Wednesday, July 22, 2009

The suck spot

So, your child isn't taking the dummy? needing some time off the breast?
Here's some of the tips I have come across in practice to make you understand why it takes time for the child to understand how to take the dummy - and plus how you can help.

Firstly it is important to know how the 'suck cycle' works.

This is different in bottle feeding and breastfeeding.
  • Bottle feeding sucking requires the use of the tongue being thrusted up and forward to control the milk flow.
  • Breast feeding requires the use of the lips, tongue, gums, cheeks, and hard and soft palates. This is classed as 'suckling'.
  • Breastfeeding: Typically the initial presentation of the nipple to the child's mouth/side of cheek, stimulates the rooting reflex which allows the child to open the mouth wide and enable the head to arch back.
  • The tongue then thrusts forward to pull the nipple into the mouth (N.B. this stage is important, I'll refer back to it later).
  • The contact of the nipple of the bridge between the hard palate and the soft palate, stimulates the 'suck spot'. This spot then stimulates the child to initiate suckling.
  • The tongue then begins it's rhythmic contractions forcing milk through the nipple and guiding it to the back to mouth to be swallowed. At the same time the cheeks are contracting and creating the negative pressure to bring the milk through.
So, as we know, it is easier for a child to bottle feed, and the technique is completely different to that of breastfeeding. That's why I always say that it is imperative that you firstly get the child used to breastfeeding and get the technique in-grained in the brain, before even trying something else like the dummy. (I usually say about 1-2 weeks after birth).

So you want to know how to get the child to take the dummy?

  1. First rule of thumb, be patient.
If you have a bottle feeding baby on your hands, this should be easier...
If the child is a breast feeder, this make take a little longer. Requiring a few practice rounds.

  1. Begin with stimulating the child's rooting reflex by gently stroking the outside of the cheek, this should initiate the opening of the mouth.
  2. Insert dummy.
  3. Then, hold the dummy in the mouth - if the child is a breastfeeder the initial response is to thrust the tongue forward (which will knock the dummy out), if this happens, push the dummy back in the mouth again. (recognise what i said earlier?: the breastfeeding technique is to bring the tongue forward to pull the nipple in). Of course the nipple (dummy) in this case is already in the mouth, so let the child run through her/his routine anyway.
  4. Eventually, the tongue will no longer be thrust forward and the dummy will stay in the mouth.
  5. Then, hold the dummy gently up in the roof of the palate. This stimulates that 'suck spot'.
  6. This should stimulate the child to begin the suck cycle.

SO the tips are: hold the dummy gently in the mouth, and hold it up onto the roof of the mouth.

If the child is crying, don't make it a horrible experience, try this out when the child is in the relaxed state.

Cradle Cap

Cradle cap (infantile seborrheic dermatitis) what is it all about and how can you treat it without using all the medications?

Cradle cap is prevalent in children usually under the age of 3 months, usually appearing within the first 6 weeks of life.

It is a oily, flaky, usually yellowish, scaley skin condition that is present over the areas of the body that are the most sebum rich. Typically on the top of the scalp, but in more severe cases can be over the face and trunk (this is then named seborrheic dermatitis of infancy).

It is not related to uncleanliness, nor part of an illness and is not related to the child not being cared for.

Whats the cause?
The most recent understanding in medicine is that cradle cap is related to a normal amount of yeast malassezia, but an abnormal immune response of the skin cells. This is typically related to overactivity of sebaceous glands, causing more oil to but put on the skin surface, causing skin cells to stick that would normally have been shed. Some doctors also relate this overactivity to the remaining mother's hormones in the child's circulation after birth.

Treatment
So what can you do at home without having to get to the parmacy and spend a fortune?

In the research, the most common advice is to wash the scalp regularly with a mild baby shampoo and gently comb the scalp with a baby brush to help remove the excess flaky skin.

To aid the removal of the flaky skin, another aid can be applying mineral oil or petroleum jelly to the scalp/skin over night and then gently brush in the morning to remove. Then wash regularly...

It seems that applying olive oil to the area, as I have heard, is actually not a good thing. By applying more oil (typically vegetable oil) to the area, you are allowing yeast to increase its growth and therby creating a possible pathway to secondary infection. This secondary yeast infection typically occurs more in the skin folds than on the top of the scalp. This is something to watch out for, as cradle cap/ seborrheic dermatitis should not be itchy, if it is, then it is likely that there is an underlying infection - which does require medication.

Do not use anti-dandruff shampoo. This is too harsh for a baby's skin and can create further irritation.

Do not use eczema creams (like Elidel) this is also too harsh for a child's skin and has not been tested on the under 2's.

Wednesday, June 24, 2009

How often should a baby poo?

Whilst trying to find out about green poo, one question that was being consistently asked by the medical profession was: 'how often should a child poo?'

Answer:
The lastest research from Archives of Disease in Childhood 2009;94:231-233
suggests that a healthy child at 4 weeks gives a stool on average 3 times a day.
When the child gets to 42 months the average healthy child gives a stool 1.3 times a day.

In terms of colour (see previous post), the colour tends to be yellow/mustard at 4 weeks and changes to brown at 6 months (the age of weaning onto solids).

DID YOU KNOW?: that according to Archives of Disease in Childhood 1993;68:317-320; the bowel habit of an infant is pretty much determined at 25 weeks of gestation. (Determined by maternal nutrition (no milk feeds), in pre-term infants).

The La Leche Legue has a great page on how often at what age...http://www.llli.org/FAQ/bm.html

Regular stool pattern in a breast-fed child is:

up to 6 weeks:
2-5 stools in 24 hours

6 weeks onwards: between 5 stools in 24 hours to 1 every few days (up to a week). (This is because the colostrum in the mothers milk diminishes and no longer provides such a laxative effect).http://www.llli.org/FAQ/bm.html


Regular stool pattern in a formula fed child is:

Anything from 2-5 times a day up to 1 every 3/4 days.

In both groups (breastfed and formula fed), by the time they reached 16 weeks, the average no of stool per day was 2.
Ref:Journal of Pediatric Gastroenterology & Nutrition. 7(4):568-571, July/August 1988.
Weaver, Lawrence T.; Ewing, Gail; Taylor, Linda C. *



In pre-term infants the first meconium poo (black) could arrive from first day through to past the second day, with inverse relationship according to gestational age.
Thereafter it seems that per every 50ml/kg increase in milk intake, the further production of one poo a day ensued.
Ref: Archives of Disease in Childhood 1993;68:317-320

As a general rule: breast fed babies produced a greater number of poos and of softer consistency, than cows milk formula fed babies.

SO what if you are worrying about your child being consitpated/fewer and harder stools when transitioning to formula? The answer is to go with a formula that is cow milk-based formula with a whey:casein ratio of 48:52 (i.e more whey than casein) and a fat blend of 42% high-oleic safflower, 30% coconut, and 28% soy oils. In the study PEDIATRICS Vol. 103 No. 1 January 1999, p. e7 this formula was named as 'Similac' with iron powder. The study found proposed that a formula with palm olein fat, that created the formula more acidic like breastmilk, made stools significantly harder. This may have been due to the creation of insoluble soaps from palmitic acids combining with calcium.

Tuesday, June 23, 2009

Green stools in infancy

During a consultation it is becoming increasingly common to hear of 'green' stools in the infants that present. What I wanted to find out was what on earth - if anything- does it mean for a child to have green poo?

Apparently it is not abnormal for the child to have green stools occasionally, like once in a few days, but if it becomes a common occurence then this is when it can be signalling something else is going on.
  • Breastfeeding and green stools..
Reading up on my ever favourite la leche league international website, they relate the child to having green stools due to a imbalance between foremilk and hindmilk. If the child is 'snacking' on the breast, poor latching, or improper feeding by the mother (i.e, not staying on the one breast long enough) then child will be getting more foremilk and less hindmilk. Of course, as stated in my previous blogs, if there is too much foremilk and not enough hindmilk, the child will be more hungry, gassy and irritable, and may have green stools.

  • Formula fed babes and green stools..
From the information databases it seems that green stools are more common in formulas that have 12mg/L of iron than 1mg/L iron.
Ref: Pediatrics. 1995 Jan;95(1):50-4.

In general:
It seems as though green stools come about from the faster passage through the digestive system. If the time of passage is slower, the poo is more mustard colour. This way it allows time for the movement of nutrients in and out of the intestine.

In pre-term infants, one study found that the colour and consistency of stool vaired according to the different pre-term formulas given.
Turk J Pediatr. 2000 Apr-Jun;42(2):138-44.

Tuesday, April 21, 2009

Jacuzzi and pregnancy?

Are you allowed to go in the Jacuzzi whilst being pregnant?

Here's the answer:

It has been advised that a pregnant woman should not stay in a jacuzzi/hot tub for any longer than 15 mins maximum. But the usual applies, that if its not that safe - don't even go there.

The main worry is over the heating effect (hyperthermia). There is evidence to suggest that a body temperature higher than 101 degrees fahrenheit (38.3 degrees celsius) can result in higher risks of birth defects in the first trimester of pregnancy. As a jacuzzi is maintained at the temperature of around 104 degrees fahrenheit (40 degrees celsius), and it takes 10-20 minutes for the body to reach 102 fahrenheit (38.8 degrees celsius), it is advised by the American College of Obstetricians and Gynaecologists not to recommend a hot tub.

It has also been mentioned to not let the jets to forcefully propel water near your vagina.

Colostrum

So I said in an earlier blog about how good this stuff is... Here's a little more information:

Colostrum is the first milk produced by the mother during pregnancy and the first few days of breastfeeding. It is a sticky, thick substance that is ultra nourishing. It is low in fat, high in carbohydrate, protein(three times more than mature milk!) and antibodies (IgA). It is easily digestable for the little one and has a laxative effect - aiding baba to produce that first meconium poo to clear the system.

Only a small amount is produced - measurable in teaspoon sizes. But to aid mothers production of milk in the first few days it is advised by the La Leche League to feed baby 8-12 times in 24 hours. Over the following two weeks breast milk changes from colostrum to mature milk (foremilk and hindmilk), and the antibodies decrease.

The high antibody content of colostrum is currently being intensively researched. IgA is the antibody that presents itself to the newborn to protect namely the mucous membranes of the digestive tract, throat and lungs. The antibodies produced are specific to the mother’s environment and are targeted against the pathogens in the infant’s surroundings. It is also responsible for continuing the passive immunities that were provided in utero by the placenta, such as poliovirus and rubella.

The main function of sIgA, along with other immunoglobulins, is to "paint" the lining of the infant’s stomach and intestines. These surfaces are then able to defend the baby against viruses and bacteria by not allowing pathogens to adhere to them. Some of these incredible immunoglobulins actually attack pathogens and kill them. These components are important in fighting and preventing necrotizing enterocolitis (NEC) in premature infants, which can be fatal.

Colostrum can also help decrease allergy reactions. Recent research looked at the content of colostrum in mothers whos children were at a high risk of allergies (due to the parents). They found that those with a relatively high level of omega -6 fatty acids (compared to omega-3), the children were more prone to cow's milk protein allergies. Those with low levels of omega-3 fatty acids, their children were more likely to be allergy prone overall. The study came to the conclusion that a diet high in a balance between omega 3 and omega 6 during pregnancy is important to pass on the low allergy ability in colostrum.

Another interesting point about colostrum is that the child doesn't need high quantities of it (per feed). The child physically cannot take in high volumes. A day 1 old child has the stomach capacity of 5-7mls. At this time the walls of the stomach are fairly inflexible and consequently the stomach will spit up that which it cannot hold.
A 3 day old has the maximum stomach capacity of 30mls. Consequently small, frequent meals are needed.
A 7 day old has the maximum stomach capacity of 60mls. By now with breastfeeding the milk flow will just about be matching need.

For more info visit: http://www.llli.org/llleaderweb/LV/LVDecJan05p123.html

Friday, March 20, 2009

Tongue tie

Tongue tie is when the skin fold underneath the tongue (frenulum linguae) being too short/tight.

Tongue tie prevelance is suggested to be at aout 1 in 1000 newborn.

On observation, the tongue can be a 'heart shaped' - when the sides of the tongue roll up, but the front/middle doesn't, but not always. When the tongue is lifted up, if normal it should be on the roof of the mouth, if not, then the tight frenulum can been seen. Also the tongue will not be able to project beyond the lower gum line.

Symptoms of tongue tie are:
  • weak and intermitten suck:
  • innability to latch well onto breast
  • slow feeding
  • needing to feed often
  • eventually if undiagnosed, can be a cause of poor weight gain
Treatment for tongue tie:
  • At home: Babies with tongue can't do the intial suck process of bringing the tongue out to bring the nipple into the mouth. Therefore, 1)try bringing your nipple to the baby's mouth. To make the child open the mouth, put their chin to the areolar area and the nose to the nipple. 2) thry shaping the breast to make a mouthful shape and bring towards baby.
  • Medical intervention: Not all paediatricians agree, but by snipping the frenulum linguae, babies have been reported to suck harder, feeding becomes easier and quicker, and weight gain begins faster again. This is a simple in-office treatment.

Thursday, March 19, 2009

Turning a breech baby

What if the baby is in a breech position? This is the baby in the postion where the bum in heading down towards the pelvis and the head is up.

Obviously this is not going to be a good position for baby or Mum. Trying to push the largest part of the body out first is not the way to go... So what can we do to turn the child?

There is a technique used by the gynaecologists/obstetricians that is pretty hectic for the child, called external cephalic version. This is when the doctor forces the baby around by pushing on the mother's belly. This technique is usually reserved until 34 weeks of the pregnancy onwards. This is performed in the hospital with a team on standby.

Another technique is the 'Webster technique' peformed by chiropractors. The idea is to help the pelvis open up (by working on the back of the pelvis) and avoid any torsion/ unequal movement from side to side, that may cause the baby to avoid lying in the head-down position.

But what can we do at home?
The idea here is to get the heaviest part of the baby - i.e. bum, to be nearer the upper part of the mother's body. Apparently, drinking a glass of juice before doing the exercises (but not so much to cause a full stomach) can increase the baby's movements. The baby likes the sugar high!

Exercises include:
  • lying on back with pillows under bum, therefore allowing the baby's bum to go towards to the diaphragm. Lie here for a long as you can at a time. If you get light-headed or get palpatations, stop.
  • on all fours doing 'cat stretch' - meaning arching back up, and then lowering buttocks towards heels and arms reaching out forwards. Again, the mother's chest will be lower than the pelvis.
  • kneel at the top of steps/stairs, slowly walk your top body down 2-3 steps and hold for 10 mins. In this position your upper body is lower than your pelvis
  • Swimming on front- frontcrawl and breastroke. Avoiding doing frog's legs for the days that the baby is still in breech position. Only do frog's legs once baby is in the right position and you want the child to head further into the pelvis.

Avoiding posteriorly positioned babies

So, after talking about baby being in a posterior position (head facing outwards/back to back) in utero, what can we do to help baby turn the right way around?

The main understanding is that the child's back is the heaviest part of the body, so it will naturally try to fall into the position with the least resistance. Therefore, using common sense, the baby's back will fall to the back of the mother's body if you are: lying back in arm chairs (lazy boys - v. bad!), sitting in car seats and leaning back (no boy racer style driving!), and anything with your knees higher than your pelvis. Of course - all these positions are bad for the mother's back anyway. All these positions place the lumbar spine into flexion and create greater pressure on the pelvis and lumbosacral junction - not good.

Positions to avoid:
  • lying on back,
  • deep squatting (to avoid baby engaging into the pelvis when in the posterior position)
  • putting the feet up (with legs above hips)
  • swimming with 'frogs legs' (especially when baby in posterior position - again, to avoid engaging in the wrong position)
  • Crossing the legs. This reduces the amount of space in the front of the pelvis, and opens it up at the back. For a baby to go into anterior position there needs to be space at the front

If the baby is lying in the posterior position, the main aim at the beginning is to avoid the baby heading down further into the pelvis. If baby is too far down, it makes it harder for it to turn around. After the child has turned, then you can focus on getting the child further into the pelvis by doing the exercises like breastroke with frogs legs and deep squatting.

Positions to AID anterior positioning:
  • Kneeling, leaning forward
  • Moving around on all fours (longer than 5 mins)
  • Sit on a chair facing the back of it and leaning over
  • Sit on a wedge cushion in the car, desk chair
  • Swimming with your belly down - i.e. front crawl or breastroke. N.B. If you are trying to turn the baby, don't do frog's legs with breastroke, only do straight kicking of the legs. Only do the frog's legs when baby is in the anterior position and you want the child to settle deeper in the pelvis.
  • On all fours: rocking pelvis from side to side, around in circles, and the 'cat stretch' - arching back upwards.
  • Sleeping on your tummy (obviously support by lots of pillows).

Wednesday, March 11, 2009

Blood sugar level in neonate

I've had quite a few mums come to me explaining all about the ordeals they get after having their child in hospital - or one even fighting with the staff even before the babies were born!

It seems like at the moment the buzz word in the neonatal unit is 'glucose'. All the nursing staff seem to have it drummed into them that the new born must be monitored closely for their blood glucose level - to avoid hypoglycaemia.

So I set about trying to find what all the fuss is about.

Hypoglycaemia in the neonate seems to be linked to two important things (well as far as I have found out so far anyway). 1) the development of neurodevelopmental impairment and 2) jaundice/ kernicterus/ hyperbilirubinaemia - if the child has something called Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency.

Hypoglycaemia can be symptomatic and assymptomatic. Thats why the testing in the early hours after birth has to be so consistent. Symptomatic hypoglycaemia can be mild or severe - and as it usually goes in neonates: mild can turn into severe rapidly.

Symptoms of hypoglycaemia can be:
depression of cerebral function: lethargic, hypotonic (limp), poor feeder,weak cry, apnoeic, cyanotic or absent moro reflex
overstimulation of cerebral function: jittery infant with high pitched cry, fixed stare and fisting, abnormal eye movements or convulsions
and excessive sweating: speaks for itself, but may not be present in pre-term infants.

Babies most at risk are:
pre-term,
low birth weight for gestational age
wasted infants,
infants born of a diabetic mother.

Medical limits for glucose in neonate:
>2.0mmol/l (up to 7.0mmol/l): normal
1.5mmol/l -2.0 mmol/l: mild hypoglycaemia
>1.5mmol/l: severe hypoglycaemia VERY DANGEROUS!

SO what is the way of helping the baba naturally?!
1)Easy: go with the feeding of the infant as soon as possible - WITH MILK - meaning colostrum. Which leads me onto the next blog...
2) Keep the child warm. If the child is cold, they burn more energy to keep warm - meaning all the energy that they should have stored up whilst inutero - should be used. If this is all used up, then they can easily go into hypoglycaemia

Don't you think it makes sense in South Africa why the c-section babies (60% of births in SA!!!) are always watched closely - if they were pulled out 'early' - without storing all the fat energy to burn in the first few days - they are going to be low on energy and can easily go into mild hypoglycaemia early on before they can feed enough to get the energy up and live off mum's milk.

Wednesday, February 25, 2009

Leopald's manoevers

According to the midwives and gynaecologists and obstetricians there are some 'manoevers' that allow you to determine in which position the baby is lying. Hard to do if you are the pregnant mum trying to feel things, but easier for the other person (plus, theres one that needs the more skilled hands).

Leopald's manoevers:
  • The initial maneuver involves the examiner placing both of his or her hands on each upper quadrant of the patient's abdomen and gently palpating the fundus with the tips of the fingers to define which fetal pole is present in the fundus. If it is the fetus' head, it should feel hard and round. In a breech presentation, a large, nodular body is felt.
  • The second maneuver involves palpation in the paraumbilical regions with both hands by applying gentle but deep pressure. The purpose is to differentiate the fetal spine (a hard, resistant structure) from its limbs (irregular, mobile small parts) to determinate the fetus' position.
  • The third maneuver is suprapubic palpation by using the thumb and fingers of the dominant hand. As with the first maneuver, the examiner ascertains the fetus' presentation and estimates its station. If the presenting part is not engaged, a movable body (usually the fetal occiput) can be felt. This maneuver also allows for an assessment of the fetal weight and of the volume of amniotic fluid.
  • The fourth maneuver involves palpation of bilateral lower quadrants with the aim of determining if the presenting part of the fetus is engaged in the mother's pelvis. The examiner stands facing the mother's feet. With the tips of the first 3 fingers of both hands, the examiner exerts deep pressure in the direction of the axis of the pelvic inlet. In a cephalic presentation, the fetus' head is considered engaged if the examiner's hands diverge as they trace the fetus' head into the pelvis.

When the baby is anterior, the back feels hard and smooth and rounded on one side of your tummy, and you will normally feel kicks under your ribs. Your belly button (umbilicus) will normally poke out, and the area around it will feel firm. When the baby is posterior, your tummy may look flatter and feel more squashy, and you may feel arms and legs towards the front, and kicks on the front towards the middle of your tummy. The area around your belly button may dip in to a concave, saucer-like shape.

If you feel the baby move, try work out what body part was moving. Remember that heads feel hard and round, while bottoms feel soft and round! It may take a lot of concentration and trying to work things out at first, but you soon get the hang of it. You may find it easier to feel your baby's position if you lie on your back with your legs stretched flat out.

If your baby is posterior, you may find that you suffer backache during late pregnancy (of course, many women suffer backache then anyway). You may also experience long and painful 'practice contractions' as your baby tries to turn around in order to engage in the pelvis.

Optimum foetal positioning

So I had a baby in today who had one painful delivery into the world. The mother, trying to hide her distress, was trying to convey her whole ordeal with 'back labour' for 24 hours and how the child proceeded to get stuck in the pelvis, due to its 'anterior positioning' with the cord around the neck. This child, needless to say, needed a little help.

So what was this 'back labour'? what was the 'anterior' positioning of the child? and what is the optimum positioning for the baby pre-labour?

Optimum positioning of the baby prior to labour should be a position called 'left occiput anterior' (LOA). This is where the child's occiput (base of the skull) is halfway facing away from the mother's back. Hard one to explain: see photo:
LifeART (and/or) MediClip image copyright 2008Wolters Kluwer Health, Inc.- Lippincott Williams & Wilkins. All rights reserved.

When the child is in this position, mothers usually complain of the child kicking the right ribs. Plus, you'll see the majority of the weight being on the left side of the pelvis/tummy.

The postion that the mother was talking about was the child being in the left occiput posterior position. It appears like the child is looking out forward and the child's back is more against the mother's spine.
In this position the mother will usually take longer to go into labour and the pelvis will be pushed to its limits with trying to expand to allow baby to engage. Its not that the baby is too big for the pelvis - it's just in the wrong position.

Due to this LOP positioning, the child's head will have the widest diameter, and cannot flex its head to get through the birth canal. Either way, its not good for mum and not good for child.
LifeART (and/or) MediClip image copyright 2008Wolters Kluwer Health, Inc.- Lippincott Williams & Wilkins. All rights reserved.

This is one of the positions that leads to 'back labour'. Meaning all the pain and contractions are felt in the back. But don't worry. Aparently it has been found in studies that up to 87% of occiput posterior babies turn to occiput anterior positioning during labour. Great!

I'll talk about trying to avoid posterior positionings in another blog. There's too much!

I also had one mum talking about 'star gazers'. This is the also another word for the posterior positioning. Basically meaning the child is looking out towards the belly.

Good website found for explaining the whole postioning thing is:http://www.homebirth.org.uk/ofp.htm


Thursday, February 19, 2009

PDA baby

I've had a few parents come into my clinic and just casually mention their child has/had a PDA.

So what on earth are they meaning? They were born with an inherant ability to tell you the time, calculate your diary, remind you of your impending appointments and meetings!?!

PDA means Patent Ductus Arteriosus. Ever heard of 'hole in the heart'? Basically its that.

"All babies are born with this connection between the aorta and the pulmonary artery. While your baby was developing in the uterus, it was not necessary for blood to circulate through the lungs because oxygen was provided through the placenta. During pregnancy, a connection was necessary to allow oxygen-rich (red) blood to bypass your baby's lungs and proceed into the body. This normal connection that all babies have is called a ductus arteriosus.

At birth, the placenta is removed when the umbilical cord is cut. Your baby's lungs must now provide oxygen to his/her body. As your baby takes the first breath, the blood vessels in the lungs open up, and blood begins to flow through to pick up oxygen. At this point, the ductus arteriosus is not needed to bypass the lungs. Under normal circumstances, within the first few days or weeks after birth, the ductus arteriosus closes and blood no longer passes through it. Most babies have a closed ductus arteriosus by 72 hours after birth". http://www.schneiderchildrenshospital.org/peds_html_fixed/peds/cardiac/pda.htm

In some babies, however, the ductus arteriosus remains open (patent) and becomes a problem, PDA. The opening between the aorta and the pulmonary artery allows oxygen-rich (red) blood to pass back through the blood vessels in the lungs, which should solely be carrying only oxygen-less (blue) blood.




















PDA is common in the preterm infant and especially when respiratory distress syndrome (RDS) is present. Also genetic kiddlies like downs syndrome and kids are more at risk if mother had german measles (rubella) during the pregnancy. PDA is the sixth most common congenital heart defect, occurring in 6 to 11 percent of all children with congenital heart disease. Patent ductus arteriosus occurs twice as often in girls as in boys.

In pre-term infants the PDA normally closes on its own within the first few weeks of life. If the PDA is in a full-term infant, it is unlikely to close on its own. The PDA can be closed by giving a prostaglandin synthetase inhibitor (e.g. indomethacin), but sometimes surgical closure is required.

So when do the doctors check for this PDA? Usually they will hear it on the initial examination once your child is born. They listen for a murmur. Sometimes you won't hear it, then they go on the signs and symptoms later on.
Symptoms of a fairly larger PDA are:
  • Bounding pulse
  • Fast breathing
  • Poor feeding habits
  • Shortness of breath
  • Sweating while feeding
  • Tiring very easily
  • Poor growth
Then its on to the tests of an echocardiogram, chest x-ray, ECG, or cardiac catheterization.

Wednesday, February 18, 2009

Lactose intolerance

I wanted to include this little tit-bit of information that I came across whilst trying to write the info about foremilk and hindmilk.

I have had a couple of mums telling me that they have been told that their breast fed children may be reacting to the amount of lactose that they are eating in their diet and may be affecting their children.

According to the La Leche League International: "Lactose intolerance is not a problem for babies. They are born with the ability to produce lots of lactase because they depend on their mother's milk for nutrition in the first year of life and the lactose in mother's milk is needed for brain development. Lactase production decreases as children get older, because in the world of mammals, milk is a food for babies, not adults. This is why some adults (especially the elderly), become gassy and uncomfortable when they eat dairy foods high in lactose, which their bodies can no longer digest. True lactose intolerance in infants is called galactosemia, an extremely rare genetic condition (approximately 1 in 30,000 US births) that is present from birth and fatal if not treated; a baby with the disorder would not gain weight well and would have clear symptoms of malabsorption and dehydration." Leeson, R. Lactose intolerance: What does it mean? ALCA News 1995; 6(1) 24-25, 27.

Yes, it is true, a high amount of lactose can affect the child/ overload the digestive system and cause the gassy symptoms with green, watery/foamy stools. However, this usually comes about by the poor breast feeding technique of too much foremilk...see my other post re: foremilk and foremilk.

No change in maternal diet (regarding lactose) is ever going to change the breast milk, the amount of lactose in breast milk is a set thing for that mum. If the child does seem to respond to decreasing the amount of dairy in the maternal diet it is more likely due to the child being sensitive to a protein from the cow's milk that CAN come through to the breastmilk.

Foremilk and Hindmilk

The statement put to me by one of my mums was concerning her production of foremilk and hindmilk when breastfeeding. She had helped her child stay satisfied longer and put on more weight by letting the child feed longer on the breast to allow the 'hindmilk' to come in.
So my question was "how long does it take for the hindmilk to come in?"

Foremilk is the watery, high in lactose milk that is meant to come in first to satisfy the thirst of the child and provide the short term energy and help for brain development. Hindmilk is the more 'fatty' satisfying milk that allows the child to grow.

Apparently according to the La Leche League International webiste: http://www.llli.org/FAQ/foremilk.html there are no different types of breast milk production cells, they all produce the same type of milk, its the fat content of the milk that is provided that varies according to how long the milk has been collecting in the ducts and how much of the breast is drained at the time. They say that the watery foremilk comes first, leaving the fat cells sticking behind in the milk ducts. The longer the child sucks, the more amount of fat cells end up coming through along with the 'hindmilk'. They describe it as the appetizer (foremilk) and dessert (creamy hindmilk).

So the question remains: how long does it take for the hindmilk to come in? Apparently it depends from person to person, each mum provides the right amount of fat content in their milk to help their child grow and devlopment. It seems the two ways to tell are: seeing how quick your milk supply comes (if you are over producing) or whether the child is getting that 'drunkeness'/ coming off the breast volontarily.

If you are overproducing milk, the child with be coming off the breast quickly and choking and spluttering - this means that your milk is coming too quick for the child and will inevitably make the child take in a lot of foremilk - which mean lots of lactose and may create gassiness and crampings, green frothy stools and less satiation (the 'colicky' symptoms). There are numerous ways of counteracting this...see link: http://www.llli.org/FAQ/oversupply.html

But, to answer the question, the best way to tell is to stay on the same breast until the child unlatches volontarily and pulls the 'milk drunk' look. The child knows when they have had enough (cool hey?). If they wake back up quickly again after 5-10mins and still seem hungry - then go on the other breast. The routine of feeding 10 mins on each breast doesn't seem to work and is appearing to be counterproductive in terms of composition. One quick note: if the child never does come off the breast on it's own accord, something is going on with the latching or positioning.

HOWEVER, there appears to be also a 'let out' clause for this understanding. In the first week of breastfeeding it seems to be quite important to make sure that the child feeds from both breasts in one feed. The mother's body needs to be 'stimulated' in a way to help get the milk production off to a good start. Hey, in a way it makes sense that you are only producing colostrum in the beginning (no worrying about foremilk and hindmilk yet). Only when you get into the routine and the milk production goes full flow...do you need to start looking at getting the right amount of time of the breast.

A good summary: the baby should be finished with the first breast before being switched to the other side - thats how long it takes....it's 'child led'. These babas are smart!