm water over a clean washcloth. Wring out the washcloth and place it over the closed eye. Rewet the washcloth when it loses heat. Continue this for five or 10 minutes. Applying a warm compress several times each day may encourage the sty to drain more quickly.

Sunburn

A young child’s skin is quite thin and susceptible to sunburn, even with only 10 to 15 minutes of exposure, and even on a cloudy or cool day. It’s not the visible light or the heat from the sun that burns but the invisible ultraviolet (UV) light. The lighter the color of your child’s skin, the more sensitive it is to UV rays, but that doesn’t mean darker skin is immune from sun damage.

Most sun damage occurs in the childhood years. While you certainly don’t want to minimize the fun your child has outdoors, it’s important to be sun smart. You can help prevent sun damage by setting up in shady areas (or using an umbrella), using sunscreen appropriately, and dressing your child in hats and light, protective clothing.

How to recognize it You may not realize that your child has sunburn because the pain and redness may not appear for several hours. Sunburn may cause red, tender, swollen or blistered skin that is usually hot to the touch and makes your child feel uncomfortable.

How serious is it? It’s a good idea to be cautious about the possibility of your child getting a sunburn. Babies and young children can develop blisters, fever, chills and nausea with an amount of sun exposure that may not affect an older person.

When to call Contact your child’s medical provider if the sunburn blisters or if your child begins vomiting or acts ill.

What you can do Treat sunburn by gently applying cool compresses every few hours, taking care not to allow your child to become chilled. Encourage plenty of fluids. Give your child acetaminophen (Tylenol, others) to relieve the pain. Avoid using anesthetic lotions or sprays on a child’s skin. Some sting, and a child’s skin may react to anesthetic sprays. Benzocaine in particular can have rare but serious side effects in children under 2 years old. Don’t use it without talking to your child’s medical provider first. It’s also important that you take steps to prevent sunburn:

In babies under 6 months Keep your child out of direct sunlight as much as possible, especially between 10 a.m. and 4 p.m., when the sun’s rays are strongest. This precaution includes cloudy days, when the clouds don’t block but simply scatter UV rays. You can also protect your child by routinely dressing him or her in a hat for outings during the middle of the day. If you can’t avoid sun exposure, use sunscreen just on areas of the body that will be exposed, such as the face and backs of the hands.

In babies older than 6 months About 30 minutes before going outside, apply a broad-spectrum sunscreen, which protects against UVA and UVB rays. Use a sunscreen with a sun protection factor (SPF) of at least 30. Don’t forget the back of the neck, ears, nose, cheeks and tops of the feet. Reapply it every two hours or after the child has played in the water, even if the sunscreen is waterproof.

If you think your child might have sensitive skin, do a patch test. Apply a small amount of sunscreen to your child’s forearm and watch for the next 48 hours for any reaction. If your child is sensitive to one sunscreen, try a sunscreen without chemical sunblock components — one with only zinc oxide or titanium dioxide.

If at any time you notice your child turning pink, take him or her out of the sun. Pink now can mean red and sunburned later.

Swollen scrotum (from a hydrocele)

A hydrocele is an accumulation of fluid in the pouch that holds the testicles (scrotum), making the scrotum look swollen and large on one side. This condition is not uncommon in newborn boys. Before birth, your child’s testicles develop in his abdomen and move through a passage into the scrotum. When the opening to the abdomen doesn’t fully close, fluid that is normally in the abdomen can pass into the scrotum and cause swelling. A hydrocele is usually painless. By the time a child is a year old, the fluid typically has been absorbed and the hydrocele goes away on its own.

How to recognize it You may notice that your child’s scrotum seems swollen on one side. It may seem more swollen when he is crying or active and less when he is lying down.

How serious is it? Generally, a hydrocele doesn’t cause your child any discomfort. It usually goes away on its own by the time your child is a year old. But if the area becomes very large and tender, part of the intestine may have moved into the scrotum, causing an inguinal hernia. In this case, surgery may be required to move the intestine back into the abdominal cavity and close the opening between the abdomen and the scrotum.

When to call If your child develops a sudden swelling of the scrotum that appears painful, call your child’s medical provider immediately. Most causes of such symptoms are benign, but if the testicle twists on the spermatic cord (testicular torsion), the blood supply to the testis can be cut off. This requires immediate surgery.

If your child’s medical provider didn’t notice your child’s hydrocele when your child was born, mention it at your office visit. Your child’s provider will likely continue to examine it regularly for changes.

In the meantime, call your child’s medical provider promptly if your child shows marked tenderness in the scrotum, or starts vomiting or showing signs of nausea for no apparent reason.

What you can do Share any concerns you may have with your child’s medical provider and watch for any change in your child’s condition.

Teary eyes

Teary, or watery, eyes in a newborn are usually caused by a blocked tear duct. Normally, tear fluid flows down the surface of the eye to lubricate and protect the eye. It then drains through a system of holes and canals into the nose, where the fluid evaporates or is reabsorbed. This system typically takes time to fully develop. Babies under 8 months of age produce enough tear fluid to coat the eye, but not necessarily to cry “real tears.”

Quite a few babies have a blocked tear duct at birth. Often, a thin tissue membrane remains over the opening (duct) that empties into the nose. This blockage causes tear fluid to well up in your child’s eyes, leaving them watery.

How to recognize it One or both of your child’s eyes may appear to be continuously watery, with tears occasionally running down the cheeks, even though he or she isn’t crying. Usually, the eye doesn’t look red or swollen, though, unless it’s infected.

How serious is it? A blocked tear duct generally isn’t serious, and most of the time resolves by about 6 to 9 months of age. Because the tear fluid isn’t draining as it should, however, infections (pink eye, or conjunctivitis) are slightly more common when a tear duct is blocked. In the morning, your child’s eyes may be crusted over with dried up discharge.

When to call Call your child’s medical provider if your child’s eye is red or swollen or looks infected.

What you can do Your child’s medical provider may show you how to massage the lower inner corner of your child’s eye, where the tears collect (lacrimal sac). Use a cotton-tipped swab or clean finger to gently press upward from the inner corner. This may or may not help open the duct, but it can help empty out the lacrimal sac of stagnant fluid.

Use moist compresses to wipe away the fluids from your child’s eyes. Keeping your child’s face and hands clean will help prevent infections.

Teething

Your child may have a first tooth by 6 months or may not begin teething until much later. Often the two bottom center teeth (incisors) appear first, but not always. When they’ve both come in, a tooth may appear on the top. Your child will probably get four top teeth before a matching set of four is completed on the bottom. Between ages 2 and 3 years, your child will have all or most of his or her baby teeth, including the second molars.

Your child’s baby (deciduous) teeth were formed during pregnancy. As these teeth come in, your child’s body will begin preparing adult teeth to take their place in a few years.

How to recognize it Drooling is a classic sign of teething. However, it may take about two months after the drooling starts before the first tooth pops up. For some babies, teething causes pain or discomfort. So your child might be crankier than usual. You might also notice swollen gums and a drive to chew on solid objects. Many parents suspect that teething causes fever and diarrhea, but researchers say this isn’t true. Teething may cause signs and symptoms in the mouth and gums, but it doesn’t cause problems elsewhere in the body.

How serious is it? Teething is a normal and healthy process in your child’s development. But where there are teeth, there’s the possibility for tooth decay. Help your toddler get in the habit of caring for his or her teeth now to prevent problems later.

When to call Contact your child’s medical provider if your child develops a fever, seems particularly uncomfortable, or has other signs or symptoms of illness — including fever or diarrhea.

The American Dental Association and the American Academy of Pediatric Dentistry recommend scheduling a child’s first dental visit after the first tooth erupts. Ask your dentist what he or she recommends. In practice, many children start seeing a dentist regularly after age 3 unless there are dental concerns. Your child’s teeth and gums will also be examined at well-child checkups.

What you can do Sometimes you may not even notice your child is teething until you see the new tooth! But if teething is making your child uncomfortable, here are some steps you can try:

Offer something to chew on. Try a teething ring. Some are made from firm rubber and others are plastic with liquid inside. Keep in mind the liquid-filled variety may break under the pressure of your child’s chewing. A pacifier may help. If a bottle seems to do the trick, fill it with water. Prolonged contact with sugar from formula, milk or juice may cause tooth decay.

Keep it cool. A cold washcloth or chilled teething ring can be soothing. If your child’s eating solid foods, you can try a homemade teething ring such as a slightly frozen bagel. Make sure you offer a frozen food that will turn soft so that your child can safely swallow any pieces that might break loose. Be careful when giving your child something frozen, however. Contact with extreme cold may hurt the gums. Cold soft foods such as applesauce or yogurt may feel soothing to your child’s gums.

Rub your child’s gums. Use a clean finger, moistened gauze pad or a clean, damp washcloth to gently massage your child’s gums. The pressure may help ease your child’s sore gums, at least for a short while.

Dry the drool. Excessive drooling is part of the teething process. To prevent skin irritation, keep a clean cloth handy to dry your child’s chin. You might also make sure your child sleeps on an absorbent sheet.

Try an over-the-counter remedy. If your child is especially cranky, acetaminophen (Tylenol, others) — or ibuprofen (Advil, Motrin, others) if your child is more than 6 months old — may help reduce gum irritation and discomfort.

Avoid certain remedies. Don’t give your child products that contain aspirin, however, and be cautious about teething medications that can be rubbed directly on a child’s gums. Avoid teething medications that contain benzocaine. Benzocaine has been linked to a rare but serious and sometimes deadly condition that decreases the amount of oxygen that the blood can carry, especially in children under 2 years old.

Tooth brushing When your child’s first teeth appear, brush them with a small, soft-bristled toothbrush, a rice grain-sized amount of fluoride-containing toothpaste and some water. (Some parents find it easier to use a soft finger toothbrush that fits over the parent’s finger.) As your child gets older, you can allow him or her to use the toothbrush. Show your child how to clean each tooth, making sure to get those teeth that may be out of direct sight. Do this with your child twice a day. As your child approaches 3 years of age, you can gradually increase the amount of toothpaste to the size of a pea.

Thrush

Thrush is the name for a fungal infection that can occur in your child’s mouth. It’s caused by the same fungus that causes yeast infections, Candida albicans. This fungus is normally found in the mouth, skin and other mucous membranes. If the mouth’s natural bacterial balance is upset — typically by medications or an illness — an overgrowth of candida may result, producing thrush. If a baby with thrush is breast-feeding, the infection can affect the mother’s breasts.

Thrush typically produces white patches on the tongue and inside of the cheeks.

How to recognize it When your child has thrush, it looks like he or she has patches of milk on the inside of the cheeks and on the tongue that won’t wash off (see photo on this page). Occasionally, thrush causes discomfort and your child may have trouble feeding or be fussy and irritable.

If your child’s tongue looks white all over but there are no white patches inside the lips or cheeks, this is probably not thrush. Milk can make your child’s tongue have a white coating.

How serious is it? Thrush can be painful in severe cases, but it doesn’t generally cause discomfort or serious problems. It can lead to a diaper rash in your child as the yeast travels through the child’s gastrointestinal tract.

Infants can pass the infection to their mothers during breast-feeding. The infection may then pass back and forth between mother’s breasts and child’s mouth. Women whose breasts are infected with candida may experience the following signs and symptoms:

Red, sensitive or itchy nipples

Shiny or flaky skin on the darker, circular area around the nipple (areola)

Unusual pain during nursing or painful nipples between feedings

Stabbing pains deep within the breast

When to call If you notice white patches inside your child’s mouth, call your child’s medical provider during office hours. Check back with the provider if your child’s mouth becomes increasingly coated and causes discomfort, or if your child has difficulty swallowing. If you’re breast-feeding and you think your breasts have become infected, talk to either your primary care provider or your child’s medical provider.

What you can do Your child’s medical provider may prescribe a liquid antifungal medication, which you apply to the patches of thrush in the mouth. If your child is having recurring infections, it’s probably a good idea to replace your child’s pacifiers and bottle nipples, which could be harboring the fungus.

If you’re breast-feeding an infant who has oral thrush, you and your baby will do best if you both are treated. Otherwise, the infection is likely to be passed back and forth. For you and your baby:

The doctor may prescribe a mild antifungal medication for your child and an antifungal cream for your breasts. You can also use a nonprescription antifungal cream, such as clotrimazole (Lotrimin AF). Apply it four times a day after feedings.

If you use a breast pump, rinse all the detachable parts in a vinegar and water solution.

If you develop a fungal infection on your breasts, using pads will help prevent the fungus from spreading to your clothes. Look for pads that don’t have a plastic barrier, which can encourage the growth of candida. Wash reusable pads and your bras in hot water with bleach.

Urinary tract infection

Urinary tract infections are fairly common in young children, especially girls. The tube that carries urine out of the bladder (urethra) is shorter in girls than in boys, making it easier for bacteria to travel to the bladder. When bacteria enter the bladder or kidneys, an infection may result. Most often, the bacteria come from stool and the anal area.

How to recognize it In children younger than 2 years old, a urinary tract infection can be hard to discern. Often the only sign is a fever with no apparent cause, one that’s not explained by an upper respiratory infection or diarrhea. Less common signs and symptoms of a urinary tract infection are irritability, poor feeding and not gaining weight properly. An older toddler might be able to describe urinary symptoms such as painful or difficult urination.

How serious is it? A urinary tract infection requires prompt treatment. Left untreated, the infection can cause permanent damage to the kidneys.

When to call Call anytime your child has an unexplained fever that persists for more than 24 hours, especially when the temperature is greater than 102.2 F. Call your child’s medical provider right away if your child is under 2 months of age and has a rectal temperature of 100.4 F or higher.

What you can do Be alert to unexplained, persistent fevers in your child, and don’t be afraid to call your child’s medical provider when necessary. The provider can diagnose a urinary tract infection with a urine sample. In infants and young children who aren’t toilet trained, a urine sample is usually obtained by briefly inserting a catheter into the urethra to withdraw a small amount of urine. Your child’s medical provider can give you tips on how to collect a sample from a toilet-trained child.

If your child has a urinary tract infection, his or her medical provider will prescribe a course of antibiotics, which may last up to two weeks. Make sure to give your child the whole prescription, even after the fever goes away. This will keep the infection from coming back. After treatment is over, the provider may request another urine sample to make sure the bacteria have been eliminated. An ultrasound of the kidneys may be performed if the provider wants to rule out a urinary system abnormality.

Vomiting

In the first few months of life, it’s common for babies to spit up or easily regurgitate their food from time to time. Vomiting is different. It’s the forceful ejection of a large portion of the stomach’s contents through the mouth and sometimes even the nose. Because your child won’t understand what is happening, vomiting can be a frightening experience for him or her. And as a parent, it can be very stressful when your child begins to vomit without warning.

Most vomiting in early childhood is caused by viral infections that affect the stomach and intestines (gastroenteritis; see this discussion). Your child also may have fever and diarrhea in addition to vomiting.

How to recognize it Normal infant spit-up seems to dribble out of your child’s mouth without much ado. Vomit, on the other hand, comes out like a projectile, fast and furious. Generally, there’s more of it, too, compared with spit-up.

How serious is it? Most of the time, vomiting is due to a viral infection and stops on its own within 12 to 24 hours. The greatest risk your child faces from vomiting is dehydration from losing too many bodily fluids.

In a few cases, vomiting can be a symptom of a more serious problem, such as an intestinal obstruction, stomach disorder or infection.

When to call If your child is very young — between 2 and 6 weeks — and vomits forcefully within 30 minutes after every feeding for six to 12 hours, call your child’s medical provider right away. This may be a sign of a stomach disorder where a narrowing of the stomach’s outlet into the intestines prevents food from passing (pyloric stenosis; see this discussion). This requires prompt attention so that your child can get the nutrition he or she needs to grow.

Also, call immediately if your child seems to be getting worse, you’re concerned about possible poisoning, or he or she experiences any of the following signs or symptoms:

Blood or green matter (bile) in the vomit

Vomiting for more than 12 hours in newborns, 24 hours in older infants

Forceful, repeated vomiting

Dehydration — reduced urination or fewer than three wet diapers in 24 hours, dry mouth, no tears (although newborns don’t usually show tears), or sunken soft spots (fontanels) in the head

Unusually sleepy or unresponsive

Inability to keep liquids down

Seems to have persistent abdominal pain

What you can do To prevent dehydration in your child:

Wait a little after a vomiting episode. After your child vomits, let the stomach settle for a while. Wait 30 to 60 minutes before offering more fluids. Sleep may ease your child’s nausea.

Offer small amounts of liquid. Start out with a teaspoon or two. Breast-fed babies usually tolerate breast milk fairly well and digest it quickly. Offer just one breast and nurse for only five minutes or so. Small amounts of regular formula for bottle-fed babies are OK, too. After 15 to 30 minutes, if the liquid stays down, offer it again.

Offer an oral rehydration solution. For older toddlers or babies who continue to vomit, offer a teaspoon or two of oral rehydration solution (Pedialyte, others). Gradually increase the volume as your child tolerates it. If your child can’t keep anything down, call your child’s medical provider.

Gradually return to normal diet. After eight hours without vomiting, gradually return to normal breast- or formula-feeding amounts. If your child is eating solids, slowly return to a normal diet. You might want to start out with easily digested foods, such as cooked cereal, bananas, crackers, toast or plain pasta.

Whooping cough

Whooping cough (pertussis) is a highly contagious bacterial infection of the respiratory tract. It’s transmitted from person to person through airborne droplets from coughing or sneezing.

A vaccine against whooping cough is part of your child’s recommended vaccinations, usually given as a series of five injections at 2 months, 4 months, 6 months, 12 to 18 months and 4 to 6 years. Because babies under 6 months haven’t been fully vaccinated, they’re at greater risk of getting the infection and of developing significant complications. Maternal vaccination during pregnancy against whooping cough will protect infants during these first six months.

The protection offered by the vaccine wears off after several years, meaning that older children who haven’t updated their vaccinations may become infected and pass it on to infants and younger children. Because of this, it’s now recommended that 11- and 12-year-olds receive a vaccine booster shot for whooping cough.

How to recognize it At first, it may seem as if your child has a mild upper respiratory tract infection — a runny nose, congestion and cough, but no fever. Only the cough worsens throughout the first week, until he or she experiences exhausting coughing fits consisting of 10 to 30 forceful, abrupt coughs, sometimes followed by a “whoop” sound as your child inhales forcefully. Many children don’t develop the whoop sound. Some vomit after a coughing fit.

In infants under 3 months of age, the initial phase of mild symptoms may not always be obvious. The first sign of whooping cough may be a sudden fit of coughing, difficulty breathing or period of not breathing, especially after coughing. In between episodes of coughing or trouble breathing, the child may appear well.

How serious is it? In infants — especially those under 6 months of age — complications from whooping cough are more severe than in older children and adults, and may include ear infections, pneumonia, respiratory failure and seizures. Complications such as pneumonia can be life-threatening in new babies.

Young infants diagnosed with whooping cough are often kept at a hospital to receive supportive care and to be closely monitored for potentially serious complications. If your child is older and has mild symptoms, hospitalization may not be necessary. Antibiotics can decrease the chances of transmitting the infection to others.

When to call Contact your child’s medical provider right away if your child:

Is under 6 months old or hasn’t been fully immunized, and has been exposed to someone with a chronic cough or whooping cough

Has severe coughing fits

Has spells of difficulty breathing, turning blue or gagging

Has had a bad cough for more than five to seven days

Vomits after a coughing fit, eats poorly or seems ill

What you can do If you’re caring for your child at home, these steps may help your son or daughter feel better while recovering.

Avoid cough medicine Over-the-counter cough medicines don’t usually help and aren’t recommended in children under 4 years old (see this discussion).

Encourage plenty of rest A cool, quiet and dark bedroom may help your child relax and rest better.

Offer plenty of fluids Keep up your child’s regular feedings of breast milk and formula. Smaller, more-frequent feedings may be helpful. Water, 100% fruit juices and soups are good choices for toddlers. If your child is having trouble consuming enough fluids, offer small amounts of an oral rehydrating solution (Pedialyte, others). Call your child’s medical provider right away if you notice signs of dehydration, such as decreased urination and increased irritability or sleepiness.

Use a humidifier Use a cool mist humidifier to help soothe irritated lungs and to help loosen respiratory secretions. If you use a humidifier, follow directions for keeping it clean. If you don’t have a humidifier, sitting with your child in a steamy bathroom with the shower turned on also can temporarily help clear the lungs and ease breathing.

Clean the air Keep your home free of irritants that can trigger coughing spells, such as tobacco smoke and fumes from fireplaces.

Prevent transmission Cover your cough and wash your hands often; keep your child away from others. Ask your family’s medical provider about getting your whole family’s vaccinations up to date.

PART 5 Managing and enjoying parenthood

CHAPTER 36 Adapting to your new lifestyle

It’s the start of your baby’s childhood, but it’s also the start of your new role as a parent. Adding a baby to your family brings some of the most profound changes you’ll ever experience, from the mundane (diapers) to the magical (the first steps). No matter how many baby care websites or books you’ve perused or how meticulous you’ve been in getting everything in place, nothing can fully prepare you for the first weeks and months after your baby’s birth.

This time of transition can be exciting — and overwhelming. You’re dealing with many different physical, social and emotional issues all at once. This includes trying to get a handle on your baby’s needs and habits and adjusting to a new role and identity. Relationships with your partner, family and friends are shifting. And round-the-clock newborn care can turn your life upside down, making even simple tasks such as showering a challenge.

The first few weeks after you bring your baby home are likely to be some of the most challenging times of your life. The changes in the daily rhythms of your life may feel chaotic and foreign. But this also is a time of great growth. A few practical strategies can help you adapt as the transition unfolds and help you create a nurturing, loving home for all members of your family.

Living on less sleep

If there’s any issue to which all parents can nod their heads and say, “I’ve been there,” it’s the fatigue that comes with caring for a baby. You’re up at all hours feeding, diapering and otherwise tending to your newborn, who needs time to develop regular sleep-wake cycles. Parents’ sleep is often disturbed for weeks to months after a baby’s birth. Lack of sleep not only leaves you exhausted but also can make you irritable and less able to focus, remember details and solve problems.

But seasoned parents will also tell you that it gets better. By age 3 months, many babies can sleep at least five hours at a stretch. By 6 months, many infants sleep through the night, and 70% to 80% of babies are doing so by 9 months. In the meantime, hang in there — and try to sneak in as much sleep as possible.

While there’s no magical formula for getting enough sleep, here are some tips that may help (also see Chapter 9).

Sleep when your baby sleeps While this is one of the common pieces of advice, it’s not always so easy to follow. Some babies doze off for just 15 or 20 minutes at a time, and you may need to seize that time to shower, eat a meal or just go to the bathroom.

Still, even an hour or two of extra sleep can make a difference, so try to make it a priority. Turn off the ringer on your cellphone, shut down your computer, hide the laundry basket, and ignore the dishes in the kitchen sink. These things can wait.

Set aside your social graces When close friends and loved ones visit, don’t worry about entertaining them. Let them care for the baby while you excuse yourself for some much needed rest. Allow them to help with cooking and cleaning.

Avoid bed sharing during sleep It’s OK to bring your baby into your bed for nursing or comforting, but return your baby to the crib or bassinet when you and your baby are ready to go back to sleep.

• • • • •

When sleep becomes a struggle

The rigors of caring for a newborn may leave you so exhausted that you feel you could fall asleep anytime, anywhere — but that’s not always the case. Some new parents experience insomnia.

Prolonged sleep deprivation can set the stage for depression and other health problems. If you’re having trouble sleeping even when you have the opportunity, try these suggestions.

Make sure your environment is suited for sleep. Turn off digital devices, including TV, and keep the room cool and dark.

Avoid nicotine, caffeine and alcohol late in the day or at night.

If you don’t nod off within 30 minutes, get up and do something else but again, avoid digital devices. When you begin to feel drowsy, try going back to bed.

If you think you have a sleep problem, consult your medical provider. Identifying and treating any underlying conditions can help you get the rest you need.

• • • • •

Share nighttime duties Work out a schedule with your partner that allows both of you to rest and care for the baby. If you’re breast-feeding, perhaps your partner can bring you the baby and handle nighttime diaper changes. If you’re using a bottle, take turns feeding the baby. You could also split the night into two shifts or trade nights to be on duty.

Wait a few minutes Sometimes middle-of-the-night fussing or crying is simply a sign that your baby is settling down. Unless you suspect that your baby is hungry or uncomfortable, wait a few minutes before responding.

Go easy on yourself If you’re not getting enough sleep, you may feel cranky and disoriented. Try not to beat yourself up about it. Set aside nonessential tasks — such as preparing elaborate meals, balancing your budget or volunteering — for a time when you’re feeling more rested.

• • • • •

A house becomes a home

Children’s book writer Christopher Harder describes the way his house changed after he and his wife had a child:

We had renovated the house by getting rid of our dining room, living room and den and replacing them with one, house-sized playroom. We had scarred the new furniture, stained baseboards and repainted walls. ... Half our books were in the attic. The hardwood floors had skid marks. And it felt like home.

• • • • •

Getting comfortable with chaos

In the first weeks after you bring home your baby, you might feel like you’re in a fog. With the baby’s constant need for care and attention, your day-to-day routine goes out the window. On top of feedings, diaper changes and crying spells, parents must find time to do household chores and other daily activities.

Although your days will likely include moments of awe and enjoyment, you still might miss your former carefree life, a predictable schedule and control over your time. Maybe you long for the comfort of your old routines, such as a quiet morning cup of coffee, a structured workday, weekly get-togethers with friends or movie night with your partner.

Over time, you’ll adjust to the new normal, revive old routines and create new ones. In the meantime, you can bring some order to the chaos — and learn to embrace it.

Check your expectations Many new parents start out with unrealistic expectations, perhaps thinking that life won’t be much different from before. The gap between expectations and reality can lead to stress and disappointment, or even a feeling that something’s wrong with you. Throw out any preconceived notions about what life with a new baby should be like, and be realistic about the increased demands you face.

Go with the flow It’s never too early to establish a routine — but let your newborn set the pace. Allow plenty of time each day for nursing sessions, naps and crying spells. Keep scheduled activities to a minimum. When you need to head out, give yourself extra time to pack your supplies and change the inevitable out-the-door dirty diaper. As your baby develops a more regular routine, you’ll find a new rhythm. Over time, your schedule for naps, meals and playtime will continue to change with your child’s needs.

Decide what’s important Determine the tasks and activities you want to keep from your pre-baby days, and prioritize them. Then find ways to streamline other areas. Perhaps you learn to live with a messier house, or you use shortcuts for household tasks. Keep clean clothes in a laundry basket instead of putting them away, for example. Buy a month’s supply of toilet paper, diapers and other essential household items. Accept meals from friends and family. Freeze leftovers, buy healthy heat-and-serve options, or use meal delivery services that bring meals to your door.

Establish visiting rules Friends and loved ones may seem to come out of the woodwork to admire your newborn. Let them know which days work best and how much time you have for a visit. Insist that visitors wash their hands before holding the baby, and ask anyone who’s ill to wait for a better time to visit.

Accept help When family members and friends ask if there’s anything they can do, it’s OK to give them a job. It can be as simple as watching the baby while you take an unhurried shower or a nap. If you have other children, let someone take them for a few hours or the whole day so you can have some alone time with the new baby. If someone is staying with you, let that person wait on you. You deserve it and need it, and it will probably make your guest feel special as well.

Keep your perspective The newborn days won’t last long. Before you know it, your infant will be a toddler, walking and talking. Try to step back and appreciate the moment, even amid the chaos.

• • • • •

Shifting roles for dads

Just a few decades ago, fathers weren’t expected to play much of a role in family life. Dads were viewed mainly as breadwinners. That meant long hours at work, which was generally a man’s first priority. Moms, as “homemakers,” assumed most or all of the responsibility of raising the children.

Today, this family structure is the exception. It’s been replaced largely by dual-earner couples and single parent households. As women spend more time at work, they expect more help at home, and men and women are increasingly sharing child-raising responsibilities.

It’s not just external influences leading men to be more involved with their families. Most dads today want to fully embrace their roles as fathers — being a “good father” means caregiving as much as being a breadwinner. Dads want to be there for their kids physically and emotionally. One new father explains: “I’d like to be close to our son. … and I’d like to do the things that maybe weren’t typical of a father before — feedings, changing diapers, holding him, getting him to relax before bed, walking with him in the middle of the night.”

Men’s shifting roles have led to new options and opportunities. For some men, shared parenting is better than “allowing work to take over every nook and cranny of your life,” as one dad puts it. For others, taking care of the children provides a greater sense of purpose and fulfillment. An increasing number of fathers are choosing to stay at home with the children while the mothers work outside the home. It’s an exciting new era of redefining traditional roles, one in which fathers have the opportunity to be much more involved in child care.

• • • • •

Adjusting to your new role

Taking care of a new baby is an awesome responsibility — both in the sense of “amazing” and of “what am I doing?” Infants depend utterly on their parents to meet all their physical and emotional needs. Even if you’ve dreamed about being a parent since you were a kid, the realities of dressing, feeding, bathing and performing the many other child care routines take time to learn. Along with the joy, excitement and fulfillment parenthood brings, don’t be surprised to experience doubts and uncertainties in your new role.

Feelings of incompetence are normal. Like many new parents, you may be going from a working life where you feel confident and successful to a job for which you lack experience and won’t get instructions or feedback from your new “boss.” You’re acquiring a whole new skill set at a rapid pace. Although the “maternal instinct” is supposed to kick in, new mothers (and fathers) don’t automatically know exactly what their babies need. You may feel anxious, helpless or powerless as you try to figure out why your baby is crying or not sleeping. Should you feed her, entertain her, or just let her take in the new surroundings?

If you’re wondering how you’ll handle one of life’s biggest responsibilities, take a deep breath and try to relax. Becoming a parent is a process. As you gain experience, you’ll learn to read your baby’s cues and begin to master the tasks of child care. In turn, your sense of competence and satisfaction will increase. As one mom remarked six weeks after giving birth, “I know how to put him back down to sleep. And I can tell if he’s hungry when he’s crying or he’s just tired. ... I have my little tricks now that I feel like I know him a little more.”

Believe in yourself Parenting brings a seemingly endless array of decisions. Where will baby sleep? Cloth or disposable diapers? What about child care? Ultimately, you’ll have to trust that you do know what’s best for you and your family. Each parent and each baby is an individual, so there’s no one right answer for every situation. Your parenting is now and always will be a work in progress. You’ll learn as you go.

Let go of being perfect These days, moms and dads experience a new level of anxiety as parenting has become a verb and often feels like a competition, posted for all to see on social media. You may find yourself searching online for the “best” way to care for your child or painstakingly following the latest trend in baby care. Well-meaning friends and family may offer unsolicited advice or critique your methods in an attempt to be helpful.

All of this external input can be exhausting. Try to filter the “noise” around you as best you can. Rely on a medical provider you trust, as well as evidence-based information from reputable sources, to help you answer your parenting questions. Quite often, you’ll find there are multiple ways of doing things that are acceptable. You have your child’s best interests at heart, and that’s what matters most.

Tune in to your baby Your baby will also help build your confidence. As you respond to your child’s needs, you receive in return a response — a contented gaze, a grasp of your finger, a fleeting smile and soon enough, an excited babble. Spending time alone with your baby, away from distractions, can be ideal for fostering this relationship. Bonding with your baby and learning his or her habits and rhythms takes time.

Build a network of social support Social support is one of the most important buffers against stress. Take time to seek out and appreciate individuals who can give you encouragement and practical help. This may include your partner, a friend, parents, siblings or neighbors. The quality of friendships is more important than the quantity of them.

Talking with other new parents can help you realize you’re not alone and that you’re in the same boat. Other parents can offer support and empathy. Find ways to connect with other parents in your neighborhood or community, such as a new parents group organized by a hospital, place of worship, community center or school district. You can also reach out to other new parents through online support groups or at the neighborhood park. By sharing stories, you’ll not only realize that you’re dealing with similar issues but you might also form strong, lasting friendships. Having friends who can really relate makes your journey easier and more fun.

Minimize stress Your bundle of joy also brings a bundle of stress, which typically accompanies any major life change. Besides the disrupted sleep, new responsibilities and changes in your lifestyle, other sources of stress include financial strain, hormonal fluctuations, changes in your identity, less time with your partner and for yourself, and loss of sexual activity (at least temporarily).

Realistically, you won’t be able to avoid stress altogether as a parent. But feeling stressed doesn’t make you a bad parent. Learning to handle the new challenges in your life can spur personal growth and help you enjoy the riches parenting has to offer. Your daily routine and the demands on your time and resources will continue to shift as your child gets older. But rest assured that with each new phase, you’ll find a new rhythm that works for your family.

Eat well and get some exercise every day, even if it’s just a couple of stretches or a short walk. Remember to do things you enjoy, whether it’s reading, lounging in the backyard or playing a half-round of golf.

Support your partner in his or her new role. Be an active listener. Whether your partner just wants to talk about how he or she is feeling or needs to vent — even if it’s not baby related — provide your undivided attention. Laugh together at your mistakes and remind each other that things will get smoother. Experiencing this life transition together can ease stress and make you stronger friends in the long run.

Grow with your child Many parents find that they have plenty of help with their newborn, but that assistance is less forthcoming when that baby becomes a toddler. While you’re sure to find yourself in a new routine with a lot more confidence in steering your toddler, still consider accepting help when it is offered.

The connections with other parents that you developed when your child was a young baby may develop into deeper friendships and play dates with active toddlers. Sometimes connections fade, and that’s okay, too. You’ll likely form a variety of social links as your child’s needs and preferences — as well as your own — change over time.

As your toddler becomes more active, but not yet ready for independent play, remember to continue to set aside one on one time with any other children, with your partner and with friends.

• • • • •

Focus on relationships, not guilt

Opinions on whether child care is good for kids can run strong. Some people insist that to be a good parent, you have to be home with your child. But there’s no evidence that children are harmed when their parents work, and good-quality, stimulating and nurturing child care offers some benefits. Spending time in child care can improve social competence, language development, independence, school readiness and peer interaction skills. See Chapter 15 for more on child care.

The most influential factor in parenting is not the sheer quantity of time you spend with your child but that you have a loving, nurturing relationship. For example, studies have found no difference between working mothers and stay-at-home mothers in the quality of mother-child interactions or their influence on children. And contrary to what some may think, both moms and dads are spending more hours a week on child care than they have in the past, in addition to more combined hours spent working. What’s important is that when you’re with your child — whether you’re a stay-at-home parent or you work outside the home — the time you spend together is quality time.

Whatever your choice, if you feel happy and fulfilled, your child will enjoy the happiness as well. If you resent your current arrangement or feel cheated by it, you’ll likely pass on these feelings to your child.

• • • • •

Juggling work and family

Working a full- or part-time job is a fact of life for a majority of American parents. While there’s no wrong or right way to mix work with parenthood, most parents would like to find a good balance between their jobs and their families.

Both moms and dads struggle with work-life balance. According to surveys, both are equally likely to say that parenting is a big part of their identity, but a good number also feel “rushed” or constantly pressed for time. Despite the challenges, it is possible to manage and even thrive with the juggling routine. Here are some suggestions for creating balance.

Embrace ‘good enough’ If you’ve always set high standards for yourself, this is the time to let go of perfectionism. Balance requires being good enough rather than perfect. Your home might not be as tidy and organized as it was before you had a child. You might not have time to cook meals from scratch anymore or go out as much as you used to. Maybe you can’t work as many hours a day — or get as much done. Focus on the positive aspects of your situation, and let go of guilt about what you’re doing or not doing.

Seek flexibility If possible, talk to your employer about creating a work schedule where you can be both productive and in tune with your family. Today’s workforce is changing in many ways, and more family-friendly options — such as flexible hours or working from home — are becoming available.

If you and your partner are both employed, consider who might have more flexibility at the moment and work together to create an arrangement that is positive for the whole family.

Get organized Make a to-do list. Divide the list into tasks for work and tasks for home, or divvy up tasks between you and your partner. Identify what you need to do, what can wait — and what you can skip entirely. Organization can help you get more work done in less time.

Seek support Accept help from your partner, loved ones, friends and co-workers. Speak up if you’re feeling guilty, sad or overwhelmed. If you can afford it, consider paying for weekly or biweekly housekeeping to have extra time for your family or yourself. Keep up your friendships, whether for a night out or for people you can call to talk with or to ask for baby-sitting help.

Long days, short years

Despite the ups and downs of these first few years, chances are your sense of accomplishment and joy will make up for the long days and nights, the fatigue, and the worries. As your baby grows and changes, you’ll grow and change, too. You’ll create new routines, discover your parenting quirks and learn from missteps. You may even discover a new sense of meaning in life, greater self-esteem, and a deeper connection to your family and community.

CHAPTER 37 Parenting as a team

As new parents, you’re busy keeping your child fed, clean, safe, loved and nurtured. But parenting also entails getting dinner on the table, doing laundry, keeping up with housework and earning money to support the family. Along with sharing the joys and pleasures of parenthood, you and your partner must also juggle a never-ending, round-the-clock set of tasks and responsibilities. The stepped-up demands of life with a child require you to negotiate new arrangements for dividing up duties. At the same time, your relationship as a couple is changing as your focus shifts to your child and you have less time and energy for each other.

Sometimes, these new stresses — especially when layered on top of sleepless nights and altered routines — can set the stage for strife and ambivalence. Yet it’s possible to learn to adapt to family life while maintaining a positive view of your relationship with your partner. What makes the difference? Creating practical strategies to share decisions, responsibilities and rewards. Staying alert to potential pitfalls as well as new opportunities for closeness. Remaining committed to preserving a deep connection with your partner. The goal is to work as a team.

As you and your partner develop complementary roles and support, you may be surprised at the strengths you uncover. And the stronger your bond is, the more effective you’ll be as parents. A supportive, mutually satisfying relationship serves as the foundation for a healthy, happy family.

A new bond

Many couples say that having a child brought them closer than ever, and it gave them a new and powerful point of connection. Watching your partner cuddle with the baby, lying next to one another with the baby nestled between you, joining hands with your child as he or she takes those first wobbly steps — sharing moments such as these bonds you and your partner in new ways.

Many people also appreciate the feelings of closeness and belonging that come with being in a family. You and your partner may feel a sense of achievement and fulfillment, especially if you’ve both longed for a baby or your journey to parenthood included a few bumps in the road. A baby can be a powerful symbol of your love and commitment. And then there’s the fun and humor you enjoy together, from the silly stuff you do to entertain your baby to the sight of your child covered in peas or carrots as you start solid foods. You can even bond over your tales from the trenches, such as surviving a week of the flu.

New challenges

The rewarding moments are interspersed with the day-to-day stresses of child care and housework. The first year or so of parenthood can be especially hard on a couple’s relationship. No matter how well you got along before the baby arrived, you may find yourselves disagreeing and becoming annoyed with each other now. As one new mom says, “We bickered. We said crazy things to each other that we never did before.”

Part of the problem in the first year is the unique demands of caring for an infant, including the lack of a regular schedule, the crying and the nighttime feedings. Infant care adds an estimated 35 to 40 hours of work each week to the average household. Many new parents say they didn’t realize how difficult and time-consuming caring for a baby would be. In addition, disagreements that might have lived in the background — about life goals, for example, or how to handle finances — may be brought to the forefront. Other issues also may put a strain on your relationship.

Division of labor Along with sex and money, the issue of “who does what” is one of the most common arguments among couples. How partners divide their responsibilities both inside and outside the home is an ongoing source of discussion and debate, not only in individual couples but also in books, blogs and articles about parenting.

Less time as a couple After your baby arrives, your couple time may seem to vanish overnight. Gone are the leisurely meals, evenings snuggling in front of the TV and impromptu nights out. Now that you’re a family, you have less time, energy and attention to devote to your partner. Even your identity as a couple may seem threatened at first. “It was always about the baby,” notes one mom. You may feel less like a couple and more like business partners checking items off your endless to-do list.

Fatigue and exhaustion Lack of sleep adds to couples’ stress. Sleep deprivation can make you irritable toward anyone, but perhaps especially toward someone who shares your living space and who very likely is also sleep deprived. You might find it harder to convey your needs and goals in an effective way. It may also be harder to consider your partner’s point of view. Both skills are essential for healthy communication.

Decline in disposable income The financial squeeze of increased costs, along with a possible dip in income if one parent reduces work hours, can leave you with little money to spend on a baby sitter or outings as a couple.

Changing roles Most parents struggle with the competing demands of work, parenting and their relationship. In dual-earner families, which accounts for the majority of two-parent families with children these days, balancing the competing demands can be challenging. Even though men are taking a more active role in caring for children and doing housework, working moms often spend more time handling child care and household chores than dads.

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Added stresses

Some couples may be more prone than others to relationship problems after the birth of a baby. You may be more at risk of stress during this transition if you:

Are young

Are unmarried

Haven’t been in the relationship for very long

Have an unplanned or unwanted pregnancy

Are experiencing depression or another mental health disorder

Are going through other stressful life events

Grew up with parents who had a poor relationship

Had a poor relationship with your parents during your childhood

Have an infant with a difficult temperament

If you’re dealing with one or more of these issues, the first step is to be aware of the risk, and take steps proactively to bolster your relationship. Seek support from family, friends or a counselor if you’re struggling.

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Sharing the load

Who will do the baby’s bath? Who’s responsible for planning meals, buying the groceries and cooking? Will you or your partner be the one to work more hours or spend more time at home with the baby?

As the saying goes, “The devil is in the details.” Working out the nitty-gritty of the day-to-day duties causes many of the conflicts among parents. Before childbirth, most parents-to-be share the ideal of participating equally in family life, household management and child rearing. After childbirth, traditional gender patterns may reassert themselves, even among nontraditional parents. Although both partners may have similar workloads overall, one may spend more time doing paid work, while the other puts in more hours on the home front. The difference between expectations and reality can sometimes come as a surprise and disappointment to both partners.

To avoid this scenario, jointly work out a division of labor that distributes the stresses — and the rewards — of parenthood. It’s not that you have to split all the responsibilities of life 50-50, but you want to come up with a plan that you can both embrace — one that allows you to work as a team in caring for your child and sharing decisions and tasks.

How much responsibility should you each take on? Negotiate. Make a list and talk about what you can do, want to do and are good at. Structure the arrangement as an experiment, and tweak it as you go. Keep communicating about what’s working and what’s not. One dad comments, “It’s a lot of give and take. In the morning I wake (the baby) up, get her dressed, and I get her out the door. (My wife) picks her up, she takes care of her while she’s cooking, and when I get home we feed her together. Then my wife takes care of her while I do the dishes and then we play for a while. I put her to bed.”

Acknowledge different priorities Discuss what matters most to each of you in terms of your child, your career, your free time and the household chores. You and your partner aren’t going to agree on everything — and you probably won’t find a perfect balance. Be willing to negotiate some compromises. When you’re dividing up household chores, take into account your preferences and strengths and the most efficient use of your time.

Stay flexible about how things get done Your partner won’t do chores and child care the same way you do. Agree that it’s OK for each of you to have different ways of doing things, as long as you’re providing consistency for your child.

Avoid scorekeeping You and your partner are on the same team — you don’t need to keep score. Instead of taking inventory of everything your partner is (or isn’t) doing, trust that you’re both committed to your family’s success. Work together to solve problems, and show gratitute for what your partner does. Pitting yourselves against each other shortchanges everyone.

Watch out for gatekeeping Your partner always dresses the kids wrong, constantly leaves the house a mess or can’t seem to soothe a crying baby. Does this sound familiar? You may be falling into the trap of thinking that only you know how to do things the “right” way.

This phenomenon, known as “gatekeeping,” happens when one parent assumes he or she knows more about child rearing than the other parent or criticizes the other parent’s efforts. You can positively influence your partner’s involvement by encouraging his or her efforts and ensuring that each of you has opportunities to gain experience.

Consider alternatives If you can afford it, think about hiring someone to help with the housework or yardwork. But be clear whose responsibility it is to make those arrangements. Join a baby-sitting co-op, if available, or start one yourself.

Nurturing your team

To parent together as a team, you have to nurture your couple relationship as well as your child. You and your partner depend on each other for support, both physically and emotionally. By tending to your relationship, you’ll feel more satisfied as a couple. In turn, this improves your parenting ability. Studies show that couples who experience ongoing conflict are less responsive and sensitive to their infants in their first year of life. Negativity in a couple’s relationship expands to family interactions.

On the other hand, supportive, mutually satisfying couple relationships enhance the well-being of the whole family. Making a special effort to see yourself not just as a mother or father, but as a partner, is good for both of you — and your child. Here are some other ways you can nurture your team.

Communicate openly Discuss issues and difficult situations as they arise. Express your feelings, and be specific and honest about your concerns. Don’t use this as an opportunity to blame or criticize your partner. Make sure you both have time to talk.

Set realistic expectations Couples do better when they share realistic expectations about their relationship and parenting. Discuss what you expect of each other and your family life. Acknowledge that the first years of parenting are challenging and your relationship requires maintenance.

Encourage each other Both of you need support and encouragement in handling the challenges of parenting. Be sure to talk about what’s positive as well as what’s more difficult. Tell your partner what you need to feel supported, and do the same for him or her. Discuss how well your needs are being met.

Be courteous and considerate When you’re feeling depleted or overwhelmed, you’re more prone to lash out at your partner and to be less forgiving. Try not to let courtesy and caring go by the wayside. Cut yourself and your partner some slack by not overreacting if one of you is irritable. Try to see situations from your partner’s point of view.

Be adventurous Plan something small but special for your family each month, and look forward to it together.

Rekindling romance

Sex after pregnancy happens. Honestly. But it might not happen very soon, or very often — romance usually isn’t a priority for new parents. Many factors contribute to a decrease in sexual activity in the first year after childbirth. These may include vaginal soreness, exhaustion, postpartum blues, an unpredictable schedule, changes in libido and body image, and the adjustment of going from partners to parents. Your bedroom may have turned into a nursery, pumping station and diaper storage center — not exactly conducive to romance.

Some women feel ready to resume sex within a few weeks of giving birth, while others need a few months or longer. In surveys of new parents, most say they’re having sex by six weeks after the baby is born — and most also say that sleep is more important than sex, and they’re not having sex as often as they did before.

New moms need time to let their bodies heal, whether the birth occurred vaginally or by C-section. Many medical providers recommend waiting six weeks before having sex. This allows time for the cervix to close, postpartum bleeding to stop, and any tears or repaired lacerations to heal. After a vaginal delivery, decreased muscle tone in the vagina may reduce pleasurable friction during sex — which can influence arousal. This is usually temporary. Due to hormonal changes, the vagina may be dry and tender, especially during breast-feeding. If this is bothersome, talk to a medical provider about estrogen cream to alleviate some of the dryness.

Until you’re ready to have sex, you can maintain intimacy in other ways. Spend time together without the baby, even if it’s just a few minutes in the morning and after the baby goes to sleep at night. Share short phone calls throughout the day or occasional soaks in the tub. Rekindle the spark that brought you together in the first place.

Most sexual problems that occur after pregnancy resolve within a year. In the meantime, concentrate on promoting your physical and mental health, be patient, and ease back into intimacy and sex.

Agreeing on child rearing

From infancy on, child rearing brings countless decisions about a range of issues — rules and expectations, discipline, structure and routines, time with grandparents, and exposure to TV and other media, to name a few. Granted, during your baby’s first year or so, discipline won’t be a major issue, but by the time he or she is a toddler, you’ll be dealing with misbehavior as your child tests the limits. You may not know exactly what those limits are yet, but commit to talking them over with your partner and presenting consistent guidelines for your child.

New parents tend to emulate their own parents in their child-raising beliefs and behavior — though some people make a point of doing the opposite of what their parents did. What’s important is for you and your partner to discuss your parenting beliefs and come to agreement on the strategies you’ll use. For example, what type of consequences will you set when your toddler breaks a rule? How will you handle tantrums or requests to sleep in your bed? How will you encourage cooperation?

You and your partner may not agree on everything. Acknowledge any differences, and develop compromises that allow you to maintain a united front. Make sure you and your partner (and other adults who care for your child) observe the same rules and discipline guidelines. This reduces your child’s confusion and need to test you. Work together to provide love, attention, praise, encouragement and a degree of routine.

Both you and your partner come to parenthood with inner visions of what you hope it will be. To build a life that satisfies both of you and nurtures your child, share your core values and choose goals that matter to both of you. Some partners don’t want to discuss their hopes and anxieties because they’re afraid that they’ll reveal unbridgeable differences or start major conflicts. But confiding what you hope will happen and what you’re concerned about strengthens the bond between you.

A firm foundation

Your relationship with your partner serves as the foundation for your family. You make your foundation stronger by engaging with each other with respect and mutual appreciation, sharing tasks and responsibilities, and regularly tending to your relationship. Parents in satisfying relationships report feeling more confident in their parenting and more resilient in the face of challenges. They’re less worried and stressed.

Your parenting patterns are the least stable during your baby’s first year. Over time, you’ll establish patterns that work for you, and the stress on your relationship will ease. Practice does makes perfect — handling the initial challenges together will help you and your partner weather future stresses better.

By approaching parenting as a team, you create an optimal environment for your baby to grow and form a secure attachment to you. You’ll set the tone for an affectionate, communicative family life. For all the challenges parenting brings, you and your partner are also in for a lot of fun, love, surprises and deep satisfaction.

CHAPTER 38 Single parenting

If you’re raising your baby on your own, you’re not alone. Single-parent families are more common than ever — more than one-fourth of children in the United States live with one parent, according to the U. S. Census Bureau. Although most single-parent households are headed by mothers, the number of single fathers is increasing. Close to a quarter of single parents today are fathers, compared with 14% in 1960.

Whether by choice or otherwise, parenting without a partner brings special challenges. The responsibility for all aspects of daily child care may fall squarely on your shoulders. Juggling work and child care can be financially difficult and socially isolating.

But single parenting can also be rewarding, and it can result in an especially strong bond between you and your child. Yes, you can raise a healthy, happy child while tending to your own needs and happiness as well.

One of the keys to raising a child on your own is to develop a solid support network. Other strategies also can help you manage the challenges that come with the territory.

Hard work, added pressure

All new parents face many of the same challenges in taking care of a baby and raising a child. But parenting without a partner puts more pressure on you. Along with handling the day-to-day duties and decisions, it’s up to you to support your family. One woman who chose to become a single parent felt panicked after she came down with a severe bout of flu: “What if anything happens to me?” Another single mom worried, “What happens if (my baby) gets sick, and I have to go to work? Will I lose my job because I’m on my own?”

Many single parents can relate to these fears. You may face several specific challenges as you adjust to your new role and raise your child.

Financial and work issues Single parents often are the sole providers for their families. For some, being the only earner can make it hard to make ends meet. Single parents may also find it more difficult to build a safety net for emergencies. In general, single parents tend to have fewer financial resources than partnered parents.

To juggle their work and caregiving roles, some single parents find that they may need to reduce their work hours, turn down promotions or take less demanding jobs. Single parents in rural areas may lack public transportation, employment opportunities, family support programs and subsidized child care centers.

Still, single parents can find creative ways to make their financial situations work for them. Here are some suggestions to consider.

Assess your finances Make a list of your income and expenses so that you can budget your money. Will you receive child support? Pay for child care? Now that you have a child, your expenses will likely increase, and your income may be altered if you shift to fewer hours or change jobs. If necessary, seek financial advice from a trusted source. Some communities, local libraries or banks regularly offer free financial workshops.

Cut down on spending If you need to make the most of money coming in, figure out where you can minimize money going out. Some expenses are have-to’s but others may be decreased or cut. Take advantage of free or low-cost activities, and eat out less often.

Prepare for emergencies Even if money is tight, try to build up an emergency fund. Ideally, you’d have enough to cover several months’ expenses.

Find out if you qualify for assistance Public programs offer supplemental nutrition assistance and subsidized child care and housing that can help you stay afloat. In addition to receiving federal benefits, you may qualify for grants, scholarships and other assistance from state governments, private foundations and faith-based organizations.

Check into employment resources If you need help with finding a job (or getting a better job), contact your state employment office.

Consider getting more education Getting a high school diploma, college education or special training can boost your chances of finding a job.

Getting it all done The advantage of being a single parent is that you automatically have final say in all household and child-rearing decisions. You don’t have to worry about fighting over where your baby will go for child care or what foods are best for your toddler. On the other hand, you bear the burden of child care and housework, including the logistics, organizing and planning. As one single mother notes, “There is a constancy of parenting on your own that you don’t understand until you’ve had to do it. Nothing ever stops. The minute you wake up in the morning, you hit the ground running, and needs don’t stop until you pass out. That’s when things go right.”

Support issues In the first weeks and months after having a baby, you’ll likely be feeling more physically and emotionally vulnerable. As a single parent, it’s important to reach out for support — see the suggestions here.

Being a single parent in itself doesn’t increase your risk of depression or other mental health problems, but single parents are more likely to have other risk factors for depression, such as financial hardship and unemployment. Keep in mind that having a partner doesn’t help much if your partner isn’t supportive. A relationship with an unsupportive partner may be worse for your mental health than is single parenting.

Emotional challenges Many single parents say that the emotional challenges of single parenting can be as difficult as the practical ones. It’s hard to feel exhausted all of the time and not have someone to hand your child off to for a break when you need one. You might feel guilty about raising a child without another parent. If your relationship with the other parent has ended, you may be grieving the loss of your partner, as well as your dreams and visions of how your life would be as you raised your child together.

Acknowledge your feelings and mourn any losses, even if you don’t regret your choices. If you’ve recently lost a partner or are going through a divorce, recognize that it can take months or even years to resolve the emotional ups and downs that follow. As you accept your new reality and your feelings, you can form a new life and create new dreams.

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Single dads

One of the first hurdles single fathers must face is their invisibility in society. When people hear the words “single parent,” they usually think of a mother. But in the United States, close to 2 million fathers are raising kids on their own. Most became single parents as a result of divorce, separation or out-of-wedlock birth.

In general, single fathers have higher economic status compared with single mothers but are older and have a lower level of education.

Finding support and a peer group for single dads can be a challenge. Many parenting classes, support groups, play groups and books are geared toward women. As a single father, you might feel like you stick out at the playground. You might not appreciate the unsolicited advice you get. Eventually you’re likely to meet other men in the same situation. And if you don’t, make an effort to seek out — or create — a support group in your community.

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From surviving to thriving

As a single parent, some days it may feel like you’re doing all you can just to survive. It will get better. As one mother says, ”I learned that regardless of whether or not this is the life I planned, this is my life and I need to embrace it. I love being a mom and wouldn’t trade it for the world. My son makes all of the difficult times worthwhile.”

Several strategies have been shown to improve outcomes for single-parent families. With these in mind, you can create an environment that helps you and your baby thrive and grow.

Seek and accept support Probably the most important thing you can do as a single parent is to develop a strong support network. Practical and emotional support from others can not only help you handle your responsibilities but also boost your well-being. Asking for help can be hard on your pride, since many people are brought up to believe they should and must do everything by themselves. But it’s better to lean on others a little than to become so overwhelmed or stressed that you can’t parent effectively.

Many single moms say their own mothers are their best sources of both practical and emotional support. You can also turn to other trusted family members, friends or co-workers. Ask for what you need, whether it’s someone to babysit while you run errands, a friend to call when you need to talk, or someone who’s willing to provide backup child care if your baby is sick or your regular arrangement falls through.

In addition to seeking help from family and friends, look for a support group for single parents, or seek social services. Faith communities can be helpful resources, too. A support group, whether in person or online, offers a great opportunity to share feelings and get advice.

Find quality child care Good child care is crucial for your baby’s well-being and your peace of mind. If you need regular child care, look for a qualified caregiver who can provide stimulation in a safe environment. See Chapter 15 for more information. Many single parents say they view their child care providers as valued partners in raising their children.

Be careful about asking a new friend or partner to watch your little one. Anyone who cares for your child should be someone you know and trust and who has some experience with young children.

To learn more about child care in your area, contact your local child care resource and referral (CCR&R) agency. The agency can help you find out if you qualify for free or subsidized child care. Links to state CCR&R agencies are available through Child Care Aware of America (www.childcareaware.org). You can also find child care resources by state at the Office of Child Care (https://childcare.gov). The federally funded Head Start program serves infants and toddlers in low-income families. Local government, United Way agencies and other community or faith-based organizations sometimes provide child care scholarships. Some employers may provide child care benefits or discounts.

Aim for a stable family life Changes in family structure, such as one parent leaving or a new adult entering the family, can be hard on kids. Try to ensure consistency in your family and your child’s caretakers and, if possible, keep moves and major changes to a minimum.

Create routines Family routines — such as regular bedtimes, mealtimes, naps and reading — promote good health and cognitive development in children. A lack of bedtime and mealtime routines, for example, increases the risk that children will have sleep problems, eat a less healthy diet and become overweight.

Single-parent families are often less likely to keep daily routines for young children than are two-parent families. Some of the reasons include time constraints, financial pressure, fatigue and lack of support. Do the best you can to establish routines.

During your baby’s first months, you’re still helping him or her develop regular sleep habits, and the feeding schedule might vary from one day to the next. As your child gets older, create a regular schedule for meals, naps and bedtime. If you’re having trouble establishing daily routines, figure out what’s in your way and brainstorm solutions. You can also seek assistance from your child’s medical provider.

Take care of yourself To take good care of your child, you must take good care of yourself. Include physical activity in your daily routine, eat a healthy diet and get plenty of sleep. Make sure you get some “me time” regularly. Time away from your child will help replenish your energy and spirit, helping you to be a better parent. Even taking 15 or 20 minutes to relax can be helpful.

Of course, this is all easier said than done. Here are some tips:

Arrange for a baby sitter for a few hours once a week so you can get out of the house and do something you like, either by yourself or with friends.

Find a gym membership that includes child care.

Take naps when you can.

Read or walk on your lunch break.

Work out or read a magazine after your child is in bed.

Once your child is sleeping regularly, get up a little early to enjoy a quiet cup of coffee or do some yoga stretches.

Reduce stress with relaxation techniques.

Let go of guilt about taking time for yourself.

Accept your limits, and don’t be too hard on yourself.

Prioritize family time Throughout your child’s life, and particularly in the early years, time with parents is important to health and development. Single parenting can put the squeeze on your time with your child. Make it a priority — even if it means having a messier house or not getting something else done that day. Set aside time each day to cuddle, play with or simply hold your child. Find out if you can modify your work schedule to have more time with your son or daughter.

Get organized Being organized can help reduce stress. Try these tips:

Stock up on basic household supplies, such as toilet paper and diapers, as well as easy-to-prepare foods and meals that can be frozen and reheated.

Eliminate clutter.

Plan your week on a calendar.

Develop a list of timesavers.

Keep a list of baby sitters.

Prioritize. Figure out what’s most important for your child’s needs and your needs, and focus on those.

Provide opposite-sex role models Children benefit from interactions with both women and men. If your child’s other parent isn’t involved, create opportunities for your son or daughter to interact with an opposite-sex adult who can be a positive role model. It doesn’t have to be a romantic partner. If you’re a single mother, spend time with a responsible, positive male family member or trusted friend. Involve the men in your life in family rituals, such as holidays and birthdays.

Stay positive Make a conscious decision to focus on the positive and not dwell on the negative aspects of single parenthood. Try to keep your sense of humor when dealing with everyday challenges, and don’t forget to have fun. Take a break from the routine and plan a fun activity you can do with your child, such as a hike in the park, trip to the zoo or picnic with friends.

One single mother advises recognizing your accomplishments and blessings: “Give yourself a pat on the back daily. What worked out well and what made you smile today? There is no question that being a new single mom is one of the hardest challenges life will throw your way, but you will get through it and it will get better.”

If you’re feeling down much of the time or find yourself stuck in a pattern of negative thinking, talk to your doctor, a counselor or a psychologist.

Rewards and strengths

Despite the challenges, being a single parent can bring great rewards, including a deep parent-child bond. In this relationship, the parent and child depend on each other, and they may become more communicative and supportive. Over time, you may create special routines and rituals together or discover places you like to go and things you like to do.

Children growing up in single-parent families often learn to take on more responsibility at home and develop self-reliance. As for the parents, many say they find a strength they never knew they had. Some also appreciate the freedom to make child-rearing decisions on their own, without constant negotiation and compromise. You may find yourself with a welcome clarity about what’s important and learn to let go of what’s not. As a single parent, you can take pride in your accomplishments and feel good about what you’re giving your child.

If at first you feel overwhelmed and alone as a single parent, overcoming such feelings can foster a sense of inner strength. As one parent comments, “I have done things I never thought I was capable of all by myself. I am in control of my own happiness.”

CHAPTER 39 Siblings and grandparents

Bringing home a new baby can be an exciting experience for your family. If you already have one child or more, your baby is a new sibling. He or she will likely become someone your older child or children will play with, laugh with and share a lifelong relationship with. If this is your first baby, your parents might be more eager than you expected to dote on and help care for your newborn. You and your partner might also begin to view your parents and your relationships with them differently.

Bringing a newborn home can require some adjustments within a family. Babies need a lot of attention — which can cut into the amount of time you spend with your older child or children and cause jealousy. Grandparents, on the other hand, may be so excited about your new baby that they unknowingly overstep certain boundaries, such as by giving unwanted parenting advice.

Don’t underestimate the impact your tiny newborn might have on your family. Consider your personal family dynamics, and understand how you can help your older child or children, as well as your parents, adjust to their new roles.

Siblings

The experience of bringing a newborn home is a little different the second time around. With your first child, you were probably focused on the transition to parenting and figuring out how to care for a baby. With the second — or third or fourth — baby, you’re more likely wondering how your older child or children are going to react to having a new sibling and how you’re going to juggle and meet all of their needs. Help set the tone for your children’s early interactions by preparing your older child or children for what’s ahead.

Introducing your new baby You’ve probably been talking to your older child for a while now about the arrival of your new baby. Perhaps your child has asked questions about mom’s growing stomach, gone along to prenatal checkups or helped set up the nursery. Or maybe your child attended a sibling preparation class at your hospital. But it may still be difficult to know how your child will react to an addition to the family and the changes a new baby will bring.

While older children are typically eager to meet a new sibling, young children may be confused or upset and have a hard time adjusting — especially as the new baby sleeps less and begins to demand more of your attention. Explain to your older child that your newborn will probably cry, sleep and eat most of the time. The baby won’t be a playmate right away.

To minimize the stress your child might experience once the new baby comes, think ahead. If your child will need to change rooms or move out of the crib so that your new baby can use it, do this before the new baby is born. It will give your older child a chance to get used to the new setup before dealing with the other changes associated with the new baby’s arrival. Arrange for your child’s care during labor and delivery, and explain the plan to your child.

When the new baby arrives, arrange to bring your child to the hospital for a brief visit to meet your newborn. This is a great way for your child to meet the new baby and spend special time with mom and dad. Ask another family member to hold the baby for a while so that you can give your older child plenty of cuddles. Consider giving your older child a gift that’s from the baby — such as a T-shirt that says big brother or big sister — to celebrate the new baby’s arrival.

• • • • •

When your newborn is sick

If your new baby has health problems, try to answer your older children’s questions about the new baby simply. You might explain that their baby sister or brother is sick, and you’re worried. Reassure your children that the baby’s illness isn’t their fault. If your baby needs to stay in the hospital after he or she is born, ask about the sibling visitation policy. You might also take pictures of the baby and show them to your older children.

Keep in mind that even if you don’t talk to your older children about the baby’s illness, they will sense that something is wrong and may act out to get your attention. Rather than keeping them in the dark, give your older children some basic information about the situation, and do your best to show that you are there for them.

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Sibling reactions

Your older child’s age and development will affect how he or she reacts to having a new sibling.

Children under age 2 Young children likely won’t understand yet what it means to have a new sibling. Try talking to your child about the new addition to your family and looking at picture books about babies and families.

Children ages 2 to 4 Children at this age may feel uncomfortable sharing your attention with a newborn. Explain to your child that the baby will need lots of attention. And encourage your child’s involvement by taking him or her shopping for baby items. Read to your child about babies, brothers and sisters. Give your child a doll so that he or she can practice taking care of it. Look at your child’s baby pictures together. Tell him or her the story of his or her birth.

If there’s time, complete your child’s toilet training before the baby is born. Otherwise, wait until a few months after you bring your baby home to start the process. Keep in mind that siblings sometimes regress after the arrival of a new baby — such as by having toilet training accidents, drinking from a bottle or asking to be carried to bed. They want to be sure they still have your attention. There’s no need to punish such behavior. Instead, give your child plenty of love and assurance. Don’t forget to praise your child when he or she demonstrates good behavior.

School-age children Children age 5 and older generally are pretty excited about having a new baby in the house. But they also may feel jealous of how much attention the baby gets. Talk to your child about your newborn’s needs. Encourage your child to get involved by helping to decorate the baby’s room with handmade artwork and participating in taking care of the baby. Be sure to explain the importance of being gentle with the new baby. Point out to your child the advantages of being older, such as being able to go to bed later or play with certain toys. Show your appreciation for your child’s help in caring for and entertaining the baby and share your delight in the baby’s behaviors.

All children Regardless of your older child’s age, make sure that he or she gets plenty of individual attention from you and other family members once your baby arrives. Grandparents can be particularly helpful during this time. Watching mom and dad coo over a new baby can be frustrating for an older child. If you’re taking lots of pictures or videos, be sure to include your older child, too. Take some pictures or videos of him or her alone, as well as with the new baby. During your newborn’s feedings, try to make your older child feel included by talking or reading stories together. Reassure your older child that you love him or her and your new baby. And remind your older child that he or she has an important role to play now, too — that of big brother or big sister.

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Teaching gentleness

Sometimes older children, stressed by the changes happening around them, take out their frustrations on a new baby. If your older child tries to pull your baby’s hair, take away the baby’s bottle or harm the baby in any way, it’s time for a serious talk. Take some time to calmly explain to your older child that he or she isn’t allowed to hurt the baby. In addition, make an effort to give your older child some extra attention, and include him or her in activities that involve the baby, such as singing, bathing or changing diapers, to encourage positive interaction between the siblings. Keep in mind that, for safety reasons, you shouldn’t leave your newborn alone with a child who is younger than age 12.

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Sibling rivalry

Right now, sibling rivalry may not be a concern, but it can become an issue as your youngest gets older and competes with other children for parents’ love and respect. Signs of sibling rivalry might include hitting, name-calling, bickering and regressive behavior. This kind of behavior is common after the birth of a new baby — but it can also happen anytime one child in the family receives extra attention.

While sibling rivalry is a natural part of growing up, many factors can affect how well your children might get along with each other, including their sexes, ages and personalities, as well as the size of your family and each child’s position in it. For example, younger children might be more likely to fight physically, while older children might argue instead.

Children who have less than a two-year age difference might battle each other more than children who have bigger age gaps between them. Although children of the same sex might share more of the same interests, they might also be more likely to compete against each other. Middle children might feel less secure and be more likely to seek affection because they may believe they don’t get the same privileges or attention as the oldest or youngest child in the family.

Although all siblings are bound to fight, tease and tattle on one another at some point, there are things you can do as a parent to encourage healthy sibling relationships now and as your children get older. Consider these tips.

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Sibling safety hazards

If you have an older child, you probably have toys in your home with small pieces that an exploring baby could easily choke on or swallow. Be sure to round up games and toys that have small parts, and keep them out of your baby’s reach. When your older child wants to play with these kinds of toys, keep the toys in an enclosed area. This will give your older child a chance to play without fearing the intrusion of little hands. Encouraging your children to play separately with their own toys may also help you sidestep a few battles — especially if your older child is younger than age 3 and isn’t eager to share his or her things. For more information on childproofing your home, see Chapter 17.

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Respect each child’s unique needs Treating your children uniformly isn’t always practical — and the harder you try, the more your children may look for signs of unfairness. Instead, focus on trying to meet each child’s unique needs.

Avoid comparisons Comparing your children’s abilities can cause them to feel hurt and insecure. While it’s natural to notice your children’s differences, try to avoid discussing them out loud in front of your children. When praising one of your children, stick to describing his or her action or accomplishment — rather than comparing it with how his or her sibling does things.

Set the ground rules Make sure your children understand what you consider acceptable and unacceptable behavior when it comes to interacting with each other, as well as the consequences of their misbehavior. Consistently follow through with consequences, such as a loss of certain privileges or a timeout, when your children break the rules.

Listen to your children Being a sibling can be frustrating. Let your children vent their negative feelings about each other, and listen. Respond by showing your child that you understand what he or she is feeling. If your child is old enough, you can ask him or her to help in devising an acceptable solution to whatever is bothering him or her. If you have siblings, share stories of conflicts you had with your brother or sister when you were a child. Holding regular family meetings can give your children a chance to talk about and work out sibling issues.

Don’t take sides Try to avoid being drawn into your children’s battles, unless physical aggression is involved or safety is in jeopardy. Encourage your children to settle their own differences. While you may need to help younger children resolve disputes, refrain from taking sides. In addition, avoid using teasing or derogatory nicknames for your children that might perpetuate sibling rivalry.

Give praise When you see your children playing well together or working as a team, compliment them. A little praise and encouragement can go a long way.

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Managing siblings during breast-feeding

If you’re breast-feeding your baby, you may wonder how your older child will react to your nursing sessions — or how to keep your older child busy while you nurse. Try not to worry. Your child will likely express curiosity and may hover upon first seeing you breast-feed. Simply explain what you’re doing, and try to answer any questions your child might have. If you breast-fed your older child, explain that you did the same thing for him or her when he or she was a baby. To keep your child entertained while you nurse, consider setting out a couple of toys, picture books or even a special new item to play with only while baby is nursing. You might also play music or audio versions of children’s books.

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If you have multiples

Sibling rivalry often isn’t an issue for twins and other multiples. While the children may compete against each other, multiples typically also depend on each other and develop close relationships early on. However, they may have problems maintaining their individuality. For example, twins are often treated as a unit, rather than as two children with unique personalities. As a result, twins are often dressed alike and given the same toys. If you have multiples, pay attention to their different needs and try to foster individuality.

Multiples can also cause other children in the family to feel left out or jealous — since they are not part of this unique relationship. If you have multiple babies and an older child, be sure to spend plenty of special one-on-one time with your older child. Also, encourage your multiples to play separately with other children. For example, arrange a play date for one of your twins while the other twin plays with a sibling. Your multiples may resist separation, but being able to be apart without anxiety is a skill your children will benefit from as they get older. For more information on multiples, see Chapter 42.

Grandparents

Grandparents can play a major role in your newly expanded family. Your parents (yours and your partner’s) will likely give you and your partner emotional support and encouragement, and calm first-time parent jitters as you figure out life with a baby (and soon enough, a toddler).

They may share their experiences as well as helpful tips. They’ll likely be great baby sitters and helpful in a pinch. Grandparents can serve as role models for the kinds of parents you want to become. And, best of all, they can provide your child with a special kind of love and affection that can only come from grandparents.

Changing relationships The arrival of a baby often causes new parents to re-examine their relationships with their own parents. As you prepare for your future as parents, it’s only natural that you and your partner think about the ways in which you were raised — what you would like to carry forward from the past or would like to change. In the process, you might find that you have questions for your parents about how they handled becoming a mom or dad and why they made certain decisions. Your parents will likely be able to share advice, discuss some of the ups and downs they experienced as new parents, and reassure you that you’ll be able to handle your new role.

Typically, the birth of a new baby brings families closer together, giving new parents and their parents a chance to renew and strengthen their bonds. But the shift in your role and your parents’ roles may not always go as smoothly as you might hope. You and your parents might unknowingly have different understandings and expectations of your new roles. Make an effort to talk to your parents about how you feel about becoming a parent and your parents becoming grandparents — and be sure to listen to their feelings on the subject, too.Be sure to keep the conversation going as your child gets older.

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Giving grandparents time

Sometimes, new grandparents aren’t quite ready for their new role. They may still have career aspirations and life plans, and the idea of being grandparents may make them feel old. If your parents are uncertain about becoming grandparents, give them an honorable out. Don’t immerse them in all of the grandparent language or expect them to perform the traditional grandparent duties or tasks. With time, things may change, but until your parents are ready, take it slow.

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Receiving help As you navigate the early years of parenthood, your parents will likely want to provide help and support. Sometimes, however, the support you get isn’t the support you need. For example, excited new grandparents might want to come to stay for a few days once the baby is born. While some new moms and dads might find this helpful, others might find it stressful. Or grandparents may have different views from yours — and sometimes, pretty strong opinions — on when to introduce solid foods, how to dress your child or how to handle toddler tantrums.

Think about what might work best for you and your family, and discuss your needs with your parents. Would you and your partner like to spend a few days on your own with your new baby before relatives visit? Would it be helpful for your parents to have a standing “date” with your child so you can have a night out? Would you like to have your parents and in-laws visit at different times so that each set of grandparents can have time with their grandchild?

Tell your parents what they can do to be most helpful — household chores included. This may help prevent misunderstandings and tension, as well as help you make the most of your parents’ desire to be there for you.

Like it or not, your parents might go a little overboard on getting gifts for your child. While you might not be able to stop your eager parents from buying the gifts, be sure to tell your parents what your child needs. Also, remind your parents that, for a child, nothing really rivals spending quality time with grandparents. Doing an activity together, such as taking a walk in the park or going to the zoo, can be a fun way for grandparents and new babies to begin bonding.

And don’t forget that as much as your parents want to help you during this time, they likely also want to spend some time cuddling with your child and building that special connection. This is especially important if your parents don’t live nearby or won’t be able to visit your baby frequently. Offer your parents as much time with your child as you’re comfortable giving them. Remember, this is a precious and exciting time for them, too.

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Letting go of the past

If you and your parents aren’t close or have a difficult relationship, the birth of your baby might serve as motivation to work through your problems — especially if you want your parents and your child to have a strong connection. During your pregnancy or after your baby is born, consider making an effort to work on your relationship with your parents. In addition, remember that your child will have a separate and different relationship with your parents than you do. If couples divorce, the grandparents on both sides of the family will still want to spend time with their grandchild.

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Conflicting opinions You and your partner likely have some ideas about how you plan to care for your child — and they might be different from your parents’ ideas. For example, while your parents might have fed you formula, you might plan to breast-feed. One of your parents might have stayed home to take care of you, while you and your partner both plan to continue working. As your baby gets older, you and your parents may also have different opinions about the toys your child should play with — wood or plastic? — or the amount of television he or she should be allowed to watch. This can be tricky territory.

If your and your parents’ parenting styles differ, it might be difficult for your parents to keep their opinions to themselves. Consider explaining to your parents that what you could really use is support or help around the house, not unsolicited advice. You and your partner have the final say over the way your child is raised and the rules in your house. However, try not to dwell on these issues. Keep in mind that your parents are probably trying to help and may still be working through the transition from being your parents to being grandparents, too. And expect that if your parents baby-sit your child, they will likely handle things slightly differently than you would. These little differences may even help your child learn to be more flexible.

In addition, just as you and your partner have your own thoughts about what kinds of parents you’d like to be, your parents might have thoughts about what kinds of grandparents they’d like to be. Some grandparents aren’t comfortable baby-sitting and prefer a formal relationship with their grandchildren. Others are playful and enjoy engaging their grandchildren in activities. And still others want to be a part of their grandchildren’s daily lives, serving as surrogate parents. Consider talking to your parents about what kinds of roles they’d like to play in your child’s life. Do they want to baby-sit? How available do they plan to be? Are they willing to help out in case of a crisis? When making requests for help in taking care of your child, be sure to keep in mind your parents’ ages, abilities and any other limitations. To avoid unnecessary misunderstandings or resentment, ask your parents what they can handle and if you’re expecting too much from them.

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Name preferences

Your parents may have their own ideas about what they would like to be called — beyond grandma or grandpa. For some grandparents, these traditional titles just don’t jibe with the way they see themselves. Consider talking to your parents about what names they might have in mind for themselves. Some grandparents wish to be called what they called their grandparents. Others prefer first names, nicknames or terms that reflect their ethnicity. Remind your parents, however, that when your baby begins to talk, he or she might come up with some names of his or her own.

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The holidays Your baby’s first holidays and birthdays will likely be important events that his or her grandparents will want to help celebrate. But while big family parties can be fun, they’re not always possible. Chances are that you’ll end up alternating holidays with different grandparents. Or perhaps you’ll have two celebrations, one with each set of grandparents, on different days.

Either way, if holidays are particularly important to your parents, talk to them ahead of time about your plans and your desire to make sure everyone feels included in your child’s big days. If your parents are having a hard time understanding the situation, explain that alternating holidays will allow each set of grandparents to spend more quality time with your child in a more relaxed setting. You might also encourage your parents to focus on new or different traditions, such as taking your child out for his or her half-birthday.

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Grandparenting from a distance

If your parents don’t live nearby, they might miss out on your baby’s first smile, giggle or attempts at rolling over. Consider helping your parents keep in touch with your child through regular phone calls or video chats — perhaps at the same time each week — or by frequently sending videos or pictures. While it might still be awhile before your little one can talk much, he or she will likely enjoy listening to your parents’ voices and grabbing the phone or computer. If your parents aren’t up on current technology, regularly mailing printed pictures might be your best option. To help your child get to know your parents and other family members, make a photo album with their pictures and look at it with your child during playtime or before bed. Be sure to tell your child the names of the people in the photos.

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Grandparents as child care providers

Some couples rely on grandparents to provide part-time or full-time care for their children. Having someone you know and trust take care of your child can be comforting. Grandparents are often flexible with their hours, may be able to watch your child in your home and may not ask for payment. However, grandparents might not have any training in car seat use, CPR or other emergency care. These types of arrangements can also cause tension, especially if you don’t feel comfortable communicating expectations to your parents about how you want your child cared for, or if you don’t want unsolicited parenting advice.

Think about the pros and cons before asking your parents to provide regular child care. If you decide to go that route, ask them to take a CPR class if necessary. Be sure to discuss the details and come to an agreement beforehand about how the arrangement will work. For more information on child care, see Chapter 15.

If your parents will be watching your child in their home, consider asking them to purchase their own crib or highchair — or offer to get one for them. This will make meals and naps easier on your baby, as well as your parents. You might also consider providing your parents with their own stroller, car seat and basic medications, such as for a fever or diaper rash.

If it’s been awhile since your parents took care of a baby, they might need a refresher on the basics — especially in areas where the rules have changed over the years, such as in car seat safety and baby sleeping positions. Before you leave your child in your parents’ care, discuss safety topics. Make sure your parents are aware of all safety precautions discussed in Chapters 16-18. If your baby is going to be at their house, the house needs to be childproofed. It’s also important that they not leave medications and other dangerous items within a child’s reach, and that they take precautions around hot liquids and other items that could lead to a burn. These are just some of the safety issues that need to be addressed.

Car seats Make sure your parents have a reliable car seat and know how to use it properly when transporting your child. Explain the importance of having your child ride rear facing or forward facing as appropriate until he or she reaches the maximum weight or height allowed by the car seat manufacturer. For more information about car seat safety, see Chapter 16.

Sleep positions Insist that your parents put your baby to sleep resting on his or her back, rather than on the stomach or side, until your baby can roll over both ways without help. Make sure your baby is put to sleep on a firm mattress in a crib. Remind your parents that adult beds aren’t safe for infants. For more information about sleep safety, see Chapter 9.

CHAPTER 40 When to have another child

As your first baby approaches toddlerhood, family, friends and perfect strangers inevitably feel free to ask if you’re going to have another child. (Often it’s “when” and not “if.”) And the question may be foremost on your mind as well.

Like other parenting decisions, figuring out how many children you want is a personal process, though you may receive plenty of advice and opinions. Deciding whether or not to have another child is one of the most important decisions you’ll make for your family, and it may be even harder than deciding to have the first one. It’s normal to worry about how another child will affect your family, relationships, lifestyle, finances and work and to wonder whether you’re making the right choice.

If you think you want another child, when might be the best time? Again, only you and your partner can answer that question. Pregnancy spacing affects how close your children are in age and may have an impact on your health and your baby’s health. There are many factors to weigh when planning your next pregnancy.

As you and your partner consider the possibility of having another child, approach each other with compassion, respect and a willingness to listen. Talk about the issues with an eye toward strengthening your relationship and your family.

Deciding on another child

Maybe you’ve always dreamed of having three kids, each spaced three years apart. Or you’re agonizing over whether you can really handle another baby. Whatever your hopes, fears and dreams, there are a number of issues to consider as you think about expanding your family.

Added responsibilities Caring for a growing family can be physically, mentally and emotionally taxing, despite its many rewards. Most parents say that adding a second child more than doubles the work. You need plenty of time and energy to care for an infant, while your older child also needs your attention. With two kids, your life will be more hectic — and your house will no doubt be messier. But you’ll also find that you grow to meet the challenges.

“I felt like my life as a parent finally had a rhythm to it (he finally slept at night, I didn’t need to lug around all the baby paraphernalia anymore, etc.) and I wasn’t sure how I’d do once a second child came along,” writes one mom. “Taking care of the needs of two little people can definitely be more stressful, but you get progressively more creative to get everything done.” With a second baby, you’ll realize how much you learned the first time around. You’ll have increased confidence in your abilities and knowledge, and you’ll find it easier to handle things that might have seemed daunting the first time around, such as breast-feeding and taking care of a sick baby.

Your preferences Sometimes one partner is ready for another baby and the other isn’t. It’s important to understand each other’s concerns. Sit down together and talk about your points of view and your differences. What does having a second child mean for each of you? What are your goals and dreams? Explore ways to resolve concerns and conflicts. If your partner is worried that your relationship will suffer, make specific plans for keeping date night alive. Work together to come up with ways to lessen the financial burden.

Both of you need to be on board with the decision. If you remain at odds, perhaps you can agree to revisit the issue in a year or two. It might also be helpful to talk to other couples who’ve been in the same position or to consult a marriage and family therapist.

Family finances A new child adds to your family’s expenses. You’ll want some extra money in the budget before you conceive another child. Think about what your financial picture will look like with a new baby. Will you or your partner need to reduce your work hours or stay home to care for your children? Can you afford to pay for the new baby’s child care if you keep your job? Are you willing to sacrifice certain things in order to cover baby costs? Will you have enough money to save for college tuition? If you’re living paycheck to paycheck or fear a layoff, you may decide to hold off on having the next baby.

In the longer term, having babies close together frees you from child care costs sooner. On the flip side, spacing children further apart can give you more time to recover from the financial impact of pregnancy and early child care.

Impact on your career It might be harder to juggle your job and child care responsibilities when you add another baby to the mix. Will you be able to keep up with your job after the next baby? Is it important for you to reach another level in your career path before you take on pregnancy, childbirth and caring for an infant again? Then again, it might be easier to focus on careers later if your kids are in school at the same time.

Family dynamics Many people have more than one child because they don’t want their firstborn to be an only child. Providing a sibling for your child may be part of your motivation, but it’s important to want to raise another baby just for himself or herself. You can’t predict how well siblings will get along, and there are pros and cons to having siblings or not. (See “Deciding one is enough,” here.)

Another common concern is that you’ll disrupt the smoothly functioning, happy family structure you’ve created. Change of any sort can bring up fears, and a second child will change the dynamic and logistics of your family life. However, most parents say that soon after the arrival of the second baby, they can’t imagine life without him or her.

Sharing the love Probably most parents have wondered how they could possibly love the second child as much as they love their first. You may worry that you’ll lose your special relationship with your first child and shortchange the second child by having to share your attention and time. It’s common to worry that the second child will feel less wanted and loved and that the first one will feel resentful. Rest assured that your relationship with each child will be unique, like the children themselves, and that you’ll have plenty of love to go around.

As writer Lisa Belkin notes, “I remember, with Polaroid clarity, the moment I said goodbye to Evan as I left for the hospital to deliver Alex. I had the overwhelming feeling that I was about to ruin his life. I tried to remember what I try to remember in all tough parenting situations — that I am giving them something, not taking it away. … And when I brought home a baby brother, I gave each of them proof that neither of them was alone in the world, and that neither was the center of the universe.”

Social pressures Although one-child families are increasingly common, couples still face cultural and family pressure to have a second child. If your friends are all having a second or third child, you may feel left out. You may feel the pressure from your partner or feel guilty if he or she wants another baby and you don’t. Be honest with yourself about what’s right for you. Parenting another child is a big responsibility to take on because someone else thinks it’s a good idea.

Thinking in reverse If you’re having trouble making a decision about having another child, you might try turning the question on its head. How would you feel if you were told you couldn’t have another child? Your sadness or your relief may give you insight into what you really want.

Until you make a decision about when to have another child, be sure to use a reliable method of birth control — even if you’re breast-feeding. If you’re still contemplating the possibility of another pregnancy, you may want a method that’s easily stopped or quickly reversible. Examples include an oral contraceptive or a barrier method, such as a condom. If you and your partner agree that your family is complete, you can switch to something longer lasting, such as an intrauterine device (IUD) or implantable rod. You might also opt for something permanent, such as a vasectomy or tubal ligation.

Remember that a decision as big as this one takes time and thought. Do your research and discuss any concerns with your medical provider. Make sure you have the information you need — and the time you need to process it — before going through with a permanent plan.

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Deciding one is enough

The number of families with one child has nearly doubled since the 1960s, as more people are starting families later in life and facing financial pressures. But negative stereotypes about only children — that they’re spoiled, selfish, lonely and bossy — still persist. Such beliefs may prompt couples to have more than one child.

Years of studies in several countries have found no evidence to support these stereotypes. Only children are no different from their peers in terms of character, sociability, adjustment or personal control. One way they are different is that they score consistently higher in intelligence and motivation compared with children with siblings. Interestingly, some research suggests that parents of only children are happier than are parents with more than one child. When you have just one child, you spend a lot of time with that child, which can make for a close relationship. However, parents with multiple children also are close to their children.

If you’re struggling with the idea that a childhood without siblings will damage or shortchange your child, you can let go of that fear. Yes, having brothers and sisters can be a positive experience and help kids learn skills such as dealing with conflict. As a parent of a singleton, you’ll want to make an effort to give your child opportunities to interact with other children.

What’s most important is to know what’s right for you and your partner. “I am being honest with myself when I admit that I will be a much happier and better parent to one child than more,” says one mother. “Some people thrive in a busy, spirited environment. ... I fall apart. I think the worst thing about deciding to have an only child is dealing with my own feelings of needing validation.” Another says, “By having a second child, we would stretch ourselves way too thin mentally, emotionally, financially, physically, and we know we would end up in pure misery.”

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Second pregnancy timing

Once you’ve said yes to another baby, the next decision is when to start trying. There’s no perfect time to have another baby, and if you wait until the circumstances are just right, you might never do it. Even with careful planning, you can’t always control when conception happens. You might get pregnant sooner than you thought or long after you hoped you would. In the end, pregnancy spacing is often based on a combination of personal preference and luck.

You can make an informed decision about when to grow your family by understanding the health issues associated with timing your pregnancies too close together or too far apart, as well as the advantages and disadvantages of different pregnancy intervals for parents and children.

Health issues Some studies show that spacing pregnancies too close together or too far apart can pose some health risks for both mother and baby.

Short interval Closely spaced pregnancies may not give a mother enough time to recover from the physical stress of one pregnancy before moving on to the next. It can take a year or longer to develop stores of essential nutrients that may have been depleted during pregnancy and breast-feeding. If you become pregnant before replacing those stores, it could affect your health or your baby’s health.

Getting pregnant within 18 months of giving birth may slightly increase the risk of low birth weight, small size for gestational age and preterm birth. If you had a cesarean birth and allow for less than an 18-month interval before your next child is born, you may increase your risk of uterine rupture if you decide to try a vaginal birth.

Limited research suggests that a pregnancy within 12 months of giving birth is also associated with an increased risk of placental problems. One study reported a link between pregnancy intervals of less than 12 months and an increased risk of autism in second-born children.

It’s possible that behavioral risk factors, such as smoking, substance misuse or lack of prenatal care, as well as stress and poverty, are more common in women who have closely spaced pregnancies. These risk factors — rather than the short interval itself — might explain the link between closely spaced pregnancies and health problems for mothers and babies.

Long interval Spacing pregnancies many years apart also may pose some health concerns for mothers and babies. A pregnancy five years or more after giving birth is associated with an increased risk of:

High blood pressure and excess protein in your urine after 20 weeks of pregnancy (preeclampsia)

Slow or difficult labor or delivery

Preterm birth

Low birth weight

Small size for gestational age

It’s not clear why long pregnancy intervals are linked to these potential problems. Researchers speculate that women who wait five years or more to have another baby may lose some of the protective effects generated by the first pregnancy. Maternal age or factors such as maternal illnesses also may play a role.

To reduce the risk of pregnancy complications and other health problems, wait at least 12 months before getting pregnant again. If you’re looking for an ideal interval, consider waiting at least 18 to 24 months but no more than five years before attempting your next pregnancy.

If you do get pregnant while breast-feeding and decide not to wean your baby, you’ll need to take extra care with your diet. You may want to meet with a dietitian to be sure you’re meeting your nutritional needs.

Spacing pros and cons

Is there an ideal spacing between children for their sake and yours? Probably not. Many families settle on an interval of two to three years, but various types of spacing all have advantages and disadvantages.

1 to 2 years apart Having children one to two years apart can be the ultimate test of your endurance. But that doesn’t mean it can’t work.

Advantages Some of the benefits are:

Your children will be close in age as they grow up. They may share many of the same interests and activities, making it easier to juggle family schedules. Parents often hope that siblings close in age will be close companions and play together.

You condense the time when you’re dealing with carrying, feeding, diaper changing, sleep deprivation and toilet training. Also, you may not need to childproof your home as many times as you would if you had your children further apart.

You can double up on some tasks, such as reading to your older child while nursing the baby or having them nap at the same time.

Your first child may have an easier time adjusting to a sibling and will barely remember what life was like without him or her.

Disadvantages Some possible drawbacks are:

Caring for two in diapers is likely to leave you exhausted much of the time and with little personal space for a few years. Life with two little ones can feel like constant chaos.

Stress and fatigue can take their toll on your relationship with your partner. You’ll need to work together as a team to meet the challenges ahead. And you’ll need to set aside some quality time for each other.

Supplies for two young children can be costly.

Sibling rivalry may be a problem as your children grow up.

2 to 5 years apart A spacing of two to five years is what most experts recommend. Your first child is a little more independent, and you and your partner have had some time to regain strength and energy.

Advantages Some of the benefits are:

During the interval between pregnancies, you’ll have time to bond with your first child and give him or her your undivided attention.

Your first child will have the opportunity to be the baby of the family without any competition.

When the new baby arrives, the older sibling will be more likely to play on his or her own at times, giving you some one-on-one time with the baby.

Your children will still be close enough in age to bond easily.

You’re only paying for diapers for one. Some baby supplies, such as a crib or stroller, can be recycled.

Your body has time to restore its nutritional supply to prepare for the next pregnancy.

You’ve fine-tuned your parenting skills, but it hasn’t been so long that they’re rusty.

Disadvantages Some possible drawbacks are:

Your first child may feel jealous of the new baby. It’s not uncommon for 3- and 4-year-olds to revert to baby-like behavior when faced with competition for a parent’s attention. This usually goes away with time, though.

Rivalry issues regarding toys and activities may occur as the baby gets older and starts getting around on his or her own.

Your older child may be outgrowing his or her naps just as your baby is settling into a regular nap schedule.

The further apart your children are, the more different each child’s activities are. Coordinating schedules may require considerable organization and planning and can be stressful.

5 years or more apart Some parents liken having kids who are five years or more apart to having an only child twice.

Advantages Some of the benefits are:

You get a big break between babies. This may give you some time to go back to doing things you enjoyed before having an infant, such as going out for dinner or a movie or taking adventurous vacations. It may also give you a chance to refocus on your career or your marriage. Waiting five years or more can also give you a financial break and allow you to save money for the next baby.

Each child gets plenty of individual attention in infancy and beyond.

You get to enjoy and focus on specific stages of growth and development with each child.

Because of the difference in age, sibling rivalry tends to be less intense. Instead, your younger child may regard his or her older sibling as more of a hero, while the older child may assume a more protective or guardian-like role. Depending on the age of your first child, you may even have a built-in baby sitter.

Disadvantages Some possible drawbacks are:

After several years of being out of baby mode, you may have a hard time getting back into it. You tend to forget how much work caring for an infant can be and how exhausted you become at the end of the day.

It may be a challenge to keep up with your older children while caring for a baby.

You’ll probably need new baby gear, because your car seat and stroller will likely be out of date.

Schedules in your household may vary widely. It can be stressful to keep them all coordinated.

Due to the age difference, your children may not share many of the same interests. They may not be as close as children who are more similar in age.

Other issues Other factors also can influence the timing of a second baby.

Your age. Couples who start a family when they are older sometimes must race against the biological clock. If you’re in your late 30s and you would like two more kids, you may not have the luxury of spacing your children three years apart.

Your fertility. If it took you a long time to conceive the first time, or you used fertility procedures, you may not want to wait long before trying to conceive again.

How many children you want. If you would like to have a large family, you may need to space your children closer together.

Most important, listen to what your heart says. Whatever the pros and cons of various pregnancy intervals, if you and your partner both want another baby, this might be just the right time.

PART 6 Special circumstances

CHAPTER 41 Adoption

One way to become a parent is through adoption. Adoption is an active process, often involving a great deal of paperwork to be filled out, personal information to be shared, home studies to complete and agency fees to work into the budget. And unlike a nine-month pregnancy, adopting a child can take anywhere from several months to several years. The wait can be difficult, and adoptions can sometimes fall through.

Prospective parents, whether through adoption or surrogacy, are often required to undergo a level of introspection and outside scrutiny that can be considerably greater than for others making the transition into parenting. In short, those who undertake adoption are some of the best prepared parents around! This can be a great strength when it comes to facing the challenges and opportunities ahead.

Most of what you need to know about caring for a baby is already in this book: All babies require love, nurturing, guidance and medical care. But because you may have no control over the prenatal and postnatal care of the child you adopt, you may have some unique concerns. This chapter offers basic advice on adoption and addresses medical and emotional issues that may be on your mind.

Supporting your child’s health

One of your jobs as a parent is to keep your child as healthy as possible. Since you may not know ahead of time what your child’s health status or medical history is, you may need to take a few extra steps to ensure your child gets on the right track.

Find a medical provider The best time to choose a medical provider is before your child arrives, if at all possible. Although many professionals who care for children’s health have experience with adoption, you may need to shop around a bit before you find one that suits your needs. Talk to other parents who have adopted and ask for recommendations. Call a few of those providers to say you’re planning to adopt, and ask if there’s any specific medical information you should request from the agency concerning your child. If you’ll be adopting internationally, ask providers if they’ve had experience with international adoptions.

If possible, schedule a pre-adoption visit with the medical provider you prefer. Most providers appreciate the opportunity to meet parents before the child arrives so that they can discuss issues such as sleeping, eating, making the house childproof, immunizations and any pertinent medical concerns. They can also discuss with you general developmental expectations based on the age your child will be on arrival.

Some international adoption clinics offer physician services, such as reviewing a child’s medical information before a prospective parent accepts a referral, travel consultations for parents traveling abroad to pick up their child, and post-adoption checkups.

Update family immunizations Adults and children who will be in close contact with the child being adopted may need to catch up on immunizations, including vaccines against measles, hepatitis A and B, tetanus, diphtheria, and pertussis. If you’re traveling to a different country to receive your child, your medical provider can give you advice on travel safety and any necessary vaccines or medications you’ll need to receive before or during your trip, depending on your child’s country of origin.

Try to track down a medical history If possible, try to acquire any medical, genetic and social records of your child’s history in writing from the birth parents or adoption agency. There might not be much information, but it will be easier to track down now rather than years later.

It’s important to gain full disclosure from the agency before you adopt so that you get a more accurate representation of any medical conditions your child may have. This is where having a medical provider for your child already selected may come in handy. The provider may be able to help you make sense of medical reports you obtain, explain the implications of a medical condition, or alert you to what might be missing from the records.

• • • • •

International adoptions

Immigration laws in the United States require that all immigrants seeking permanent residence in the U.S. show proof of having received the vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). Internationally adopted children under 10 years of age are exempted from this law, however, as long as the parents sign a waiver declaring their intention to comply with immunization requirements within 30 days of the child’s arrival in the U.S. Over 90% of children adopted from abroad need catch-up vaccinations when they arrive.

Certain countries also have high rates of infectious diseases or parasites that prompt testing and treatment, if necessary, both for the care of the child and protection of the rest of the family. In addition to a complete physical examination (including vision and hearing screenings, your child’s medical provider may recommend screening for the following:

Hepatitis B

Syphilis

HIV

Intestinal parasites

Stool pathogens

Tuberculosis

Anemia and blood disorders

Vitamin and mineral deficiencies

Thyroid disorders

High lead levels in the blood

Depending on your child’s country of origin, the medical provider may also recommend testing for:

Hepatitis A

Hepatitis C

Chagas’ disease

Malaria

Treatment exists for many of these conditions. The sooner a health concern is detected, the more effectively it can be treated.

• • • • •

Get post-adoptive care If your baby has a known medical condition or arrives ill, you may need to visit your child’s medical provider soon after arrival. But if your baby appears healthy when he or she joins your family, you might wait a couple of weeks or even a month. This gives your child a chance to adjust and you a chance to get to know your new arrival. After this period, you may be better able to answer a provider’s questions about your child’s “usual” behavior.

If you received your baby through an open adoption, you might be able to follow the same well-child schedule as any new baby. (For more on well-child care, see Chapter 13.) First-time parents, especially if they did not have a pre-placement visit, may want to consult their child’s medical provider sooner if they need information and support.

For children arriving from overseas, the Centers for Disease Control and Prevention recommends a medical examination within two weeks of arrival in the United States, or sooner if your child has a fever, difficulty eating, vomiting or diarrhea. In addition to a comprehensive exam, your child’s medical provider may also recommend certain screening tests and vaccinations, depending on your child’s country of origin.

At the first appointment, your son’s or daughter’s medical provider will review the child’s immunization status and perform any age-appropriate screening tests, as well as any further tests indicated by the examination. If your child has no written record of immunizations or has missing or ineffective vaccines, the provider may recommend starting a new schedule. The risk of side effects from repeating a vaccination is lower than the risk of getting an infection. If your child is older than 6 months, his or her provider may recommend checking antibody levels in your child’s blood before recommending certain vaccines to see if he or she has already had certain infections.

A few children have no official birth date. Determining their age can be difficult if their growth is delayed because of prematurity, problems at birth, malnutrition or neglect. Your doctor will try to make an educated guess based on the information available.

After your child’s first medical examination, it’s important to follow the schedule of examinations and immunizations recommended by your medical provider.

Give it time It’s not uncommon for children adopted internationally to show delays in development when they arrive. But most are able to catch up within the first 12 months of arrival, after being on a nutritious diet coupled with a stimulating, nurturing environment. For example, a baby who may not have had the opportunity to learn to crawl because of his or her previous conditions may quickly learn to do so by being placed on a blanket on the floor and given the incentive of a toy just out of reach.

Get support If you’re adopting an older child, especially one who has had a difficult past, or a child with special needs, your child’s medical provider may refer you to a counselor or mental health professional who has experience with adoption. Such a therapist can help ease the transition for the whole family and provide help in working through issues of loss and change. Support groups for families created through adoption also can be helpful.

• • • • •

Making room for grief

Adoption is a wonderful event and most people rightly want to focus on the joy and fulfillment that comes from uniting parent and child. But while a family formed by adoption has many things to celebrate, it’s important to acknowledge that those involved often experience some sense of loss during the process. For the child, this may include loss of the opportunity to be raised by birth parents or to be raised in his or her birth culture. For the birth parent, there may be loss of an intimate connection with the child. An adoptive parent may grieve the loss of a biological connection. It’s important to create time and space for each party to grieve such loss. Glossing over the loss in an attempt to meet expectations of happiness, whether within yourself or those around you, can cause problems down the line.

Sometimes just acknowledging the loss and accompanying grief is enough to allow you to move forward. Doing the groundwork now can help set the foundation for a healthy relationship with your child over time. But if you’re having difficulty or just want advice, don’t hesitate to reach out to a mental health professional. Your child may struggle with emotional or behavioral issues or both and may benefit from talking with a behavioral health specialist such as a child and adolescent psychiatrist. He or she will be able to determine whether further help is needed.

• • • • •

Bonding

Some parents bond immediately with their baby the first time they meet their son or daughter. It seems as if the family they’ve established was always meant to be. But for others it takes a little longer. Don’t fret too much if the first time you meet your baby, both you and your child feel more bewildered than besotted. As with any relationship, it takes time and commitment to establish a deep, solid connection.

The longer you’re there to provide consistent, loving care, the more your son or daughter will realize that you’re in this for the long haul and that he or she is safe and secure. With time and consistent effort, you both will become more confident and comfortable with each other and in the way you interact.

The same activities can foster the attachment process for both biological and adoptive parents: holding your baby close, cuddling, feeding, laughing, serenading, playing games, going through the daily activities of living.

Allow time for adjustment Parents who adopt have sometimes waited so very long for a baby that they cannot wait to smother the child with love and attention. Depending on your child’s age, he or she may have just been separated from everything that was familiar and needs time to warm up to you and take in a new environment.

Holding children close is important because it helps them get accustomed to your scent, to hear your heartbeat and to feel your body warmth. But pay attention to their signals. Some children prefer to be held more than others do.

In general, the best way to nurture a healthy attachment to your child is by observing closely what he or she needs and determining how best to make your son or daughter feel supported, safe and loved in any situation. This may call for different strategies in a young infant when compared with an older child. Older children are more likely to have difficulties with attachment, and parents of these children may wish to connect with specialists in post-adoption services either through their adoption agency or through their medical provider.

Talk, sing and read to your child These activities allow the child to get used to the sound of your voice. This is especially important for children who come from another country because it helps them get acquainted with the natural rhythms of a new language.

Respond to your child’s needs Be quick to find out why he or she is crying. Tending promptly to your child in the first few months won’t spoil the child but will provide reassurance and comfort. Eventually, your son or daughter will become more secure in his or her role in the family and less clingy or demanding. In fact, this is common advice for every parent.

Also keep in mind that your child may not yet signal his or her discomfort. Children who have spent time in an institution or have been neglected may internalize feelings of abandonment and insecurity by withdrawing from others and failing to make their needs known. Keeping a quiet eye on your child and maintaining a regular schedule for meals, naps and bedtime will help promote health and provide a sense of security and well-being.

Learn about your child Inquire about the child’s environment and routine before he or she enters your family so that you can help smooth the transition. For instance:

A child who shared a crib or a mat with other children or family members may be frightened at night in a room by himself or herself. You may want to bring the child into your bedroom and keep his or her crib in your room for a while until he or she gets used to the new environment and has had time to adjust. After a while, the child likely will establish more independence and be able to sleep on his or her own. You might also consider giving your child a soft blanket or stuffed animal (see safe sleep precautions in Chapter 9). Having a loved object to hang on to while everything seems to be in transition may help your son or daughter feel more secure.

A child who was carried everywhere on the back of his or her caregiver, as is the custom in some countries, may feel right at home if you put him or her in a back carrier. Even a child who isn’t used to it may enjoy the security of being carried close to you in a front or back baby carrier.

A child who is used to falling asleep with the room light on may be extremely attached to that simple routine. Be sensitive to any routines that seem important to your child, and allow some time before gradually trying to change habits.

A child may experience sensory overload with a nursery full of toys, unable to decide what to play with first. Introduce one toy at a time, as the child is ready.

• • • • •

Breast-feeding an adopted baby

Many adoptive mothers are surprised to learn that nursing their babies may be an option for them. Because lactation, or the production of breast milk, can sometimes be induced (with a combination of pumping and nipple stimulation), it’s possible to breast-feed without ever having been pregnant.

Adoptive mothers who seek to nurse young infants usually do so to enhance their relationships with their children. Although most adoptive mothers can’t produce all the milk their infants need, even limited breast-feeding allows them the opportunity for physical and emotional attachment with their babies.

When the baby’s arrival can be anticipated, some women try to establish a milk supply in advance by using an electric breast pump at regular intervals.

Others wait until the baby arrives, because the baby’s sucking will stimulate lactation better than any pump on the market. These mothers use a supplemental nursing device that allows infants to receive formula through a soft tube inserted in their mouths while nursing. Even after their milk comes in, many mothers continue to use supplemental nursing devices if they need to increase their breast milk volume.

Babies are usually more willing to breast-feed if they are younger than 8 weeks of age, but some adoptive mothers have reported success with older infants, too.

If you try breast-feeding but aren’t able to produce milk, don’t be anxious. There are plenty of other ways to foster attachment with your baby, including holding your baby close with skin-to-skin contact during feedings, and at other times, too.

If you think you might like to nurse your adopted infant, discuss the advantages, disadvantages and techniques with your doctor or a lactation consultant well ahead of the time you anticipate your child’s arrival. There may be a lactation consultant on staff at your hospital, or you may contact the International Lactation Consultant Association or La Leche League International. Check their websites for more information.

• • • • •

Identify your child’s developmental stage On joining your family, your child’s developmental stage can affect how he or she interacts with you. For instance, in the first four months, babies cry mostly when they need something and they’ll bond most easily with the person who responds to their cries. Later, they begin learning cause and effect and may cry just to see what happens. This behavior could frustrate parents meeting their child for the first time at this stage. At around nine months, separation anxiety can be very intense for a child who’s been attached to another caregiver.

Read through the chapters in Part 3 of this book that correspond to your baby’s developmental stage. You’ll find that some of your child’s behavior is indicative of the developmental phase he or she is in rather than of his or her personality.

If you’re adopting a child who’s 6 months or older, keep in mind that he or she may have already learned certain cultural behaviors. For instance, a child from a country where passivity is encouraged may appear unresponsive. If you’re adopting a child of 12 months or older, it may take more time and understanding to get acquainted and develop mutual trust. You may find reassurance in reading about parenting, talking to someone from the adoption agency or a counselor familiar with the adoption process, and in doing what you can to help your child feel loved, secure and wanted. Eventually, the majority of children — especially those who arrive most needy — make great gains in their social and behavioral skills, a testament to the resilience of human nature.

Take care of yourself It’s tempting to let everything else fall by the wayside — including yourself — when focusing on your newest family member. But becoming worn down and stressed out isn’t helpful to anyone and may in fact undermine the attachment process.

For any new parent, it’s not uncommon to feel overwhelmed when faced with the intense demands of parenting. Accept help from family members and friends with housecleaning and other chores, spend some time on your own, get some exercise (even if it is just a walk around the block), and eat regular, healthy meals. If you take care of yourself, you’ll be better equipped to care for your new son or daughter and your family.

• • • • •

One mom’s story

We have a fairly open relationship with my 4-year-old daughter’s birth mother. My daughter knows her birth mother’s name and a picture of the two of them hangs above her bed. Her birth mother and I exchange emails and pictures, and we all talk on the phone on holidays and birthdays. When my daughter and I discuss our family story, it goes something like this.

I feel so lucky that your birth mom (we use her first name) chose me to be your mommy! I remember the day that you were born ... when I first held you, I couldn’t believe how small you were! I’d been waiting for you and seeing you made me smile so big. You had tiny little fingers, and you wrapped them around my little finger right away — I think maybe that’s why we like to hold hands today. Your birth mom and I took turns holding you and feeding you. We talked about how cute you were and about what we hoped you’d do when you got older. We both want you to be happy and to do good in school and be nice to your friends. We want you to have lots of adventures and to go to college when you’re bigger. Most importantly, we want you to know that you’re loved. You grew in your birth mom’s tummy and you grew in my heart and that means that you get two people to love you.

• • • • •

Get help when needed All children are individuals with definite likes, dislikes and inborn personality traits. Some adjust quickly and respond with joy to their new families, but others might have a longer and more difficult adjustment period.

Many families benefit from talking to an outside party who has seen and talked to other adoptive families, and can help them work through the necessary steps to achieve mental and emotional wellness and to bond as a family.

If you’re feeling discouraged or lost, or if your child exhibits behavior problems or doesn’t seem to be building a relationship with you, seek professional help. Your child’s medical provider, adoption agency, a social worker or mental health professional may be able to help you understand and resolve the challenges you’re facing.

• • • • •

Siblings and adopted children

If you have other children in addition to your adopted child, you’ll probably face some of the same issues as any parent has when introducing a sibling to brothers and sisters (see Chapter 39).

Help your other children with the transition by including them in plans for the new baby’s arrival, welcoming him or her home and in daily caregiving activities. Children typically love babies and will be thrilled to help out. Even after the novelty wears off, big brothers and sisters still continue to bond with the baby, even when conflicts arise. Also, try to find some time to spend with each child individually, even if it means running a quick errand together or snuggling for a few minutes before bedtime.

The younger the siblings and the adopted child, the more likely they are to bond with little trouble. Most children under the age of 4 generally don’t notice differences among themselves and like to hear the adoption story. Older children are more likely to ask questions and feel some differences.

In some cases, an older adopted child may have developed certain behaviors before joining a permanent family that persist for weeks or months after adoption. This might include survival behaviors, such as hoarding food or sleeping with his or her back against a wall. Other siblings may perceive this as “weird.” But it’s important to realize that these behaviors are likely there for a reason. Over time, as your new child continues to receive consistent, loving care, these behaviors are likely to fade. In the meantime, encourage your children to focus on the positive aspects of their relationship with the new brother or sister. Younger children, for example, are usually easily distracted by a new topic of conversation or by the suggestion of a game. Older children may be able to better understand the possible reasons for unusual behaviors and may be able to help you in providing consistent support to their sibling.

Sibling relationships can be a lifelong gift, continuing to be a source of strength even after parents are gone. Look for opportunities to promote bonding between all of your children. If you have doubts or questions, or you feel your family needs help in bonding together, talk to someone who is knowledgeable in the matter. This may be someone from your adoption agency, your medical provider, a social worker, or a family counselor or therapist.

• • • • •

Sharing your family story

A renewed focus on an adoptive child’s well-being has paved the way for increased openness when it comes to telling the adoption story. More adoptions are now carried through as open adoptions, where the birth parents are in contact with the adoptive family during the adoption process and possibly beyond. This avoids the scenario of previous generations when parents didn’t always tell their children they were adopted. The news might be revealed by a relative or come as a surprise later on, leaving the children feeling puzzled, angry or betrayed.

But even with open adoptions, it’s not always easy for a child to understand the relationship between the two sets of parents. While it’s best not to keep the adoption a secret, you also don’t want to overwhelm your child with information. Right now your adoptive son or daughter may be too young to understand, but when he or she is older and the time is right, look for natural opportunities to weave your family’s story into your daily life. If you start early and simply, the transition to more complex discussions down the road may be that much smoother. Keep in mind that this is your own family story; how you share it with others outside of your immediate family is up to you.

Be positive Experts agree that if parents demonstrate they’re comfortable talking about adoption as a positive experience, their children will be much more likely to feel comfortable with it themselves. They will also be more willing to share their questions and concerns about adoption as issues arise.

Use books Even before your child is old enough to ask questions, you can begin to introduce age-appropriate books that explain adoption through simple concepts and words (see following section).

• • • • •

Books about adoption to read with your child

Reading age-appropriate books about adoption together with your child is a great way to jump-start a conversation about your family’s adoption story. Here are some suggestions.

Rosie’s Family: An Adoption Story, by Lori Rosove

Forever Family, by Kelly Bullard and Lindsey Bullard

Is That Your Sister? A True Story of Adoption, by Catherine Bunin and Sherry Bunin

The Mulberry Bird: An Adoption Story, by Anne Braff Brodzinsky

Susan and Gordon Adopt a Baby (Sesame Street Books), by Judy Freudberg

Through Moon and Stars and Night Skies, by Ann Turner

Why Was I Adopted? by Carole Livingston

Tell Me Again About the Night I Was Born, by Jamie Lee Curtis

I Love You Like Crazy Cakes, by Rose Lewis

We Belong Together, by Todd Parr

• • • • •

Tell your story Many experts recommend that parents develop their own story of how their family was created and tell it to children from the very beginning. Children won’t understand everything at first, but the words and phrases will become a natural part of their vocabulary. And all children love hearing stories about themselves.

Use the story to introduce your child’s birth parents in an understanding way, explain why you chose adoption to build your family, and give your child a sense of personal history and belonging. You can say, for example, “Just as you were growing in your birth mommy’s tummy, you were also growing in my heart.” Any details you can add to such a story about the joy of your first encounter will make it more delightful to your child.

Creating a “life book” for your child is another way to celebrate the unique way he or she joined your family. Save any mementos such as letters, toys, hospital name tags or documents that came with your child at the time of placement; they can serve as a source of “roots” later. Include pictures, too. Save any information or mementos that are directly from your child’s birth parents, no matter how small they may appear to be. Even a slip of paper with the birth parent’s handwriting may ultimately become a treasured possession for your child. If your child is from another country, pictures, trinkets and other mementos from your trip there can provide a sense of background.

Tell the truth Be factual about your child’s story, while keeping in mind what’s age appropriate. It’s important not to embellish or add details that you don’t know to be true. You may feel uncomfortable with the fact that there are holes in the story, and you may wish you knew all of the answers. Your child may ultimately grieve the loss of those details, too. However, it’s healthier to acknowledge the missing information and deal with the ramifications of not knowing than it is to make up details that you don’t know to be true. And don’t feel the need to share all of the information with your child right away; there may be some details that are better saved until your child is mature enough to handle them.

Use positive language Let your language reflect your own positive values toward adoption. Be open and honest about the adoption, but don’t use it as a label. Say “my child” and not “my adopted child.” Phrases such as given up for adoption may leave children feeling there was something wrong with them that made their parents give them away. Instead, talk about the decision made by the birth parents to make an adoption plan or arrange for an adoption so that their child could be well cared for.

Celebrate your family Some families make a tradition of doing something special on the day their family was created, such as having a family anniversary party or doing something special for the birth parents. This is a great way to get your other children involved, as well.

Seek out other families like yours Look to make connections with other families that have been touched by adoption. Both the children and the parents will find this type of peer group helpful, as well as a source of friendship and support. Transracially adopted children will get the added benefit of spending time with children — and other families — who resemble them.

Handling difficult remarks

At one time or another, parents and children may be faced with ignorant or even hurtful remarks from others. It isn’t always easy to speak up when someone says something naive or offensive, but it is important to keep your child’s well-being in mind. You don’t have to answer every question, and you don’t have to let everyone know you adopted your child. Instead, your response may be more for your child’s benefit than to educate the person asking the question or making the comment.

You’ll likely develop your own responses to things people might say. But here are some approaches suggested by adoptive parents to frequently asked questions:

Who are the real parents? We are — we’re not imaginary. We are the ones who do the parenting. (There’s no need to explain any further. Information about the birth parents is the child’s to give.)

Are they really brother and sister? Yes, they have the same parents. (Whether or not they are biologically related is also the child’s information.)

I don’t know how anybody could give up a child. The decision to place a child for adoption is a painful, difficult decision for anyone, but it’s always made in the best interests of the child. It’s not because the birth parents don’t care, but because they couldn’t really provide for any child at that time in their lives.

Too bad you couldn’t experience pregnancy. You don’t get to experience everything in life. I may never get to travel around the world either. But my adoption experience has been wonderful, and I wouldn’t trade it for anything.

Parenting is parenting

Becoming a parent opens up opportunities for amazing fulfillment and incredible challenges, no matter how you come into that role.

In the end, parenting is parenting. In order to move successfully from dependent infant to independent adult, every child requires consistent, loving care in a warm and nurturing environment. Providing this to your child makes you a parent, and research indicates that parents through adoption are keenly aware of their parental responsibilities. Together, you and your child make a family, a family that more often than not is abundantly prepared for the adventures ahead.

CHAPTER 42 Caring for multiples

Congratulations on not one but two (or more) babies! Your first years together will likely be busy ones, filled with chaos and, yes, delight. Like any new parent, there may be times when you wonder if you’ll ever make it through and times when you feel that it’s all more than worth the effort.

Raising multiples, especially in the early months, can seem truly overwhelming, simply because of the extra logistical and physical demands involved. Daily parenting tasks may be doubled or tripled, and the amount of time left to yourself may very well be minuscule. But most parents of multiples are able to rise to the occasion and find inner reserves of energy and strength they never imagined they had.

You already have plenty of helpful information in other sections of this book. This chapter aims to give you some practical tips on caring for multiple infants and finding time to care for yourself. If your babies were born prematurely, you may also find Chapter 43 to be helpful.

Feeding

Nursing mothers of multiples report that one of the most stressful aspects of caring for their babies involves feeding them. Newborns and young infants need to eat frequently — generally between eight and 12 times a day. When you’re feeding more than one child that many times, you may feel as if all you do is sleep, eat and feed your babies. Even formula-feeding, which many assume would be the most efficient method, takes a surprising amount of time and technique — not to mention a lot of bottles that require washing and storing!

Feeding your infants may seem to be an insurmountable task at times, but there are a couple things to keep in mind.

Regardless of which method you choose to feed your babies — breast-feeding or formula-feeding — a source of support and help is invaluable. This may come through your partner, grandparents, support groups or a hired caregiver. No one says you must do this alone.

This stage doesn’t last forever (even though it may feel that way). As one experienced mother said, “The days are long, but the years are short.” In a few months, as your children begin eating other foods and become more independent, the demands placed on you will become less intense.

A quick note: Don’t let others pressure you into one form of feeding or another. This is a personal decision between you and your partner, based on sound advice from your children’s medical provider or another specialist. The most important things are that your children grow and thrive and that you and your partner are able to enjoy the process (at least some of the time).

Breast-feeding Most experts agree that breast milk is the ideal source of nutrition for infants. Breast milk’s nutritional value is also one of the biggest reasons that mothers of multiples seek to breast-feed. While it takes a certain amount of dedication, it is possible to do, as shown by so many mothers who have successfully breast-fed multiples. Some mothers even say that breast-feeding is easier and less time-consuming, once lactation is established, than is bottle-feeding. And research studies indicate that most women will generally produce as much milk as is demanded, so it’s possible to produce enough milk for multiple children.

If you decide to breast-feed, it’s helpful to find a mentor who can give you insights and tips. This may be an experienced mother of multiples, a medical provider or a lactation consultant. Support groups for parents of multiples, such as local chapters of Multiples of America, are another way to meet experienced mothers and fathers of multiples.

At first, most women breast-feed one infant at a time. This allows them time to recover from childbirth, get the hang of breast-feeding and spend time with each infant. You can find out more about breast-feeding basics in Chapter 3.

Simultaneous breast-feeding Many mothers find that once their milk supply is established and breast-feeding is going well for all involved, they’re able to feed their babies simultaneously. This may or may not be for you, but it’s worth a try because it can save time and energy. As with feeding one baby, be sure to get comfortable. Use pillows to support yourself and your infants. Some manufacturers make breast-feeding pillows designed specifically for multiples.

To breast-feed two babies at once, you might use the double clutch, or double football, hold. In this position, you hold each baby in a clutch, or football, hold under your arms. Make sure each baby lies on his or her back with his or her head at the level of your nipple. Place the palm of one hand at the base of each baby’s head to provide support.

Here are some commonly used positions for breast-feeding twins:

Double clutch, or double football, hold. In this position, you hold each baby in a clutch, or football, hold. Place a pillow on each side of your body. You might also want to place another pillow on your lap. Place each baby on a pillow beside your body — almost under your arm — so that the babies’ legs point toward the back of your chair. Make sure each baby lies on his or her back with his or her head at the level of your nipple. Place the palm of one hand at the base of each baby’s head to provide support. Alternatively, you can place both babies — head to head — on pillows directly in front of you. Be sure to keep your babies’ bodies turned toward you, rather than facing up. Use the palms of your hands to provide support for each baby’s head.

Cradle-clutch combination. In this position, you hold one baby in the cradle position — with his or her head on your forearm and his or her whole body facing yours — and the other baby in the clutch position. If one of your babies has an easier time latching onto your breast or staying latched, place him or her in the cradle position.

Double cradle hold. To use the double cradle position, place both of your babies in the cradle position in front of you. Position your babies so that their legs overlap and make an X across your lap.

Rather than assign one baby to each breast, try to alternate them. This way, if one infant sucks less vigorously, the other may make up the demand and balance out the supply in each breast. If you have three or more babies, use a rotation system so that each one gets milk from both breasts. For example, if you have triplets, you might breast-feed one on each breast simultaneously and then the third on both breasts. At the next feeding, rotate their positions.

Combined breast- and bottle-feeding Breast-feeding doesn’t have to be all or nothing. While frequent breast-feeding helps establish and maintain your milk supply, any amount of breast milk you can give to your children is beneficial.

Many moms find that a combination of breast- and bottle-feeding (pumped breast milk or formula) works well because it allows them to breast-feed their babies but also share the job of feeding with a partner or other caregivers. For example, you might breast-feed one baby while your partner bottle-feeds the other one, then swap at the next feeding. Or your partner might take over a double bottle-feeding session while you get some rest. Ideally, you want to establish a milk supply before supplementing regularly with formula.

Some mothers of triplets prefer to set up a rotation where they breast-feed two infants supported by pillows while bottle-feeding the third sitting in an elevated infant seat. This is usually easier when babies are a little older and can hold up their heads well.

If you give your babies formula, keep in mind that your milk production might begin to decrease if you breast-feed or pump less than eight to 10 times within 24 hours.

Pumping If one or more of your babies are preemies or require an extended stay at the hospital, you can still establish a milk supply by renting a hospital-grade breast pump and pumping milk until you’re able to nurse. A breast pump may also be beneficial if you have a baby at home and one at the hospital, or one or more babies have difficulty latching on or sucking. Pumping is also helpful if you need to return to work but would like to continue feeding your babies breast milk. See Chapter 3 for how-tos on pumping.

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Tips to optimize milk production

Taking care of your body will help you make the most of breast-feeding:

Rest when you can. Although a solid night’s sleep may be a thing of the past, take every chance you get to rest. Extreme fatigue can interfere with breast milk production.

Eat a healthy and adequate diet. Avoid dieting while breast-feeding. Breast-feeding itself burns calories. Eat a well-balanced diet with plenty of liquids.

Continue taking prenatal vitamins. Your prenatal vitamins provide nutrients that may be missing from your daily diet.

Drink plenty of fluids. Although extra intake of fluids hasn’t been proved to increase milk production, nursing does tend to make you thirsty. Have a glass of water or juice before you sit down to nurse and keep water handy while nursing. Some nursing pillows even have pockets for just such a purpose.

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Formula-feeding Parents decide to feed their babies formula for a variety of reasons — illness on the part of the mother or one of the babies, difficulty sustaining an adequate milk supply, the ability of both parents to feed their babies, or simply because it feels more convenient. Ultimately, it comes down to the babies’ needs — getting adequate nutrition is the ultimate goal.

As with breast-feeding, it may be best to start out feeding one infant at a time. Chapter 3 will tell you what you need to know about formula-feeding basics. Once your babies are feeding well, you can save time and bottle-feed them simultaneously with the right techniques. One thing to avoid is propping up bottles and leaving a baby unattended, as this can increase the risk of aspiration and choking.

Two pediatricians who are also mothers of twins offer some different ways to bottle-feed twins simultaneously:

Sit on the floor with your legs extended in a V shape. Place the babies between your knees with their feet toward you and heads propped on a pillow. Hold a bottle in each hand and use your thighs as armrests.

Sit in a comfortable armchair with your left elbow propped on the armrest. Hold both babies with their heads resting against your left arm and their bodies supported in your lap. Hold one bottle with your right hand and lean the other bottle against your chest.

Cradle one infant in your left arm and curl your left wrist and hand around the baby to offer this baby’s bottle. Support the other baby’s head in your lap with his or her feet extended away from you and offer this baby’s bottle with your right hand.

Lean back in an armchair or against pillows and put both babies on your lap facing away from you with their heads supported against your chest. Offer a bottle from each hand.

Place one baby in an elevated infant seat next to you on the floor and hold the other baby in your lap. Offer a bottle from each hand.

Use two infant seats and sit between them on the floor. Offer a bottle from each hand.

Are my babies getting enough? If your babies are growing adequately, then they’re getting enough milk. Your babies’ medical provider may recommend some extra office visits to make sure each is gaining weight properly. You may also consider renting a scale, such as a baby scale, for the first month to monitor each baby’s weight gain. Knowing your babies are getting enough to eat and they’re gaining weight properly may help you feel more confident in breast-feeding. As a general rule, after the first week of life, weight gain should be ½ to 1 ounce a day.

During the first few weeks, you might find it helpful to maintain a daily chart to record feedings, wet diapers and bowel movements. In general, a baby who’s getting adequate nutrition will eat eight to 12 times a day, produce at least four to six wet diapers (and at least one that’s really soaked) and one bowel movement a day. There may be slight differences between babies that are breast-fed or bottle-fed. If you have any questions or concerns, don’t hesitate to ask your babies’ medical provider.

Raising strong individuals

Multiples are born with a strong connection to each other. They have similar genetic material. They’re usually delivered within minutes of each other. And they go through each phase of development around the same time. They come into the world with a ready-made companion and playmate at hand. They’re likely to share bedrooms, toys and even attention from others.

When you have twins or other sets of multiples, it can be easy to slide into a mode where you treat them as a pair or a set. For example, you may dress them alike or others may refer to them as “the twins.” This isn’t necessarily harmful,but it can sometimes get in the way of each child’s ability to develop separately. Also, if you treat your multiples as alike in every way, you may be missing out on some effective parenting strategies.

One-on-one time Research shows that, overall, multiples grow and develop in much the same way as single-born children — unless they were born prematurely, in which case prematurity may impact growth and development.

Some studies indicate that children who are multiples tend to display a slight delay in language development compared with singletons. This delay can be a common concern among parents. One study attempting to find out why concluded that one of the reasons for this delay may have to do with the level of parent-child interaction. In this study, mothers of twins were less likely to engage each child in back-and-forth “conversations” and less likely to report regular book sharing — looking at books together and talking about pictures or pointing at them and investigating the story further.

This seems fairly natural, as parents of twins tend to have more demands placed on them on a day-to-day basis than do parents of singletons, who may have more time to actively engage one-on-one with a child. Although the study was limited to studying mother-child interaction, in real life fathers and other caregivers also can play major roles in a child’s daily care. In the long run, being a twin doesn’t appear to affect academic performance once children reach school age. So while studies like these don’t mean that multiples are permanently disadvantaged, they do illustrate the value of spending interactive one-on-one time with each child when possible.

Parenting strategies Another reason to look at each child as an individual — one who just happened to be born at the same time as his or her sibling — is that you can learn to recognize different temperamental qualities in each one. Especially as your children get older, you can use your understanding of their different temperaments to target your parenting strategies more effectively.

For example, you may notice that one child is more flexible when it comes to transitioning from one activity to another, but the other may need ample warning that a change is coming. Knowing this difference between the two may help you plan your day and avoid meltdowns. (See Chapter 11 for a more in-depth discussion of temperament.) However, as you come to recognize their differences, try to avoid labeling your twins, such as referring to one of them as the “quiet one” and the other as the “outgoing one.”

Logistics

In addition to the physical demands of raising multiples, there are logistical challenges, as well. You don’t just need one crib, stroller, highchair and car seat. You need two or more. Here are some practical tips that may help you save money and get the job done.

Buy in bulk If you’re near a wholesale club that sells items in bulk, such as a Costco, BJ’s or Sam’s Club, it may be worth considering a membership. These places offer formula, baby food, diapers and wipes in large volumes and at a discount. Another option is to purchase bulk items online and have them delivered right to your door. Some retail websites have special membership programs for parents, such as Amazon Family, that allow parents to access baby and toddler items at a discount.

Check out supply stores Preschool and child care supply stores carry equipment that’s specifically designed for handling multiple children of the same age at once. Some examples include feeding tables with multiple seats built in, diaper storage units, activity tables built to accommodate multiple children and stackable toddler chairs. Plus, these items are generally built to withstand a fair amount of use.

Join a parent group Groups for parents of multiples not only provide regular gatherings and emotional support, members of the group also may hold resale events where families can buy and sell gently used baby equipment.

Explore your options It’s helpful to assess your needs and know what’s available when it comes to equipment:

Gates and locks. Thoroughly childproofing your home — placing gates in bathroom and kitchen doorways and in front of stairs and putting childproof locks on cabinet doors — allows you to rest more easily when you are busy with one toddler and don’t have a hand on the other.

Strollers. Double strollers for twins come in a few variations. Side-by-side ones are nice for walks in the park and jogging with your infants. Front-to-back models are easier to navigate in and out of doorways and in tight spaces. You can also clamp two lightweight umbrella strollers together to make a double stroller.

All the equipment and supplies you acquire may seem to overwhelm your house, car and every other area of your life in the first few years. But as your children get older, you’ll find that some things are no longer necessary, such as infant swings, playpens, and eventually highchairs and cribs. Hang in there!

Taking care of yourself

During your first few years together with your little ones, you’re likely to find yourself so immersed in caring for them that a life apart from your babies may seem almost surreal. Although this may come as small comfort, rest assured that your parenting job will become less labor-intensive and easier to manage as time goes by.

In the meantime, it’s important to carve out time for yourself. Extreme fatigue and lack of personal time can understandably lead to depression and isolation. If you feel overwhelmed or unable to enjoy your kids, it’s important to seek professional help from your children’s medical provider, a counselor, therapist or other mental health professional — someone who can help you get back on track.

Taking care of yourself may seem like it should come last on your to-do list, but in fact it is the first step toward taking care of your family. If your energy supply is depleted, it will be much harder for you to accomplish the daily tasks required to care for your children.

Keeping in mind that the demands of early parenthood are exponentially increased for parents of multiples and the fact that real life rarely falls together as neatly as advice found in a book, here are some suggestions that might help make life a little easier.

Get enough rest When others tell you to get more sleep, it may feel like a joke at times. How, you ask? Two nurses conducted a survey of mothers and fathers of twins, published in Applied Nursing Research, to see if they could find any consistent answers to this dilemma. Their question was simple: What strategies did parents of twins employ to obtain sleep in the first six months after taking their babies home?

Although no single answer emerged as completely effective, common strategies employed by the parents included:

Assigning shifts or taking turns with nighttime caregiving

Getting help from relatives

Sleeping while the babies slept, although some parents reported taking advantage of this time to complete other tasks

Getting the twins on the same sleeping and eating schedules

Using white noise and dimming the lights to help the babies sleep

During the first few weeks, it will likely be difficult to get enough sleep as everyone adjusts to the transition. But eventually, you’ll develop a routine and your days and nights will even out a bit. If you have difficulties or concerns about getting enough sleep or getting your children to sleep, talk to your children’s medical provider. He or she may be better situated to assess your needs and give you specific advice.

Get help and support Getting help can make a big difference. Some families hire help, some rely on extended family, and some get help from friends, neighbors, their religious community or other organizations.

Also consider attending a local support group for parents of twins or other multiples. You’ll likely get many invaluable ideas and practical suggestions from other parents. Online communities dedicated to supporting parents of multiples are another option.

Let go of guilt Some parents, after experiencing infertility and then having multiples, feel guilty when they become stressed or exhausted by the demands of caregiving. They may believe that they should only have feelings of happiness and joy after finally achieving their wish for children.

This is a false and unrealistic proposition. There’s no doubt that having children when you may have felt you couldn’t is a great source of pleasure. But this doesn’t mean you won’t feel tired, out of sorts and wondering at times what you’ve gotten yourself into. These are normal feelings for any parent. It’s important to set realistic expectations for your situation.

These parents sometimes feel as if they should be able to bear the full load of caregiving because “they got what they were asking for.” This is an emotional trap to avoid. Accepting help doesn’t make you a bad parent. In fact, as demonstrated earlier, it can help you be a better one.

Take outside attention in stride Twins, triplets and greater numbers of multiples frequently attract attention in public, which can be positive or negative. Regardless of what others say about you or your family, remember to keep your eye on the prize — raising happy, healthy and well-adjusted children who will eventually contribute to society in their own right.

Take time to replenish The stresses and demands of early parenting can take a toll on your personal life, marriage and relationships. It’s important to remain flexible about your changing roles in the family and maintain open communication so that each knows what the other is thinking.

Try to carve out time for yourself. Take periodic breaks to nurture and sustain yourself with exercise, relaxation or time with friends — whatever you need to recharge your batteries.

In addition, find time to nurture your relationship with your partner. This doesn’t have to be anything complicated — it might be as simple as watching a favorite TV show together or making a decent dinner for yourselves after the kids are in bed. Look for ways to support each other as new parents and compliment one another on a job well done.

Read Part 5 of this book, if you haven’t already, which has several chapters on managing and enjoying parenthood.

CHAPTER 43 Premature baby

Although most babies are born full term and free of medical problems, some are born too early. A premature (preterm) birth — a birth that occurs before 37 weeks of pregnancy — gives a baby less time to develop and mature in the womb. As a result, premature babies may need specialized treatment in the neonatal intensive care unit (NICU). Sometimes, even after a premature baby leaves the hospital, he or she may continue to need medical care.

If your baby was born prematurely, the marvel of birth might be overshadowed by concern about his or her health and the possible long-term effects. It can be a very stressful time as you learn to manage expectations, cope with an unexpected reality and find time to be with your baby. But there’s much you can do to take care of your premature baby — and yourself — as you look toward the future. Understand what to expect after your baby is born, the health problems that premature babies may face and how to best care for your premature baby.

Why premature birth happens

Many factors can increase the risk of premature birth. A multiple pregnancy is one cause. Chronic conditions experienced by a pregnant mother, such as diabetes, high blood pressure, and heart and kidney disease, also can lead to premature birth. However, a specific cause is often unclear. And a premature birth can happen to anyone, including women who have no risk factors.

As the parent of a premature newborn, you might feel that you did something to cause the preterm birth or that you could have done more to prevent it. Mothers especially might think about how they might have changed the outcome by making different decisions during pregnancy. Try to let go of any feelings of guilt about your baby’s premature birth by talking about them with your baby’s medical providers and your partner, who might be able to provide comfort. Focus your energy on caring for and getting to know your child.

Definitions If your baby was born prematurely, you’re not alone. It’s estimated that premature births occur in about 10% of pregnancies in the United States and that nearly 60% of multiple deliveries result in premature births. While all babies born before 37 weeks’ gestation are considered preterm, there are a few specific types of preterm birth, including:

Late preterm. A baby who is born at 34 through 36 weeks of pregnancy

Moderate preterm. A baby who is born between 32 and 34 weeks of pregnancy

Very preterm. A baby who is born between 28 and 32 weeks of pregnancy

Extremely preterm. A baby who is born at less than 28 weeks of pregnancy

Low birth weight. A baby who is born weighing less than 5 pounds, 8 ounces

Very low birth weight. A baby who is born weighing less than 3 pounds, 5 ounces

Extremely low birth weight. A baby who is born weighing less than 2 pounds, 3 ounces

The NICU Your first close-up look at your baby might be in the hospital’s NICU, which is designed to provide round-the-clock care for premature babies as well as full-term babies who develop problems after birth. You’ll probably be amazed, overwhelmed — and perhaps a little shocked — by this first look at your newborn.

Your son or daughter may be lying in an insulated enclosure (incubator). An incubator provides warmth, which is important because premature babies have less protective body fat than do full-term babies and may get cold in normal room temperatures. The unit may have a round porthole through which you and the NICU staff can reach in and touch your little one. You may also notice an array of tubes, catheters and electrical leads taped to your baby. For example, he or she may be placed on a cardiorespiratory monitor, which tracks his or her heart rate and rate of breathing. Seeing this equipment may be intimidating. It’s important to remember that these are tools to help keep your baby healthy and inform the medical staff about your baby’s condition.

In the NICU, your baby will receive specialized care, including a feeding plan tailored to his or her needs. Some premature babies may initially need to have fluids given to them intravenously or through a feeding tube that passes through the mouth or nose into the stomach. If you plan to breast-feed but your baby is unable to nurse at first, you can pump your breast milk. Your milk can then be given to your baby via a feeding tube or bottle. The antibodies in breast milk are especially important for preemies.

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The NICU team

In the NICU, your baby may be cared for by many specialists and other health care professionals. The team attending your baby may include a:

Neonatal nurse. A neonatal nurse is a registered nurse who has special training in caring for premature and high-risk newborns.

Neonatal nurse practitioner. This is a neonatal nurse who has completed additional training in the treatment of newborns, particularly babies in the NICU.

Neonatologist. A neonatologist is a pediatrician who specializes in the diagnosis and treatment of newborn health problems.

Pediatric resident. A pediatric resident is a doctor who is receiving specialized training in treating children.

Respiratory therapist. A respiratory therapist or respiratory care practitioner assesses respiratory problems in newborns and manages respiratory equipment.

Lactation specialist. A lactation specialist can help mothers who want to breastfeed establish a milk supply and learn the ins and outs of pumping.

Social worker. A social worker can provide support and resources for parents.

Keep in mind that your baby’s medical team may also call on other specialists, such as a pediatric surgeon or pediatric cardiologist, for help in providing care for your child.

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Caring for a premature newborn

A premature newborn may require some special care. The medical team caring for your baby will do everything they can to help your baby thrive. Your role as a parent is essential, too. Consider ways to get involved in your baby’s care and begin bonding with your newborn.

Appearance A premature baby may look a little or a lot different from a full-term baby. The earlier a baby is born, the smaller he or she may be and the larger his or her head will be in relation to the rest of the body. Your baby’s features may appear sharper and less rounded than do a full-term baby’s.

A preemie’s skin may be covered with more fine body hair (lanugo) than is common in full-term babies, and his or her skin may look thin, fragile and transparent. These characteristics will be easy to see because most premature babies aren’t dressed or wrapped in blankets. This is so NICU staff can closely observe a preemie’s breathing and general appearance. The medical team will likely treat your baby’s skin with care, avoiding lotions and ointments and using special tape that’s gentle to the skin.

Your son or daughter has a lot of growing to do in the coming weeks. In time, he or she will begin to look more like a full-term baby.

Condition and care Uncertainty can be frightening — as can seeing and hearing monitors, respirators and other types of equipment in the NICU. Ask questions about your baby’s condition and care or write them down and seek answers when you’re ready. Read material provided by the hospital, or do your own reading. If you prefer to be present during a procedure, let the NICU team know. If necessary, make an appointment to discuss your baby’s progress. The more you know, the better you’ll be able to handle the situation. If you’re concerned about changes in your preemie’s condition, talk to your child’s medical team.

Medical team You may see a dizzying number of medical professionals providing care for your baby. Until you become familiar with staff rotations, introduce yourself every time you see a new face and ask what his or her role is in caring for your son or daughter.

Nutrition Breast milk contains proteins that help fight infection and promote growth. Although your preemie might not be able to feed from your breast or a bottle at first, breast milk can be given in other ways — or frozen for later use. Begin pumping as soon after birth as possible, generally within 2 hours. Aim to pump at least eight times a day, round-the-clock.

Keep in mind that it will take time to establish your milk supply but that every drop of breast milk is precious to your baby, whose first feedings will be small anyway. Give the milk in a container — clearly labeled with your baby’s name and the date and time you pumped — to one of your baby’s nurses, who can refrigerate or freeze it and use it as your baby needs it.

Preemies typically require additional calories to grow and develop, as well as additional minerals for bone health. Consequently, your baby may be given a supplement in addition to breast milk.

When your baby is able to nurse, he or she might need more time getting used to the process than does a full-term baby. Give yourself and your baby time to learn and ask for help from the NICU team when you need it.

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Donor breast milk

For premature babies whose mothers are unable to provide breast milk, it may be possible for the NICU to arrange for donated breast milk as a source of nutrition. The source of donated breast milk in a NICU is taken very seriously, with the milk generally coming from established milk banks. Donor breast milk is not always feasible, partly due to the expense of ensuring a safe supply.

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Growth and development Become physically involved with your baby as early as possible. Gentle, loving contact with your premature baby can help him or her thrive.

For extremely premature babies, ask the NICU nurses for the most helpful ways to comfort your baby. Even before a baby is healthy enough to be held, you may be able to comfort him or her with a steady, calm touch. For the youngest babies, patting or stroking may be overwhelming at first. Speak to your baby in loving tones or quietly hum a lullaby. Reading to your baby also can help you feel closer to him or her.

NICU nurses can help you hold your baby to allow skin-to-skin contact by placing the baby on your bare chest, covered loosely with a blanket. This type of contact, sometimes called kangaroo care, can be a powerful way for you to bond with your baby. Eventually, you’ll become very comfortable in feeding, changing, bathing and soothing your little one. A NICU nurse can help you with these activities and teach you how to deal with equipment such as breathing tubes, intravenous tubes or monitor wiring.

Don’t hesitate to ask the NICU staff how you can become more involved in your baby’s care. Being hands-on with your baby can give you confidence as a new parent, as well as make the transition home a little easier when your child is ready to leave the hospital. While this may not be the way you imagined your baby’s first days or weeks, your time with him or her is special. Focus on enjoying your firsts together, such as the first time you feed your baby or bathe him or her, and your baby’s progress.

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Transporting your child

In some cases, a premature baby might need to be transported to a hospital that can provide specialized care. A member of your baby’s medical team will explain the situation to you and make the arrangements. Depending on your baby’s health and the travel distance involved, he or she might be transported by ambulance, helicopter or airplane. A transport team from one of the hospitals will accompany your baby on the trip. He or she will likely travel inside a transport incubator, which will provide warmth and allow him or her to receive any needed medical attention.

Being separated from your baby can be stressful and pose some challenges. Be sure to ask how you will be able to check on your child’s condition once he or she has been transported. If your baby is moved to a hospital that’s far away, consider asking a hospital discharge planner or social worker to help you find affordable nearby lodging so you can spend time with your baby. Ask your baby’s medical team about when your son or daughter might be able to return to a hospital near your home.

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Health issues

Due to medical progress, the outlook for premature newborns is much more hopeful than it was years ago. In fact, infants born at 24 weeks currently have a survival rate of 40 to 60 percent. A premature baby who is born after 28 weeks of pregnancy and weighs more than 2 pounds, 3 ounces has nearly a full chance of survival.

While not all premature babies experience complications, being born too early can cause short-term and long-term health problems for babies. Generally, the earlier a baby is born, the higher the risk. Birth weight plays an important role, too. Some problems may be apparent at birth, while others may not develop for weeks or months. Complications of premature birth may include the following health concerns.

Breathing concerns A premature baby may have trouble breathing due to an immature respiratory system. In some cases, breathing difficulties can prevent other immature organs in the body from receiving enough oxygen. If the baby’s lungs lack surfactant — a substance that allows the lungs to remain expanded — he or she may develop respiratory distress syndrome (see this discussion). This condition primarily affects infants born before 35 weeks. In addition, most preemies younger than 34 weeks experience prolonged pauses in their breathing, known as apnea.

To detect and treat breathing problems, your baby’s medical team may monitor your preemie’s breathing and heart rate. If your baby has breathing problems, he or she may be given oxygen or support through a ventilator or a breathing assistance technique called continuous positive airway pressure (CPAP).

Preterm babies, especially those born between 23 and 32 weeks, may develop chronic lung disease known as bronchopulmonary dysplasia (BPD; see this discussion). Preemies who develop moderate or severe BPD may need supplemental oxygen at home for the first 6 to 12 months. If this is the case, they will be monitored closely by a doctor who has special training in managing lung problems in children (pediatric pulmonologist).

Heart concerns The most common heart problems premature babies experience are patent ductus arteriosus (PDA) and low blood pressure (hypotension). PDA — which tends to affect babies born before 30 weeks or weighing less than 2 pounds, 3 ounces — is a passage between two major blood vessels leading from the heart (see this discussion). While this passage often closes on its own, left untreated it can cause too much blood to flow to the lungs and cause heart failure as well as other complications. Small premature babies who have a PDA may need to have their fluids limited and be given intravenous medication. In some cases, surgery is needed to close the passage. If your baby needs treatment for low blood pressure, he or she may be given additional fluid or intravenous medication.

Brain concerns Babies born before 30 weeks or weighing less than 2 pounds, 12 ounces are at risk of bleeding inside the brain, known as a germinal matrix or an intraventricular hemorrhage. Most hemorrhages are mild and resolve with little short-term impact. Some babies may eventually develop fluid accumulation in the brain (hydrocephalus) or neurological problems, such as cerebral palsy or a learning disability. Preemies who develop hydrocephalus may need surgery. If your baby has abnormal muscle tone, he or she may need to work with a physical therapist.

Gastrointestinal concerns Preemies are likely to have immature gastrointestinal systems. The earlier a baby is born, the greater his or her risk is of developing necrotizing enterocolitis (NEC). This condition, in which the cells lining the bowel wall are injured, primarily occurs in premature babies after they start feeding. Premature babies who receive only breast milk have a much lower risk of developing NEC. Measures such as antibiotics, intravenous feedings and resting the intestine by withholding feedings for a short period help most babies recover from NEC, although surgery is sometimes needed.

Infant gastroesophageal reflux (GER), a condition that occurs when stomach acid or bile flows back into the food pipe (esophagus), also is common in premature babies. It can cause a baby to vomit multiple times a day and disrupt weight gain. Most babies outgrow the condition as they reach their original due dates, though reflux remains pretty common. Frequent feedings in small amounts can help alleviate the condition. For more information on reflux, see this discussion.

Preemies are also at risk of hernias, which occur when a loop of intestine pushes through a weakened muscle or an unusual opening inside the body. While most umbilical hernias heal without intervention by the toddler years, inguinal hernias may require surgery. For more information on hernias, see this discussion.

Blood concerns Preemies are at risk of blood problems such as anemia and jaundice. Anemia is a common condition in which the body doesn’t make enough red blood cells. While all newborns experience a slow drop in red blood cell count during the first months of life, the decrease may be greater in preemies. More severe anemia may occur if your baby has a lot of blood taken for lab tests. Infants who have no symptoms may not need treatment. However, babies who experience symptoms — such as low blood pressure, a fast heart rate, weak pulse, pale color and breathing problems — may need blood transfusions. For more information on anemia, see this discussion.

Neonatal jaundice is a yellow discoloration in a newborn baby’s skin and eyes that occurs because the baby’s blood contains an excess of bilirubin, a yellow-colored pigment of red blood cells. Jaundice is common in babies born before 38 weeks. Most babies who need treatment respond well to light therapy (phototherapy). Although complications are rare, all newborns are assessed for jaundice during the first weeks of life. This is because severe infant jaundice can cause permanent deafness and brain damage. For more information on jaundice, see this discussion.

Metabolic concerns Premature babies often have problems with their metabolism. Some preemies may develop a low level of blood sugar (glucose) called hypoglycemia (see this discussion). This can happen because preemies typically have smaller stores of glycogen (stored glucose) than do full-term babies and because preemies’ immature livers have trouble producing glucose. Maternal diabetes before or during pregnancy also can increase a baby’s risk for hypoglycemia. Additionally, medications given during pregnancy to help control a mother’s high blood pressure can sometimes contribute to hypoglycemia in a preemie. If your baby is at risk of hypoglycemia, he or she may have a blood sample drawn, typically from his or her heel, and tested. Treatment usually consists of feeding the baby breast milk or formula, or giving the baby dextrose (sugar) intravenously.

Vision concerns Preemies born before 30 weeks may develop retinopathy of prematurity (ROP), a condition that develops when blood vessels swell and overgrow in the light-sensitive layer of nerves at the back of the eye (retina). Sometimes the abnormal retinal vessels leak, eventually scarring the retina and pulling it out of position. When the retina is pulled away from the back of the eye it’s called retinal detachment, a condition that can impair vision and cause blindness. Screening for ROP can help doctors detect and treat eye disease before it progresses to retinal detachment.

Premature babies are also at risk of developing other vision problems, such as misalignment of the eyes (strabismus) or nearsightedness (myopia).

If your baby is born before 30 weeks or weighs less than 3 pounds, 5 ounces, an ophthalmologist will likely examine your baby’s eyes beginning when he or she is about 4 to 6 weeks old. Generally, preemies need eye exams every couple of weeks or so until the retina has fully developed. Regardless of whether your child has ROP, your baby’s medical provider may recommend that your son or daughter be periodically examined by an ophthalmologist during the preschool years.

Hearing concerns Premature babies are at increased risk of some degree of hearing loss. Your baby will likely be given a newborn hearing screening before he or she reaches a corrected age of 1 month (see “Corrected age” below) or before being discharged from the NICU. If your preemie has abnormal screening results, he or she will likely have follow-up testing with a specialist. Early diagnosis is crucial. The sooner treatment begins the better your child’s chances are of developing age-appropriate language and communication skills.

Dental concerns Preemies who have been critically ill are at increased risk of developing dental problems, such as delayed tooth eruption, tooth discoloration and improperly aligned teeth.

SIDS Premature babies are at increased risk of sudden infant death syndrome (SIDS). When your baby is home from the hospital, always place your baby on his or her back to sleep. In the NICU, babies may be placed on their stomachs if they have respiratory problems or on their sides if they have infant gastroesophageal reflux. In these cases, the medical team will begin placing the baby on his or her back prior to discharge. For more information on SIDS, see this discussion.

• • • • •

Corrected age

Corrected age is your baby’s age in weeks since birth (chronological age) minus the number of weeks he or she was premature. It’s used for the first two years to adjust a premature baby’s chronological age so that it more accurately reflects his or her developmental stage.

For example, if your baby is 6 months old but was born eight weeks early, his or her corrected age is actually closer to 4 months (6 months minus eight weeks). This means that you can expect your baby to be achieving the skills of a 4-month-old, such as holding his or her head steady and smiling at you. By age 2, most preemies have caught up to full-term babies in terms of typical developmental milestones.

• • • • •

Future issues For some premature babies, difficulties may not appear until later in childhood or even adulthood. Children who were born premature may experience developmental delays, learning disabilities, difficulty smoothly controlling their muscles, and behavioral, psychological or other chronic health problems. Preterm babies who have a very low birth weight may also be at increased risk of autism. Research suggests that some premature babies, especially those with severe intrauterine growth restriction, may face an increased risk of type 2 diabetes and high blood pressure as adults.

Take heart. It’s normal to be concerned about your baby’s health, especially if he or she has spent time in the NICU. But most babies who spend time in the NICU don’t have significant disabilities. And many premature babies catch up and develop into typically developing healthy children. Keep in mind that the way you and your family care for, interact with and stimulate your baby in the coming months also can have a major impact on his or her development.

• • • • •

Intermediate care

While some babies go home after spending time in the NICU, many are transferred to a unit that provides intermediate care before discharge. This unit, which may be located within the NICU or nearby, typically provides care for babies who need less intensive treatment and monitoring. Be sure to talk to your baby’s medical providers about the type of treatment your baby will receive in the new unit and how you can be involved.

• • • • •

Taking care of yourself

At this point in time, all of your attention may be concentrated on your child and helping him or her to thrive. But remember that you have special needs, too. Taking good care of yourself will help you take the best care of your new son or daughter.

Allow time to heal You might need more time to recover from the rigors of childbirth than you imagined. Be sure to eat a healthy diet and get as much rest as you can. When your medical provider gives you the OK, you can start exercising.

Acknowledge your emotions Expect to feel joy, anger, fear, powerlessness and a sense of loss. Some parents report feeling strange about getting to know their newborns in the busy NICU. You might celebrate successes one day, only to experience setbacks the next. Give yourself permission to take it one day at a time. Remember that you and your partner might react to stress and anxiety differently, but you both want what’s best for your baby. Keep talking and supporting each other during this stressful time.

Take a break If you leave the hospital before your baby, use your time at home to prepare for his or her arrival and get some rest. Your baby needs you, but it’s important to balance time at the hospital with time for yourself and your family.

Be honest with siblings If you have other children, try to answer their questions about the new baby simply. You might explain that their baby sister or brother is sick and you’re worried. Reassure your children that the baby’s illness isn’t their fault. Ask if you can bring your other children to the NICU to visit your baby. If your children aren’t able to see the baby in the NICU, show them pictures.

Seek and accept help Allow friends and loved ones to care for older children, prepare food, clean the house or run errands. Let them know what would be most helpful. Surround yourself with understanding friends and loved ones. Talk with other NICU parents. Consider joining a local support group for parents of preemies, or check out online communities. Seek professional help if you’re feeling depressed or you’re finding it difficult to cope with your new responsibilities.

Bringing baby home

As your son’s or daughter’s condition begins to improve, you may wonder when you finally can bring him or her home. The criteria vary, but generally hospital staff will consider allowing you to take your baby home when he or she:

Can breathe without support

Has a stable heart rate

Is able to maintain a stable body temperature

Can breast- or bottle-feed

Is gaining weight steadily

In some cases, a child may be allowed to go home before meeting one of these requirements — as long as the baby’s medical team and family create and agree on a plan for home care and monitoring.

When it’s time to bring your baby home, you might feel relieved, excited — and anxious. After days, weeks or months in the hospital, it can be daunting to leave the support of the medical team behind. As you spend more time with your baby, you’ll better understand how to meet his or her needs and your relationship will grow stronger. In the meantime, consider ways to prepare for your child’s hospital discharge.

Understand care requirements Before you leave the hospital, take a course in infant CPR. Ask your baby’s medical team any questions you might have and take notes. Make sure you’re comfortable caring for your baby, especially if you’ll need to administer medications, use special equipment, or give your baby supplemental oxygen or other treatments. Ask if any members of the hospital medical team do home visits, which can be helpful during your baby’s first week home.

You’ll likely be asked to provide contact information for your baby’s primary medical provider so that a member of the hospital medical team can inform him or her about your baby’s medical condition. Discuss symptoms — such as infant breathing or feeding problems — that might necessitate a call to your baby’s main provider. Note your baby’s need for follow-up visits or referrals, and find out whom to call if you have questions or concerns.

Discuss feedings Ask the medical team about your baby’s need for supplementation in the form of breast milk fortifiers or preterm infant formula. Keep in mind that premature babies usually eat smaller amounts and may need to be fed more often than full-term babies. Preemies also tend to be sleepier than full-term babies and to sleep through feedings (see this discussion). Find out how much and how often your baby should be eating.

Make travel arrangements Because sitting semireclined in a car seat can increase the risk of breathing problems or a slow heartbeat, your baby might need to be monitored in his or her car seat before hospital discharge. When you have the OK to use a car seat, use it only during travel. Talk with your baby’s medical providers if you may need to take an airplane flight with your newborn. Your son’s or daughter’s lungs may be sensitive to the effects of altitude changes during flight. Also don’t place your preemie in an infant sling, a backpack or other upright positioning devices until you talk to your baby’s provider. These devices may make it harder for him or her to breathe.

• • • • •

Rehospitalization

Premature babies’ health problems can sometimes make it necessary for them to be readmitted to the hospital. Preterm babies are twice as likely as full-term infants to be readmitted to the hospital in the first year. This risk increases the earlier a baby is born before his or her due date. Common causes of rehospitalization include infections, respiratory problems, feeding problems and surgical complications.

If your preemie needs to go back to the hospital for treatment, don’t get discouraged or blame yourself. You may want to reconnect with some of the support people who helped you through the last hospital stay. For longer hospital stays or more frequent rehospitalizations, some families find it helpful to blog their baby’s progress online so that they don’t have to continuously call family members and well-wishers with updates. Ask the hospital medical team any questions you might have about your baby’s condition and find out what you need to know to care for him or her in the future.

• • • • •

Protect against illness Premature babies are more susceptible than are other newborns to serious infections. Try to minimize your preemie’s exposure to crowded places, and make sure people who come into contact with your child wash their hands first. Parents of babies at high risk of developing respiratory complications, such as babies who require oxygen at home, should minimize the number of young children their babies encounter. During the child’s first year, or at least first winter, it may be best to avoid child care centers. Your baby’s medical provider may also recommend additional protection from respiratory syncytial virus (RSV), a common cause of colds and other upper respiratory infections, with monthly antibody injections during your baby’s first winter after NICU discharge.

It’s important for all children to receive vaccinations on the recommended schedule. The same is true for premature babies. It’s recommended that vaccinations be given to medically stable premature babies according to chronological age. But depending on your baby’s age and any complications that may have developed in the NICU, a catch-up schedule may be needed. Work with your baby’s medical provider to stay on schedule for your baby’s vaccinations. It’s also very important for family members and others around your baby to receive their annual flu shots to minimize the chances of spreading the flu virus to your child.

Baby’s checkups

Depending on your baby’s age, weight and health, you’ll likely need to schedule a first visit to his or her primary medical provider within several days after discharge from the hospital. The provider may review your baby’s stay in the NICU, current medications and treatments. In addition, the provider will likely discuss your son’s or daughter’s growth, nutrition, vaccinations and specific medical problems and evaluate your baby’s progress since leaving the hospital. Be sure to tell the provider about any concerns you might have. In addition, discuss your baby’s need for future appointments with the provider and any specialists. Your preemie may initially need to see his or her provider every week or two to have his or her growth and care monitored.

Your baby’s medical provider will also monitor your baby for developmental delays and disabilities in the coming months. Babies who are identified as being at risk may receive further evaluation and be referred to early intervention services, such as physical therapy for infants. See Chapter 44 for more information on delayed development.

Extremely preterm infants and other babies who experience complications in the NICU are commonly seen in a NICU developmental follow-up clinic. This clinic specializes in monitoring and optimizing the growth and development of preterm infants and those who required critical care after birth. Oftentimes the clinic is staffed by a team of specialists that includes a neonatologist, a neurologist, a dietitian, and physical, occupational, and speech therapists. Your son or daughter may be followed in this clinic until about age 3 years.

Work with your baby’s medical providers to understand any health problems your baby might experience and what you can do to promote your preemie’s health and well-being.

CHAPTER 44 Delayed development

Throughout childhood, your son’s or daughter’s medical provider will monitor your child’s growth and development to make sure it’s progressing steadily and it falls within the range of typical development. At each well-child visit, the medical provider will likely ask you questions or have you fill out questionnaires about your child based on his or her age. These may include questions such as whether your baby is learning to hold up his or her head, grasp toys, roll over, coo, laugh, walk, or say mama or dada.

Sometimes, a child’s abilities will fall below the range of milestones achieved by his or her peers. This isn’t always a cause for alarm because children tend to develop at highly individual rates. They may fall behind in one area, such as language, while focusing intently on mastering another area, such as crawling or walking. Soon after they acquire the skill they’re pursuing, they move on to achieve other milestones that have been lagging.

But if your child is slower to achieve certain milestones or if you’re concerned about his or her development, you and your child’s medical provider can take steps to detect any potential problems. The earlier a problem is identified, the sooner you can take measures to help your child achieve his or her maximum developmental potential. If an underlying condition or disease is present, treatment may help prevent further problems.

What is delayed development?

Delayed development is when your child doesn’t reach developmental milestones within the same time frame as other children of the same age. When a child is delayed in two or more important areas of development, medical experts refer to this as global developmental delay. Milestones are usually grouped into these categories:

Motor skills — rolling over, sitting, picking up small objects, walking

Language and communication — recognizing sounds, imitating speech, babbling, pointing

Thinking and reasoning — beginning to understand cause and effect, object permanence

Personal and social skills — exploring, smiling, laughing, interacting with others

Daily activities — eating, dressing

Part 3 of this book discusses typical growth and development for the first three years of your son’s or daughter’s life. If you’re concerned that your child isn’t meeting certain milestones or isn’t developing as he or she should, talk to your child’s medical provider. He or she can reassure you about what’s considered normal and offer advice on further testing.

• • • • •

Will my child grow out of a developmental delay?

Some premature infants appear delayed based on chronological age. However, the apparent delay may disappear when the baby’s corrected age is taken into account. Among children who have true developmental delays in the preschool years — meaning they consistently lag behind in screening tests — most continue to be delayed even as they grow older. This is why early identification is so important. If you’re waiting for your son or daughter to grow out of a developmental delay, you may be missing out on early opportunities to optimize his or her potential.

• • • • •

How is a delay identified?

Usually, a developmental problem is identified over time rather than at a single medical visit. If you or your child’s medical provider has concerns about your child’s development, the provider may conduct a developmental screening test to see if your child may be at risk for a developmental disorder.

The screening tests are usually brief and inexpensive. Your child’s medical provider may ask your child to play a game or perform certain activities, such as playing with a doll or picking up a small object. You may be asked to fill out a questionnaire. Based on the screening test results, the medical provider may recommend a wait-and-see approach to give your child a little more time to develop, or he or she may refer you to a childhood development expert for further evaluation.

A developmental evaluation is a more complex procedure carried out by a professional who is specially trained to administer these tests. The evaluation is designed to identify specific developmental disorders that may be affecting the child. Along with the developmental evaluation, a medical diagnostic evaluation is conducted to identify any possible underlying conditions that may be affecting development.

If it’s determined that your child may be at high risk for a developmental disorder, even before a disorder is diagnosed, your child’s medical provider or a specialist may refer you to early intervention services. These services generally provide evaluations and other assistance that may be helpful during the diagnosis process.

Possible causes

There are many conditions that may contribute to delayed development, for example, genetic disorders, infections and toxin exposure. But most often, the exact cause is hard to identify.

Sometimes during a pregnancy, a fever or infection in the mother will create immune reactions that can harm the development of the baby’s brain. Fetal exposure to alcohol or drugs during pregnancy also can damage a baby’s developing nervous system. Premature birth or difficulties during labor that impair circulation may lead to developmental problems.

A baby’s brain continues to develop even after birth. Excessive exposure to toxins, such as high levels of lead, can harm the body’s nervous system and lead to mental deficits. In cases of severe neglect, in which the brain isn’t being appropriately stimulated or nourished, delayed development can result.

Some babies have a chromosomal abnormality or an inherited disorder that interferes with normal growth and development. Or a metabolic disorder, such as an underactive thyroid, can result in impaired growth and development and slower intellectual function. In many states, a newborn screening will identify these conditions (see this discussion).

Diagnosing a developmental delay

To try to determine what may be causing your child to lag behind in achieving developmental milestones, your child’s medical provider or another specialist, such as a developmental pediatrician or a child neurologist or geneticist, will likely do a comprehensive physical exam. He or she may also conduct a variety of tests. The tests may include vision and hearing exams, genetic tests to look for a possible genetic abnormality, imaging tests of the brain to look for an abnormality or injury, and metabolic and thyroid tests.

Usually, the tests aren’t done all at once but in a stepwise fashion. Depending on the results of one examination or test, the medical provider will make recommendations about additional testing.

What can be done?

Some causes of developmental delay are treatable, but more often, the condition causing developmental delay isn’t curable or even known. Early identification of a problem — whether an underlying cause is discovered or not — allows therapies to be provided at a time when they may be most helpful.

If your child is identified as having special needs, he or she has access to early intervention services. You may already have been referred by your child’s medical provider to your local early intervention office for an evaluation of developmental concerns. A referral can be made at any time. Once a referral is submitted, your child is assessed and a caseworker is assigned to your family to coordinate the services that meet your child’s specific needs. Together with the caseworker and therapists, you create a written plan called the individualized family service plan (IFSP). This plan outlines the services your child needs and how they will be provided.

The earlier these services are started, the better it is for your child. Therapists may come directly to your home to work with you and your child, but you may also visit a center or clinic for some parts of your plan. Common services offered by an early intervention program typically include:

Physical therapy to work on gross and fine motor skills

Speech therapy to work on language and communication skills

Occupational therapy to work on personal and social skills

Family training and counseling to help you work with your child at home

Transportation and assistive technology services if your child needs special equipment to get around

Nutrition counseling if your child has trouble feeding

Coordination of services from physicians and other agencies

Early intervention programs are funded primarily by each state but also receive support from the federal government and local resources. In a few cases, a state program will charge a small family fee. Your caseworker can discuss the cost of these services with you and may coordinate with your health insurance provider, but your ability to pay is not a prerequisite for eligibility. In general, families incur little to no out-of-pocket costs for these services.

Once he or she reaches 3 years of age, your son or daughter may be eligible for services available through the public school system. Most kids with special needs start kindergarten on time or the following year. Most attend schools that serve a variety of students, not just children with disabilities.

Your child will continue to receive special services as needed throughout kindergarten, elementary and high school. Periodic re-evaluations are done to update your child’s needs. Different states have different policies regarding when state-sponsored programs end. Your child’s caseworker or school aide or other local resources can help you find out what applies in your state and help you answer any questions you may have.

Get support

Determining whether your child has a developmental disability — and if so, what can be done to help your child — can take time. It may require making trips to various specialists, watching your child undergo different tests and waiting for results in between tests. It’s not always easy dealing with the uncertainty and anxiety that often accompany this process. Your medical provider or caseworker, if you’ve been assigned one by an early intervention program, may be able to help you navigate the various procedures and coordinate the services you need.

In the meantime, it’s important to get support — not only through meeting with specialists and reading information but also through meeting other parents in similar circumstances. These are the people most likely to know what you’re going through, and they may be able to offer valuable information you can’t get elsewhere, such as a great dentist for kids with special needs or which kind of sippy cup works best for toddlers with challenges learning how to use a cup. And sometimes a friendly chat with another parent about the ups and downs of your day is just what you need to feel a little more ready to face the next day.

Here again, your medical provider or caseworker may be able to connect you to a local parent group that fits your needs. Or you can check the internet for local chapters or online communities of national organizations for specific disabilities. For information on resources, including websites, books and other sources that may be useful to you, see “Additional Resources” here.

CHAPTER 45 Autism spectrum disorder

If you’re like most parents, there have probably been times when you’ve wondered whether your child is developing “on schedule.” Shouldn’t he be starting to smile by now? Why isn’t she talking yet? Is it a problem that he doesn’t look up when I say his name?

When it comes to hitting the major infant and toddler milestones, there’s a range of what’s typical. Each child develops at his or her own pace. Most of the time, the differences parents see in their children are well within the normal range. But some parents have an instinct that something isn’t quite right. Their baby seems to always be behind in language and social development. Or their toddler appears to be losing communication skills instead of gaining new ones. These parents aren’t sure what the problem is — or if there even is a problem — but they worry it could be autism.

This chapter will walk you through the early signs of autism spectrum disorder. You’ll also learn how autism is diagnosed and addressed in early childhood, and how to support a child on the autism spectrum. The good news is that intensive, early treatment has a major, lasting impact on many children with autism, allowing them to grow and thrive in their own way.

Understanding autism

Autism spectrum disorder is a disability that affects the brain and nervous system, interfering with a child’s ability to interact socially and communicate with other people, both kids and adults. The disorder also leads to fixed and repetitive patterns of behavior, interests or activities. These symptoms can limit or impair everyday functioning.

Not every child diagnosed with autism has the exact same symptoms or shows every sign. That’s why the term spectrum is included in the name of the disorder. Some children with autism may experience less impairing symptoms while others face more difficult challenges in their day-to-day lives. No two children show signs in the same way.

Autism spectrum disorder includes conditions that were previously considered separate — autism, Asperger’s syndrome, childhood disintegrative disorder and an unspecified form of pervasive developmental disorder. Some people still use the term Asperger’s syndrome, which is generally thought to be at the mild end of autism spectrum disorder.

What causes autism? Autism spectrum disorder has no single known cause. In most cases, the disorder likely occurs due to a complex interaction between the child’s genes and the environment. It’s probable that this interaction affects early brain development. Research continues in this field, and there may be other causes that have yet to be discovered.

Over the years, many people have speculated about possible causes. For example, some people have claimed that a parent’s childrearing style is somehow to blame. But there’s absolutely no evidence to suggest that autism is caused by bad parenting.

One of the biggest controversies centers on a suggested then debunked link between vaccines and autism. Scientists have investigated the question extensively. Despite hundreds of studies, there’s no evidence that vaccines cause autism. In fact, the original study that ignited the debate years ago has been retracted due to poor design and questionable research methods. Most recently, a 2019 nationwide study in Denmark involving over 650,000 children compared autism rates in children who were vaccinated for measles, mumps and rubella (MMR) with children who weren’t vaccinated. The large number of children involved gave the study enough power to look at other risk factors as well. The study found that MMR vaccination did not increase the risk of autism and also found it did not increase the risk for siblings of children with autism. In girls, the MMR vaccine actually reduced the chances of autism.

On the other hand, not vaccinating increases your child’s risk of catching and spreading serious diseases such as measles, mumps and rubella. (For more information about vaccinations, see Chapter 14.)

How common is autism? Over the past several decades, the rate of diagnosis of autism in children has increased dramatically. Researchers think this is largely due to a rise in the overall awareness of the disorder and a broadening of the diagnostic criteria for autism. But more investigation is needed to rule out other factors.

The Centers for Disease Control and Prevention estimates that approximately 1 in 59 children in the United States has been identified with autism spectrum disorder. Overall, autism is thought to occur in 1% to 2% of the population. The disorder is about four times more common in boys than in girls and occurs among all racial and ethnic groups.

• • • • •

Early warning signs

The list below is only a guide, not a way to diagnose your child. Many children exhibit a few of these behaviors even if they don’t have autism. Some of these behaviors can also be a sign of other developmental issues. On the other hand, a child may have autism spectrum disorder without showing all of these signs. If you’re concerned about your child’s behavior, bring it up with your child’s medical provider. The provider can help you determine if further evaluation is necessary.

By age
A child with autism might not . . .

12 months

Babble or coo

Respond to his or her name

React to back-and-forth interactions, such as waving or peekaboo

Look at objects that another person is pointing to

16 months

Say single words

18 to 24 months

Engage in pretend play (make-believe)

24 months

Say meaningful two-word phrases

Show an interest in objects by pointing at them

At any age
A child with autism might . . .

Lose language skills or social skills

Avoid eye contact

Prefer to look at objects rather than people

Show a strong preference to be alone

Have extreme difficulty with small changes in daily routines or surroundings

Repeat words or phrases without meaning (like a parrot)

Engage in repetitive movements such as rocking, spinning or hand flapping

Show a high sensitivity to sounds, tastes, texture, lights or colors

Not seem to be sensitive to pain or temperature

Show little or no desire to be picked up or held

Show little interest in toys or repeatedly focus on one aspect of a toy, such as how it feels or how one part moves

• • • • •

Early signs of autism

Many children with autism spectrum disorder show hints of the disability within the first year of life. Other children appear to develop normally but then suddenly — or gradually — become withdrawn and lose language skills that they already had. Most children show clear signs of autism before 2 or 3 years of age. However, some kids on the mild end of the spectrum might not be identified as having autism until later in childhood or even adolescence.

Parents of infants and toddlers on the autism spectrum may notice that their child doesn’t communicate or interact with adults and children the way that other kids the same age do. Initially, they might assume the problem lies with their child’s vision or hearing rather than a delay in their child’s development.

Young children who are later diagnosed with autism often show signs of the disorder at early stages of their development. Below are some possible signs in the first years of life.

Identifying autism in early childhood

If you’re at all concerned about your child’s development or behavior, don’t keep it to yourself. Bring those concerns to your child’s medical provider. While autism is most commonly identified in children who are 3 years or older, it’s possible to screen for and diagnose the disorder in toddlers. Children who are diagnosed in the toddler and preschool years greatly benefit from early intensive intervention. Research shows that early treatment for the disorder allows many children to function better in life, do better in school and manage their condition more successfully.

Screening for autism Your child’s medical provider will look for signs of developmental delays at regular checkups. If your child’s provider observes signs of autism — or if you express a particular concern — your child will likely be screened for the disorder. The American Academy of Pediatrics recommends that children be routinely screened for autism at 18 and 24 months. If your child has a sibling with autism, the provider may conduct additional screenings.

During the screening for autism, your child’s medical provider will typically ask you a series of questions about your child. Your intimate knowledge of your child’s day-to-day life, particularly details related to social and communication skills and behavior, can help the provider evaluate your child. In some cases, the provider might engage your child in a short play session to observe how he or she interacts, talks and behaves.

The most common screening for autism is the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R). This series of questions assesses the risk of the disorder in children between the ages of 16 and 30 months. If you have concerns about autism earlier in your child’s life, your child’s medical provider may use the Infant Toddler Checklist. Although this set of questions wasn’t designed specifically to screen for autism, it can be used to identify a potential risk of the disorder in infants as young as 9 or 12 months.

Diagnosing autism If your child’s initial screening identifies a risk of autism spectrum disorder, you’ll likely be referred to a team of medical providers who specialize in treating children with autism spectrum disorder. This team will evaluate your child to determine whether he or she has autism.

Diagnosing autism is often a complex process. The diagnosis is most often made by watching how the child behaves and listening to a parent or caregiver’s description of how the child behaves. The child’s age, level of development, thinking skills and language ability are also considered.

Because behavior can vary considerably depending on time of day, location, familiarity with medical staff and many other factors, it’s important that your child undergo several different observations before a final diagnosis is made.

Typically, these observations are made by different specialists. You and your child might talk with a developmental pediatrician, pediatric neurologist, medical geneticist, neuropsychologist, psychiatrist, speech and language pathologist, occupational or physical therapist, and a medical social worker. However, your child may not need to see all of these specialists.

To be diagnosed with autism, a child must show consistent difficulties in two key areas:

Social communication. This includes a child’s ability to react to social cues, such as eye contact or smiling, and engage in back-and-forth interactions, such as waving or pointing. A lack of interest in family members or other children also falls under this category.

Restricted, repetitive behaviors. These behaviors can include repetitive movements, a strong need for rigid routines, an intense preoccupation with a particular sensory experience, and an unusually high sensitivity to taste, textures, lights or sound.

To make the diagnosis, medical providers use a comprehensive list of criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. Your child’s medical team can help you understand the criteria as it applies to your child. Some children may not be diagnosed until they’re older, when the demands on their social skills become more challenging and difficulties become more apparent.

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Can a child outgrow autism?

For the majority of children diagnosed with autism, the disorder is a lifelong condition. Even so, signs and symptoms can improve significantly with treatment and time. In a small percentage of children, signs and symptoms improve so much that the children no longer meet the criteria for autism spectrum disorder. In general, these children tend to receive intensive treatment for the disorder at a young age, have mild symptoms and are of average intelligence. While these children are no longer considered to have autism, they commonly have some remaining social, language, learning and behavioral difficulties. They are also more likely to experience attention and mood disorders.

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What happens after a diagnosis

In the United States, children under 3 with autism are referred to their local early intervention program, which can provide therapies to improve signs and symptoms. These services are administered by individual state agencies under Part C of the Individuals with Disabilities Education Act (IDEA).

Early intervention services available to your child will vary depending on the state in which you live. Navigating your options may seem overwhelming at times. To help you through the process, ou’ll be assigned a service coordinator through your local early intervention program. A social worker can be another valuable resource as you begin to explore the assistance available to your child through local and state government agencies. A social worker can guide families who might be in need of financial assistance through the process of applying for Social Security aid.

Also visit the Center for Parent Information and Resources website. It offers a search function for finding a parent center in your state or territory. These agencies provide support and services to families of children with disabilities and can give you specific state information and guidance on how to negotiate your state’s early intervention program. Another helpful resource is the Autism Response Team information line run by the organization Autism Speaks. Trained team members may be able to answer questions and help you find autism services and support in your community.

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Can my child receive early intervention services without a diagnosis?

If your child shows signs of developmental delays but hasn’t received an autism diagnosis, he or she may still qualify for early intervention services. Ask your child’s medical provider for a referral or contact your state’s early intervention services office directly. Ask that your child be evaluated under Part C of the Individuals with Disabilities Education Act. Depending on the outcome of this free evaluation, your child may be eligible to receive some early intervention services.

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Early intervention services No cure exists for autism spectrum disorder, and there is no one-size-fits-all treatment. The goal of early intervention services is to help your child gain developmental skills and help your family learn ways to meet your child’s needs. Such services may help improve your child’s physical, thinking, communication, social and emotional skills.

Once you qualify for early intervention services, one of the first steps is to create an Individualized Family Service Plan (IFSP). The IFSP is a personalized plan for children who have not yet turned 3. It helps you identify how to meet your child’s needs and your family’s needs. To create this plan, you’ll typically partner with your assigned service coordinator as well as early intervention specialists or therapists.

With an IFSP in place, your child can begin receiving early intervention services. These services often occur at home but may also take place in a center or through other outpatient programs. Many early intervention services for autism address the range of social, language and behavioral difficulties associated with autism spectrum disorder. They’re commonly based on the principles of applied behavior analysis, a method used for helping children with autism and their families. Some therapies provide structured learning opportunities that break down complex skills into small, teachable steps. Therapy may also be incorporated into play sessions and other everyday activities. As a parent, you’ll play a vital role in your child’s progress and may receive training on how to support and work with your child.

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Unproven treatments

Since a cure has yet to be found for autism, many parents seek unproven complementary and alternative therapies for their children. Specialized diets, such as a gluten-free or casein-free diet, are one of the most common therapies that parents turn to. It has been proposed that such diets may help curb symptoms. But researchers have found no convincing evidence to support this claim. Other popular claims include the use of vitamin supplements, probiotics and hyperbaric oxygen. Again, there’s little evidence that these products are beneficial for autism symptoms, and they can be expensive.

Some alternative treatments are not only unproven but potentially dangerous. Chelation therapy, which is said to remove mercury and other heavy metals from the body, can be very harmful or even deadly. Another potentially harmful and unproven treatment involves intravenous immunoglobulin (IVIg) infusions.

If you’re considering a particular therapy for your child, don’t hesitate to talk with your child’s medical provider about the scientific evidence behind it, as well as the potential risks and benefits.

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Supporting your child The care you provide your child as a parent is just as important to your child’s overall growth as is the care that any specialist provides. Your child knows you and trusts you to care for him or her. For this reason, your patient and consistent guidance is key to helping your child learn to manage his or her behavior.

There are many ways you can help your child with autism succeed at home and in social or community settings.

Become an expert on your child. Do specific sensory or social experiences trigger tantrums or other challenging behaviors? Are certain routines or behaviors soothing, comforting or pleasing to your young child? When you’re aware of what stresses, calms and entertains your child, you’ll be better equipped to head off or manage behavioral problems.

Manage tantrums with empathy. Tantrums are a normal part of life with a toddler, and even more so when that child has autism. Try to understand and address what triggered the tantrum. Ignore negative behaviors that don’t cause self-injury or harm to others (see this discussion).

Praise positive behaviors. Instead of continually trying to correct negative behaviors, shift your attention to focus on your child’s positive behaviors. Model and explain to your child how to behave appropriately in different situations. When your child shows positive behaviors, be quick to pay attention and offer praise.

Maintain a consistent schedule. Your toddler will do best with a consistent schedule and routines. Many children with autism do not adapt well to changes. Challenging behaviors tend to happen more often when your child is out of his or her routine.

Provide social experiences. Get your child out and about when possible so that he or she can practice encountering new people and places. Arrange play dates and interactions with other children under your supervision. Be sure your child is rested and ready to go. Start with small groups of two or three other children and provide close supervision. Be prepared to leave when your child shows signs of having had enough.

Encourage adequate sleep. Many children with autism have sleep problems. It can help to use a relaxing bedtime routine lasting 30 minutes or less, and stick with a set time for going to bed and waking up. Avoid the use of digital devices — including television, video games and tablets — in the hour or so before bedtime. It may also help to keep your child’s bedroom cool and dark for sleep.

Promote good nutrition. Your child has the same nutritional needs as any other child. However, it’s common for children with autism to be picky eaters. To help your child toward a balanced diet have a regular meal and snack schedule, and offer new foods many times. If you have concerns about your child’s limited diet, talk to your child’s medical provider.

Take care of yourself. It may seem counterintuitive, but one of the best ways you can care for your child is to make time for self-care. When you’re refreshed, you have more energy for the challenges of parenting. Try to establish a regular routine that allows you to rest and regain your energy, even if it’s just for a few minutes to sit and read your favorite magazine or do a quick exercise session. If you have a partner, take turns getting out of the house to do something that you enjoy on your own. When possible, schedule times when you hire a sitter or have a family member watch your child while you and your partner spend quality time together.

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The importance of outside support

When it comes to parenting a child with autism, consistent, reliable support can make a big difference. As much as possible, lean on support in these three areas:

Extended family and close friends. In families where grandparents, aunts, uncles, mothers, fathers, brothers and sisters live nearby and are willing to help out, parents of the child with autism report feeling a greater sense of parenting satisfaction and improved family interactions.

Professionals. Lean into any professional support available to you, your child and your family. This can include doctors, early intervention specialists, social workers and therapists. Families that take advantage of professional help report that they have a better sense of well-being. They also have an improved understanding of autism and its symptoms and an increased level of confidence in their own abilities as caregivers.

Support groups. Consider seeking out support groups for parents and families affected by autism in your area. You may find that support group meetings become a touchstone in your life, a place where you can truly be yourself and know that group members will understand what you’re going through. Fellow members may also be a source of emotional support, providing valuable insight into addressing challenging situations or ideas for coping with stress.

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Beyond the first years

Once your child turns 3, he or she will transition from an early intervention program to special education services. Under Part B of IDEA, these services are offered through your local public school district and are typically available for children and young adults between the ages of 3 and 21, or until the completion of high school.

In addition to academic instruction, special education services aim to improve your child’s communication and social, behavioral and daily living skills. These services may take place at a dedicated school or center, but they can also be integrated into mainstream schools.

As your child grows, the challenges of autism may not go away, but neither will the rewards. You may discover added richness and unexpected joy in your family life. You may see your child achieve milestones you didn’t think were possible. Through it all, let your child know that you’ll be there, offering love and support, no matter what challenges he or she might face.

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Seeing beyond autism

Parenting a child with autism is similar in many ways to parenting any child. Every child needs love, attention, supervision and a safe home. While parenting a child with autism can bring additional challenges, try not to let the disorder take over your child’s life or your own. Work on uncovering and celebrating your child’s many strengths and interests. Instead of focusing on what your child can’t do, take the time to notice what he or she can do. Instead of comparing your child with other children, work on accepting your little one for who he or she is.

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CHAPTER 46 Other newborn conditions

Even if you do everything right during your pregnancy, sometimes complications can occur during pregnancy and childbirth or shortly thereafter. If your child faces an unexpected problem, you may be concerned, confused and even frightened.

This section describes some of the more common conditions that can occur in newborn children and how they may be treated. Listen to the advice of your child’s medical provider and ask questions until you feel you understand the condition and the possible courses of action. Also trust that your child’s provider and the medical team will do the best for your son or daughter. Keep in mind that many conditions that develop in infants can be successfully managed.

If your child is healthy, there’s no need to read this chapter. Reading about things that don’t affect your child or that could go wrong may worry you unnecessarily. However, this chapter may be helpful if a friend or relative has a newborn with a health concern.

Blood disorders

It’s not uncommon for infants to experience blood-related conditions or illnesses. Jaundice is a very common blood-related condition, which you can read about here. Anemia is another common blood disorder in young babies (see this discussion). Following are other blood disorders that can affect young children.

Low blood sugar The human brain depends on blood sugar (glucose) as its main source of fuel, so it needs a steady supply. Throughout pregnancy, a baby’s blood sugar stays at a fairly even level because he or she continuously receives nutrition from the mother’s placenta. After birth, a baby must quickly develop the ability to regulate his or her own blood sugar level. Most healthy babies are able to do this because they have a stored form of sugar, called glycogen, in their livers. Babies also develop the capability to generate sugar from other food reserves in their bodies. These abilities are important because a baby needs to adapt from a continuous supply of blood sugar to periodic supplies that come during feedings.

Fortunately, most babies handle the transition well. When the changeover doesn’t go so well, hypoglycemia may occur. Hypoglycemia is a condition in which a person’s blood sugar is lower than normal. Babies more likely to develop hypoglycemia include those born to mothers with diabetes, full-term babies who are large for their gestational age, full-term babies who are small for their gestational age (intrauterine growth restriction) and premature babies. Too little blood sugar is a problem because it can impair the brain’s ability to function. Severe or prolonged hypoglycemia may result in seizures and serious brain injury.

Some babies with hypoglycemia don’t experience any signs and symptoms or only mild ones. In other instances, signs and symptoms may be more severe. Some of the more common indications of hypoglycemia are jitteriness, bluish coloring (cyanosis), breathing problems, low body temperature, poor appetite and lethargy.

A simple blood test can diagnose hypoglycemia. A newborn’s blood sugar level is commonly measured within the first several hours after birth to make sure that it’s in the normal range.

Treatment When a baby’s blood sugar is below normal levels, feeding him or her breast milk or formula will usually cause the level to return to normal. If a baby isn’t able to feed well the first few hours after birth — perhaps because baby is too sleepy from low blood sugar — a glucose gel may be rubbed inside the baby’s cheeks. Glucose also may be given through an intravenous (IV) tube. This will quickly correct the low glucose, although it can take up to a day or two to gradually turn off the IV glucose and allow baby to eat and support a normal blood sugar. If this doesn’t happen as expected, your baby’s medical team may recommend testing to investigate potential causes for the hypoglycemia. Usually, though, no additional testing is needed.

Polycythemia Polycythemia is an uncommon blood disorder in which your bone marrow makes too many red blood cells — the opposite of anemia. Polycythemia may also result in production of too many of the other types of blood cells — white blood cells and platelets. But it’s the excess red blood cells that thicken your blood and cause most of the concerns associated with the condition.

Infants at higher risk of the condition are those who are born past term (“overdue”), are small for their gestational age, are born to mothers with diabetes, have chromosomal abnormalities, have continually decreased oxygen levels or are the recipient twin in a condition called twin-to-twin transfusion syndrome.

Often, there are no symptoms, but when they do occur they may include a reddish-purple coloring, lethargy, a poor appetite and breathing problems.

Treatment In newborns, the condition may resolve on its own within a few days. If treatment is required, blood may be withdrawn to reduce the number of blood cells and decrease blood volume, making it easier for baby’s blood to function properly. Blood that’s been withdrawn may be replaced with fluids.

Breathing disorders

The lungs are one of the last organs to fully develop during pregnancy. Most newborns have no difficulty breathing, but occasionally breathing problems can occur, especially if an infant is born prematurely. Following are some breathing disorders that can affect infants.

Bronchopulmonary dysplasia Breathing difficulties associated with premature birth generally improve within several days to weeks. Premature infants who still require assistance with ventilation or supplemental oxygen after a month are often described as having chronic lung disease (bronchopulmonary dysplasia or BPD).

BPD is most common in infants born early (prematurely) whose lungs were not fully developed at birth and in infants who have been on a breathing machine (ventilator) or who need supplemental oxygen for an extended period.

Signs and symptoms of BPD include rapid breathing, wheezing, coughing, and bluish lips and fingernails (cyanosis). BPD is often suspected in infants with respiratory distress syndrome who don’t recover within the first several weeks.

Treatment Babies with BPD need supplemental oxygen for an extended period and may also need medication. Most get better with time; however, they may need to continue treatment for months or even years. Some continue to have lung problems, such as asthma, throughout childhood and even into adulthood.

Meconium aspiration Meconium aspiration syndrome is a condition in which a newborn breathes (aspirates) a mixture of meconium and amniotic fluid into the lungs during labor.

Meconium is the first feces, or stool, of a newborn. Normally, meconium isn’t passed until after an infant is born. In some cases, though, a baby will pass stool (meconium) while still inside the uterus. Once the meconium has passed into the surrounding amniotic fluid, the baby may inhale it into the lungs, called meconium aspiration. The meconium can potentially obstruct the infant’s airways and can cause breathing difficulties due to inflammation of the baby’s lungs.

Symptoms of meconium aspiration generally include breathing difficulty — the infant has to work hard to breathe — and a bluish skin color (cyanosis).

Treatment When a baby is born with meconium in the amniotic fluid, the first step is to suction the newborn’s mouth after birth. Further treatment is only necessary if the baby isn’t active and crying immediately after delivery. A tube may be placed in the infant’s trachea and suction applied to remove the meconium.

In most cases, the outlook is excellent and there are no long-term health effects. In more-severe cases, a baby may need antibiotics to treat possible infection, specialized ventilators and other technologies to keep the lungs inflated, and oxygen to keep blood levels normal.

Pneumothorax One of the miracles of birth is that within a few breaths a newborn’s lungs inflate with air and the baby begins breathing. However, considerable pressure changes are needed to inflate the lungs that first time.

Occasionally, the lungs don’t inflate evenly, and the pressure differences between them can cause a condition called collapsed lung, or pneumothorax. In this condition, the small air sacs within a baby’s lungs rupture and allow air to leak out into the spaces between the thin membranes lining the lungs and the inner wall of the chest. Pneumothorax may also cause babies to have other respiratory conditions.

If a small amount of air leaks, the infant may have shortness of breath, rapid breathing or grunting, and perhaps bluish lips and fingernail beds (cyanosis). If a large amount of air leaks, the infant may develop more severe breathing difficulty.

Treatment Pneumothorax can be very serious if a lung collapses suddenly, but in most cases the leakage is small and the air is reabsorbed on its own. Sometimes, no treatment is necessary. In other cases, the infant may be given extra oxygen to breathe for a period of time. In the case of severe pneumothorax, air that has leaked into the chest may need to be removed by inserting a tube into the chest wall beside the lung.

Respiratory distress syndrome Respiratory distress syndrome (RDS) is characterized by rapid, difficult breathing and perhaps a bluish skin color (cyanosis). The breathing sound made by a baby with RDS, commonly referred to as “grunting,” is often very distinctive. As the child breathes out, he or she may make a noise that sounds like a lamb or a soft cry. Babies with RDS also have to work harder to move air into their lungs.

RDS is caused by lack of a slippery, protective substance called surfactant, which helps the lungs inflate with air and keeps air sacs from collapsing. It’s most commonly seen in premature infants whose lungs haven’t fully developed and is rarely found in full-term infants. The severity of RDS often correlates with the infant’s gestational age and weight. The smaller and more premature the infant, the greater the chance he or she will have RDS. However, giving steroids to a pregnant mother at risk for preterm delivery reduces the baby’s risk of RDS. Other factors that may increase the risk are an older sibling who had RDS, a mother with diabetes, a cesarean delivery and a multiple pregnancy (twins or more).

Most infants who develop RDS show signs of breathing problems and the need for more oxygen at birth, or within the first few hours that follow. Blood tests and an X-ray of the lungs can establish the diagnosis. A child with RDS is usually placed in a neonatal intensive care unit (NICU), where his or her vital signs can be constantly monitored.

Treatment Many infants with RDS require help with their breathing. Some babies are given supplemental oxygen through a tube in the nose, or a mask on the face may be used to provide continuous positive airway pressure (CPAP). For more severe RDS, a breathing tube attached to a ventilator may be inserted through the mouth into the baby’s windpipe (trachea) to temporarily assist with breathing. Another option is to place surfactant directly into baby’s lungs. Other medications may also be given to help improve breathing.

Transient tachypnea Transient tachypnea of a newborn (TTNB) is a form of respiratory distress that can occur after an uneventful vaginal delivery or cesarean birth in both premature and full-term infants. TTNB is more likely to occur after a rapid vaginal birth or among babies born by cesarean birth without labor.

Infants with this form of respiratory distress often have no signs of trouble other than rapid, shallow breathing. Among some babies, their skin may have a bluish tinge (cyanosis).

Unlike infants with RDS, these infants rarely appear severely ill and most recover within a couple of days. However, rapid breathing makes it more difficult for the babies to eat. Once their breathing becomes more stable, babies with TTNB are more willing to nurse or take a bottle.

Treatment Often, no treatment is needed. When necessary, treatment may include giving the baby oxygen until breathing improves. If the baby is breathing too fast to be fed via breast or bottle, the baby might be given intravenous (IV) fluids or milk via a feeding tube passed through the nose and into the stomach.

Central nervous system disorders

The central nervous system consists of the brain and spinal cord. Three of the more common central nervous system disorders seen in infants may occur during early fetal development or shortly after birth.

Cerebral palsy Cerebral palsy is a disorder of movement, muscle tone or posture that’s caused by infection, injury or abnormal development in the immature brain, most often before birth. Most mothers of children born with cerebral palsy had a seemingly uncomplicated course of pregnancy, labor and birth.

In general, cerebral palsy causes impaired movement associated with exaggerated reflexes or rigidity of the limbs and trunk, abnormal posture, involuntary movements, unsteadiness of walking, or some combination of these. These problems often aren’t evident until an infant is 6 to 12 months old or older. Other conditions related to abnormal brain development also may occur, including intellectual disabilities, vision and hearing problems, or seizures.

There are many possible causes of cerebral palsy. One possible cause is inadequate circulation of blood in brain tissue. Abnormal brain growth and development early in pregnancy is increasingly recognized as a cause of cerebral palsy. Injury to the brain during labor and delivery can also be a cause, as well as infection or bleeding in or around the brain of the developing fetus. Other factors related to pregnancy or birth associated with an increased risk of cerebral palsy include premature birth, low birth weight, breech birth and multiple births (twins or more).

Treatment There’s no cure for cerebral palsy, but in some cases surgery may help reduce muscle spasticity and resulting deformities. Physical therapy is a common component of treatment. Muscle training and strengthening exercises may help your child’s strength, flexibility, balance and motor development. Aids such as braces and walkers can help mobility. Occupational and speech therapy also may be part of the treatment program. As a child becomes older, medication also may be used to help lessen muscle tightness and manage complications.

Hydrocephalus Hydrocephalus is an excessive accumulation of fluid in the brain due to an imbalance between the brain’s production of cerebrospinal fluid and its ability to absorb it. Untreated hydrocephalus in a young infant can eventually result in an extremely large head and other problems.

The outlook for a child with hydrocephalus depends on the severity of the condition and whether any underlying disorders are present. If the condition is severe at birth, brain damage and physical disabilities are likely.

Premature infants are at increased risk of severe bleeding within the brain, which can eventually lead to hydrocephalus. Certain problems during pregnancy also may increase an infant’s risk of developing hydrocephalus, including an infection within the uterus or problems during fetal development, such as spina bifida. In some cases, a genetic abnormality may be responsible.

Congenital or developmental defects not apparent at birth may increase an older child’s risk of hydrocephalus. Other factors that increase risk include meningitis or bleeding in the brain.

Treatment Hydrocephalus is often treated with surgery. The most common treatment is the surgical insertion of a drainage system, called a shunt. It consists of a long flexible tube with a valve that keeps fluid from the brain flowing in the right direction and at the proper rate. One end of the tubing is usually placed in a fluid-filled chamber in the brain, and the tubing is then tunneled under the skin to the abdomen where the excess cerebrospinal fluid can be more easily absorbed.

If your child has hydrocephalus, his or her doctor may recommend working with specialists who can evaluate your child’s developmental progress on a regular basis in order to detect any delays in social, intellectual, emotional or physical development. Effective interventions are available to help your child, if needed.

Spina bifida Spina bifida (myelomeningocele) is part of a group of birth defects called neural tube defects. The neural tube is the embryonic structure that eventually develops into the baby’s brain and spinal cord and the tissues that enclose them.

Spina bifida

Normally, the neural tube forms early in a pregnancy and it closes by the 28th day after conception. In babies with spina bifida, a portion of the neural tube fails to develop or close properly, causing defects in the spinal cord and in the bones of the spine.

Occasionally, spina bifida may not cause any symptoms at all or only minor physical disabilities. More frequently, though, it leads to serious physical, and sometimes mental, disabilities. Often, the condition causes loss of neurological control of the legs, bladder and bowel. Some infants also experience accumulation of fluid in the brain (hydrocephalus) or an infection in the tissues surrounding the brain (meningitis).

Doctors aren’t certain what causes spina bifida. As with many other nervous system disorders, it appears to result from a combination of genetic and environmental risk factors, such as a family history of neural tube defects or folic acid deficiency. Folate (vitamin B-9) is important to the healthy development of a fetus and can help prevent spina bifida. The synthetic form of the vitamin, found in supplements and fortified foods, is called folic acid. Folic acid deficiency before or in early pregnancy increases the risk of neural tube defects.

Treatment Treatment of spina bifida depends on the severity of the condition. It usually requires surgery to put the spinal cord and exposed tissue back in place and close the opening in the vertebrae. At some centers, this surgery may be done while the baby is still in the womb. More surgeries and other forms of treatment may also be necessary.

Digestive disorders

Disorders of the digestive tract can cause a variety of problems, including poor eating and excessive spitting up. Other chapters in this book discuss conditions such as reflux (see this discussion) and milk allergy (see this discussion), which can affect newborns. Following are less common digestive disorders that can cause complete or partial obstruction of the passage of food or stool.

Esophageal atresia In an infant born with esophageal atresia, the tube leading from the throat to the stomach (esophagus) isn’t properly connected. The condition may be accompanied by other disorders. It may occur with certain genetic disorders, including Down syndrome.

Signs and symptoms of esophageal atresia are typically detected soon after birth. The infant may have an unusually large amount of secretions coming from the mouth, or may cough, choke or turn blue when attempting to feed.

Treatment Infants with this condition require surgery. If the underdeveloped segment is short, repair may be attempted immediately. If the segment is long, further growth of the esophagus may be necessary before doing surgery. Until surgery is performed, a tube is temporarily placed through the abdominal wall into the stomach for feeding.

Hirschsprung’s disease An infant with Hirschsprung’s disease gradually develops an abnormally large (dilated) colon. The condition is due to a failure of the muscles of the colon to propel stool through the anus.

Muscle contractions in the gut help digested materials move through the intestines. Nerves in between the muscle layers synchronize the contractions. In Hirschsprung’s disease, these key nerves are missing from a part of the bowel. Areas without such nerves cannot push material through. This causes a blockage of intestinal contents.

Early signs may include a delay of or failure to pass baby’s first stool (meconium). Baby may also experience vomiting and abdominal distention. Dehydration and weight loss are common. Many infants with Hirschsprung’s disease have alternating constipation and diarrhea.

Treatment Treatment generally involves surgery to remove the abnormal portion of the intestines. In cases where surgery can’t be performed right away, an opening on the outside of the abdomen (stoma) is created so that stool can pass into a disposable pouch. After surgery, most children pass stool normally, but they may need long-term follow-up for constipation and other problems.

Imperforate anus An infant with imperforate anus has not formed an anal opening, preventing passage of stool. The condition may be noticeable during a physical examination, or it may be suspected when a baby fails to pass his or her first stool (meconium) a few hours to days after birth. A child with imperforate anus may have other birth abnormalities.

Treatment Treatment depends on the location of the obstruction. In some cases, an instrument can be used to gently widen (dilate) the opening. More typically, surgery is necessary. Children with a less complicated obstruction generally do well after surgery and develop normal bowel control. If the obstruction is more complicated, the child may require a series of operations and have long-term challenges with passage of stool.

Intestinal blockage Intestinal atresia is the medical term for an obstruction anywhere in the intestines. The obstruction may be complete — blocking all passage of fluid and intestinal content — or it may be partial. The condition is sometimes associated with certain genetic disorders, including Down syndrome.

A high obstruction just beyond the outlet of the stomach or in the upper small intestine can cause persistent vomiting. An obstruction in the lower small intestine or the colon may cause a swollen (distended) abdomen. Vomiting may also occur with a lower obstruction, but it may come later. If a baby has a partial obstruction, symptoms may not be immediately apparent.

An infant with an intestinal obstruction generally doesn’t have a bowel movement, although baby’s first (meconium) stool may pass if the obstruction is high in the small intestine.

Treatment Treatment depends on the type of obstruction. A complete obstruction generally requires immediate surgery. A partial obstruction may also require surgery. With a prompt diagnosis and proper treatment, most infants recover from intestinal atresia completely.

Pyloric stenosis Pyloric stenosis is a condition that affects the muscles of the pylorus, which is at the lower end of the stomach. The muscles of the pylorus (pyloric sphincter) connect the stomach and small intestine.

Pyloric stenosis

In pyloric stenosis, the pyloric sphincter becomes abnormally large, causing the lower stomach to narrow. The enlarged muscles block food from entering the baby’s small intestine, typically resulting in excessive spitting up or forceful (projectile) vomiting.

Signs of pyloric stenosis usually appear within three to five weeks after birth. The condition is rare in babies older than age 3 months.

In addition to spitting up and vomiting, other signs and symptoms may include persistent hunger — baby always wants to eat, even after vomiting — wave-like stomach contractions, dehydration, constipation or very small stools, and failure to gain weight or weight loss. Repeated vomiting may irritate baby’s stomach and cause mild bleeding. The wave-like contractions are caused by stomach muscles trying to force food past the outlet of the pylorus.

Treatment Pyloric stenosis is generally treated with surgery. During the procedure, the surgeon spreads apart the outer layer of the thickened pylorus muscles to widen the lower stomach. For a few hours to days after surgery, intravenous (IV) fluids are given until the child can eat. The surgery doesn’t increase the risk of future stomach or intestinal problems.

Facial and extremity disorders

A child is sometimes born with a condition that involves the face or the hands and feet. Why this happens is often unknown. It may result from a combination of genetic vulnerability and environmental factors. In some cases, exposure to certain medications or other toxins during pregnancy may be a contributing factor.

Often, these defects can be corrected. In most babies, a series of surgeries can restore normal function and achieve a more normal appearance with minimal scarring.

Cleft lip and cleft palate Cleft lip and cleft palate are among the most common birth defects. A cleft is an opening or split in the upper lip, the roof of the mouth (palate) or both. Cleft lip and cleft palate result when developing facial structures in an unborn baby don’t completely grow together.

Often, a cleft — or split — in the lip or palate is diagnosed during a prenatal ultrasound exam. Otherwise, it is typically identifiable at birth. Cleft lip and palate can affect one or both sides of the face. Clefts can appear as only a small notch in the lip or can extend from the lip through the upper gum and palate into the bottom of the nose. Less commonly, a cleft occurs only in the muscles of the soft palate (submucous cleft palate), which are at the back of the mouth and covered by the mouth’s lining. Because it’s hidden, this type of cleft may not be diagnosed until later.

Cleft lip (left) and cleft palate (right)

Treatment Surgery to correct cleft lip and palate is based on your child’s particular condition. Following the initial cleft repair, your doctor may recommend follow-up surgeries to improve speech or improve the appearance of the lip and nose. Surgeries typically are performed in this order:

Cleft lip repair. Between 10 weeks and 3 months of age

Cleft palate repair. Between 6 and 18 months of age

Follow-up surgeries. Between age 2 years and late teen years

Before surgery, medical staff will help you with strategies to feed your baby, such as a special bottle or feeder, if needed.

Clubfoot Clubfoot describes a range of foot abnormalities usually present at birth in which your baby’s foot is twisted out of shape or position. The term refers to the way the foot is positioned at a sharp angle to the ankle, with the foot curling inward. Also, the calf muscles in the affected leg are usually underdeveloped, and the affected foot may be slightly shorter than the other foot.

Clubfoot is a relatively common condition and is usually an isolated problem for an otherwise healthy newborn. The disorder can be mild or severe, affecting one or both feet. Clubfoot will hinder your child’s development once it’s time for your child to walk, so treating clubfoot soon after birth, when your newborn’s bones and joints are extremely flexible, is generally recommended.

Treatment The goal of treatment is to restore the look and function of the foot before your child learns to walk, in hopes of preventing long-term disabilities. Treatment options include stretching and casting or taping the foot. When clubfoot is severe or it doesn’t respond to nonsurgical treatments, surgery may be necessary. Even with treatment, clubfoot may not be totally correctable. Orthopedic care throughout childhood is common.

Finger and toe abnormalities One of the first things parents often do after a child is born is to count the fingers and toes to make sure they are all there. On rare occasions, the number of fingers or toes doesn’t add up to 10.

Finger and toe abnormalities

Extra fingers or toes A child may be born with one or more extra digits, such as an extra finger or extra thumb on the hand or extra toes. Often, the extra digit consists only of skin and soft tissue and can easily be removed. If the extra digit contains bone or cartilage, surgery may be necessary. This may be done after the infant is a few months old.

Webbed fingers or toes A child may be born with one or more fingers or toes that are joined (“webbed”) together. Simple webbing of fingers or toes involves only the skin and other soft tissues. Occasionally, webbing may involve fused bones, nerves, blood vessels and tendons. Surgery can correct the condition and enhance use of the fingers or toes.

Hip dysplasia This condition results from abnormal development of the hip joint. The hip is a ball-and-socket joint. In some newborns, the socket is too shallow and the ball (thighbone) may slip out of the socket, either part of the way or completely. Left untreated, the affected leg may turn outward or be shorter than the other leg. Occasionally, both hips are involved.

Hip dysplasia is often detected during an initial examination at birth or in the first weeks to months of life. Babies born breech are at greater risk of hip dysplasia and may require an ultrasound of the hips at about 6 weeks of age.

Treatment Hip dysplasia can be successfully treated. When the condition is diagnosed early, a device or brace is used to hold the hip joint in place while the child grows. Children who are diagnosed after 6 months of age may need surgery.

Genital conditions

Some birth conditions affect the genitals. These conditions are typically diagnosed on physical examination at birth.

Ambiguous genitalia This term refers to the uncertain appearance of a baby’s external sexual features. Sometimes, a female with normal ovaries who’s been exposed to an excess of male hormones in the womb is born with male-like genitals. Conversely, a male may be born with testicles but with ambiguous or female genitals. Some newborns have both ovaries and testicles and ambiguous genitals.

Ambiguous genitals can result from tumors, chromosome abnormalities or other genetic problems, and hormone excesses or deficiencies. When a newborn’s sex is in question, thorough testing and evaluation can establish a correct diagnosis. Because ambiguous genitalia is an uncommon and complex condition, the baby may be referred to a medical center with doctors who have expertise in disorders of sex development.

Treatment Treatment depends on a variety of factors. It may include hormone therapy or reconstructive surgery.

Enlarged clitoris The clitoris of the newborn girl is often enlarged, especially in premature babies, as a result of hormonal changes that affect the genital area.

Treatment Typically, the size of the clitoris decreases after birth and no treatment is necessary. If the clitoris seems unusually large, tests may be performed to confirm the child’s sex.

Vaginal discharge Vaginal discharge often occurs in newborn girls. During the first three weeks, you may notice a thick, white discharge or a tinge of blood from the baby’s vagina.

Treatment Treatment is unnecessary as the bleeding usually resolves on its own. Vaginal bleeding is sometimes a newborn girl’s response to the absence of the maternal hormone estrogen after birth.

Hydrocele A hydrocele is a fluid-filled sac surrounding a boy’s testicle that results in swelling of the scrotum, the loose bag of skin underneath the penis. Up to 10% of male infants have a hydrocele at birth, but most hydroceles disappear without treatment within the first year of life.

Treatment If the testicle can be easily examined and the amount of fluid remains constant, treatment is generally unnecessary. Usually the fluid gets absorbed within a year. If a hydrocele doesn’t disappear within a year or if it continues to enlarge, it may need to be surgically removed. Sometimes, a hydrocele may recur.

Hypospadias Hypospadias is a condition in which the opening of the urethra is on the underside of the penis, instead of at the tip. The urethra is the tube through which urine drains from the bladder and exits the body. The severity of the condition varies. In most cases, the opening of the urethra is near the head of the penis. Less often, the opening is at midshaft or at the base of the penis.

Treatment Surgery is typically performed to reposition the urethral opening and, if necessary, straighten the shaft of the penis. Rarely, a second procedure is needed. With successful treatment, most boys will be able to stand while urinating and have normal adult sexual function.

Undescended testicle An undescended testicle is a testicle that hasn’t moved into its proper position in the bag of skin hanging beneath the penis (scrotum) prior to the birth of a baby boy. Usually just one testicle is affected, but in some cases both testicles may be undescended. The condition is more common among baby boys born prematurely or before 37 weeks.

Undescended testicle

Testicles form in the abdomen during fetal development and gradually descend into the scrotum. Sometimes the process is stopped or delayed at some stage of development, and the testicle is not where you would expect it to be — it may still be in the abdomen. The disorder is typically detected when your baby is examined shortly after birth.

Treatment In most cases, the testicle descends into the scrotum during the first few months of life on its own. Sometimes, hormones are given to bring the undescended testicle into place. If it hasn’t descended by the child’s first birthday, it won’t do so spontaneously, and the condition is commonly treated surgically.

Sometimes, the opening in the abdominal muscles left by an undescended testicle fails to close properly, allowing the intestines to push through the muscle opening (inguinal hernia). If your son has an inguinal hernia associated with the undescended testicle, the hernia is repaired during the surgery. Often the operation can be done on an outpatient basis.

Heart disorders

Some infants are born with a problem in the heart’s structure. These problems are often mild, but some can be serious. The risk of having a baby born with a heart condition may be higher if you have another child with a heart defect or there’s a family history of congenital heart defects.The precise cause of a congenital heart defect is often unknown. Genetic defects and certain viral infections contracted during pregnancy may be possible causes. Fortunately, with continued advances in heart surgery, many heart disorders can be successfully treated. For many of these conditions, regular long-term follow-up visits with a cardiologist is an important part of treatment.

Aortic stenosis Aortic stenosis is a narrowing of the valve through which blood leaves the heart to enter the aorta, the main artery carrying blood away from the heart. Because the valve does not fully open, blood flow from the heart is decreased.

Severe stenosis, which may be accompanied by breathing difficulties, is usually detected in early infancy. Mild or moderate stenosis may not produce any noticeable symptoms, but during a physical examination your baby’s medical provider may detect a distinctive heart murmur.

Treatment Surgery may be needed to treat severe stenosis. It may not be necessary for mild to moderate disease, but your baby should have periodic examinations to monitor the condition to make sure it doesn’t worsen.

Atrial septal defect Atrial septal defect is an opening high in the heart between the heart’s upper chambers. The opening produces abnormal blood flow and allows oxygen-rich and oxygen-poor blood to mix.

If the hole is large and a lot of blood is mixed, the blood that circulates through your child’s body is not carrying as much oxygen as normal. The condition may also cause increased fluid in the lungs. Children with the condition often don’t experience any signs or symptoms.

Treatment If the hole is small, it may close with time and no treatment may be necessary. In more-severe cases, surgery may be needed to close the hole.

Coarctation of the aorta In this condition, there’s a narrowing (constriction) in the main artery carrying blood away from the heart to the rest of the body. The heart may have to pump harder to force blood through the narrowed area and blood pressure above the constricted area may be increased.

Initially, no symptoms may be evident. If the constriction is significantly interfering with blood flow, it may result in pale skin and breathing difficulties.

Treatment In more-severe cases, immediate surgery may be necessary to fix the narrowing and increase blood flow. In less severe cases, surgery is still likely, but doesn’t need to be done immediately.

Patent ductus arteriosus The ductus arteriosus is a vessel that leads from the pulmonary artery to the aorta while an infant is in the womb. It allows blood to bypass the baby’s lungs by connecting the pulmonary arteries (which supply blood to the lungs) with the aorta (which supplies blood to the body). Soon after an infant is born and the lungs fill with air, this blood vessel is no longer needed. It will usually close within a couple of days.

When the ductus arteriosus doesn’t close, it causes abnormal blood circulation between the heart and lungs. Babies born prematurely are more at risk of patent ductus arteriosus (PDA) than are those born at term.

When the opening is small, often there are no symptoms. A large opening will produce a heart murmur and may cause pulmonary hypertension and poor growth.

Treatment Often, especially in premature infants, the ductus will close on its own within weeks. If it doesn’t, medication or surgery may be used to close the opening. In older infants with a ductus that remains open, surgery or procedures done by cardiac catheterization are used to close the opening.

Pulmonary stenosis Pulmonary stenosis is a condition in which the flow of blood from the heart to the lungs is slowed by a deformed pulmonary valve, or a narrowing above or below the valve. Mild or moderate obstruction may cause no symptoms. A newborn with a severe obstruction may have a bluish skin color (cyanosis) and show signs of heart failure.

Pulmonary stenosis is often diagnosed in early infancy. Your baby’s medical provider may suspect pulmonary stenosis if he or she hears a heart murmur in the upper left area of the chest during a checkup.

Treatment Mild pulmonary stenosis usually doesn’t worsen over time, but moderate and severe cases may get worse and require surgery. Fortunately, treatment is highly successful. Children with pulmonary stenosis should have regular follow-ups with a medical provider.

Tetralogy of Fallot Tetralogy of Fallot is the name for a combination of four heart defects that are present at birth. These defects, which affect the structure of the heart, cause oxygen-poor blood to flow out of the heart and into the rest of the body.

Infants and children with tetralogy of Fallot usually have bluish skin color (cyanosis) because their blood doesn’t carry enough oxygen. Sometimes, infants with tetralogy of Fallot will suddenly develop deep blue skin color after crying, feeding, having a bowel movement or kicking their legs upon awakening. These episodes are called “tet spells” and are caused by a rapid drop in the amount of oxygen in the blood.

Tetralogy of Fallot is often diagnosed early in life. However, it may not be detected until later years, depending on the severity of the defects and symptoms.

Treatment All babies with tetralogy of Fallot need corrective surgery. Without treatment, a baby may not grow and develop properly. He or she is also at increased risk of serious complications, such as infective endocarditis, an inflammation of the inner lining of the heart caused by a bacterial infection. With early diagnosis followed by appropriate treatment, most children with tetralogy of Fallot do well, though they’ll need regular follow-up care and may have restrictions on exercise.

Transposition of the great vessels This is a complex condition in which the two arteries rising from the heart — the aorta and the pulmonary artery — are reversed. Because of this, blood returning to the heart from the body is pumped back to the body without ever going through the lungs to pick up oxygen. Newborns with this condition are often dusky blue in color and require intensive immediate medical care within the first hours to days after birth.

Treatment The most common treatment is an arterial switch operation that brings the pulmonary artery and the aorta back to their normal positions. Other surgical options are also available.

Ventricular septal defect A ventricular septal defect (VSD), also called a hole in the heart, is a common heart defect that’s present at birth. It occurs when the septum, the muscular wall separating the heart into left and right sides, fails to form fully between the lower chambers of the heart during fetal development. This leaves an opening that allows mixing of “red” (oxygenated) blood and “blue” (deoxygenated) blood. As a result, blood may overfill the lungs and overwork the heart.

A baby with a small ventricular septal defect may have no problems. A baby with a larger ventricular septal defect may have a bluish skin color — due to oxygen-poor blood — often most visible in the lips and fingernails. Other signs and symptoms may include rapid breathing, a poor appetite and failure to gain weight.

A ventricular septal defect at birth typically doesn’t cause problems in early infancy. If the defect is small, symptoms may not appear until later in childhood — if ever. Signs and symptoms vary depending on the size of the hole. The condition may be diagnosed during a regular checkup. While listening to your baby’s heart with a stethoscope, a medical provider may detect a distinctive heart murmur.

Treatment Many babies born with a small ventricular septal defect don’t ever need surgery to close the defect. After birth, your baby’s medical provider may want to observe your baby and treat any symptoms while waiting to see if the defect closes on its own. Infants who have a ventricular septal defect that’s large or is causing significant symptoms usually require surgery. Surgical treatment generally produces excellent long-term results.

Other disorders

Two other disorders that can affect a newborn include cystic fibrosis and intrauterine growth restriction.

Cystic fibrosis Cystic fibrosis is an inherited condition that affects the cells that produce mucus, sweat and digestive juices. Normally, these secretions are thin and slippery, but in cystic fibrosis, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs.

Signs and symptoms can vary from child to child, depending on the severity of the disease. Even in the same child, symptoms may worsen or improve as time passes. In some children, symptoms begin during infancy. Other children may not experience symptoms until adolescence or adulthood.

One of the first signs of cystic fibrosis is an excessively salty taste to the skin. People with cystic fibrosis tend to have higher than normal amounts of salt in their sweat. Parents often can taste the salt when they kiss their child.

Most of the other signs and symptoms of cystic fibrosis affect the respiratory system or the digestive system. The thick and sticky mucus associated with cystic fibrosis clogs the tubes that carry air in and out of the lungs. This can cause a persistent cough, wheezing, and repeated lung and sinus infections.

The thick mucus can also block tubes that carry digestive enzymes from the pancreas to the small intestine. Without these digestive enzymes, the intestines can’t fully absorb the nutrients in the food. The result is foul-smelling and greasy stools, poor weight gain and growth, a distended abdomen from constipation, and intestinal blockage, particularly in newborns.

Newborns in the U.S. are routinely screened for cystic fibrosis. This test checks a blood sample for a particular component that’s commonly elevated in babies who have cystic fibrosis. Other tests are needed to confirm the diagnosis. Early diagnosis means treatment can begin immediately.

Treatment There’s no cure for cystic fibrosis, but treatments can ease symptoms and reduce complications. Treatment generally includes medications and therapy.

Infants with cystic fibrosis may be given medications to treat infection, break up mucus in the lungs and reduce lung inflammation. A child may also receive enzyme supplements with each meal to help his or her body absorb food properly.

To help loosen mucus in the lungs, a parent or caregiver may need to thump the baby’s chest with a cupped hand. This often needs to be done a couple of times each day for about 30 minutes each time. There are also electronic devices that can perform this task, such as a vibrating vest.

In the past, most children with cystic fibrosis died in their teens. Improved screening and treatments now allow many children with cystic fibrosis to live into their 50s or even longer.

Intrauterine growth restriction A baby who is born full term but weighs less than 5 pounds, 8 ounces is often referred to as being at a low birth weight. The medical term for this condition is intrauterine growth restriction, or IUGR.

Intrauterine growth restriction refers to the poor growth of a baby during pregnancy. Specifically, it means the developing baby weighs less than 90% of other babies at the same gestational age.

Intrauterine growth restriction can result from a variety of genetic, metabolic and environmental influences. Congenital or chromosomal abnormalities are often associated with below-normal weight. Infections during pregnancy may affect the weight of the developing baby. A placenta that’s particularly small or isn’t functioning normally also can result in a growth-restricted baby.

After birth, the growth and development of a low birth weight baby is generally influenced by the severity and cause of the condition. Many IUGR babies see improvement in growth during the first months after birth. However, some babies continue to experience slow growth despite ample nutrition.

Treatment A baby born at a low birth weight may need to stay in the hospital longer than normal, until he or she gains sufficient weight and other problems are resolved, such as jaundice or maintenance of normal body temperature. Babies with IUGR may need specific nutritional supplements and assistance with feeding until they are growing well.

A baby with IUGR may have trouble fitting safely in a car seat. Some infants need to be transported in a crash-safe car bed until they grow large enough for a regular infant car seat.

• • • • •

Birth to 36 months: girls

Source: Centers for Disease Control and Prevention

• • • • •

• • • • •

Birth to 36 months: boys

Source: Centers for Disease Control and Prevention

• • • • •

• • • • •

Pain reliever dosage by weight

Acetaminophen (Tylenol, others) — For children over 2 months

Ibuprofen (Advil, Motrin, others) — For children over 6 months

• • • • •

Additional resources

If you’re looking for additional information on a particular topic, you may find the following resources helpful.

American Academy of Pediatrics

www.aap.org

News and research on parenting, helpful tips, and more.

American Red Cross

www.redcross.org

Search tool for local classes on pediatric first aid and CPR.

Center for Parent Information and Resources

www.parentcenterhub.org

Information and support for parents of children with disabilities.

Centers for Disease Control and Prevention

www.cdc.gov

Resources including developmental milestones, vaccine charts and more.

Child Care Aware

www.childcareaware.org

Search tool for quality local child care.

Child Mind Institute

www.childmind.org

Information on the child brain, behavior and emotions.

Consumer Product Safety Commission

www.cpsc.gov

News and recalls on consumer products.

Food and Drug Administration

www.fda.gov

Information on food, drugs and medical devices used in the U.S.

HealthyChildren.org from the American Academy of Pediatrics

www.healthychildren.org

Expert information on children’s nutrition, safety, behavior and wellness.

Mayo Clinic

www.MayoClinic.org

Comprehensive health information, including on babies and toddlers.

Multiples of America

www.multiplesofamerica.org

Information and support for multiple birth families.

National Center for Fathering

www.fathers.com

Research and articles on fatherhood.

National Center on Birth Defects and Developmental Disabilities

www.cdc.gov/ncbddd

Information on childhood disabilities.

National Council for Adoption

www.adoptioncouncil.org

Resources for adoptive families, adopted individuals and birth parents.

National Highway Traffic Safety Administration

www.nhtsa.gov/equipment/car-seats-and-booster-seats

Interactive guide to car seat selection and installation.

National Safety Council

www.nsc.org/home-safety

Information on safety in the home.

Office on Women’s Health Breast-feeding

www.womenshealth.gov/breastfeeding

Basics of breast-feeding and pumping.

Pathways.org

www.pathways.org

Resources to help understand and track milestones from infancy to preschool.

Poison Help

www.poisonhelp.org

Online help for a possible poisoning; call 800-222-1222 in the U.S. to talk to someone directly.

Safe to Sleep

www.safetosleep.nichd.nih.gov

Basics of safe infant sleep.

IMAGE CREDITS

The individuals pictured are models, and the photos are used for illustrative purposes only. There is no correlation between the individuals portrayed and the subjects being discussed.

Illustrations on pages 33, 34, 44, 45, 46, 561, 562, 563, 565 and 566 by John Karapelou. All photographs and illustrations are copyright of MFMER, except for the following: