Sleep Training: The SleepEasy Solution

I am far overdue for an update on this topic now that my baby toddler is 17 months old.  But sleep is a topic I get a LOT of questions about....so for now, I leave you with the below post, originally written when Benji was about 6 or 7 months old.  There are many methods for sleep training, but combining my professional and personal experiences, this is what has worked for us!  

Good morning!

People are always commenting on how happy Benjamin seems to be.  Family, friends, and strangers alike tell us that they're amazed he's constantly smiling, laughing, and observing the world around him.  It's true, he rarely cries unless he has a good reason to (teething, very overtired, bored/frustrated), and on a day to day basis I would guess he cries a total of about 10 minutes, on a bad day up to 20 minutes.  I fully admit that one aspect of this is pure luck.  We have a very good baby - a truly easy baby.  But I've also been fortunate to have the ability to take my education and experience as a Pediatric Nurse Practitioner and put it to use to teach Benji how to be a happy baby.  In our case, sleep has been the most important aspect of ensuring his easygoing nature.

I wake up HAPPY!

Since the beginning we've been blessed with a good sleeper overall.  From the start (well after the first 2-3 weeks in reality), Benjamin seemed to understand the difference between day and night, and while he woke every 2-3 hours to eat around the clock, he was kind enough to go "right" back to sleep (within about 15 minutes) after overnight after feedings.  Of course there were exceptions to this trend, and there were a handful of nights where we both cried in exhaustion, but when comparing his sleep patterns to those of most of my patients, I knew we were lucky when it came to sleep.

Babies all naturally go through growth spurts with fairly predictable patterns.  Ahead of time, I knew that these growth spurt weeks would be the hardest on me physically, mentally, and emotionally, because in all likelihood he would need to nurse every 1-3 hours instead of his typical 3 hour routine.  And sure enough, at 2-3 weeks, 6 weeks, and just shy of 4 months we hit those dreaded growth spurts, and they were trying.  I am very against co-sleeping for safety reasons, so it was constant back and forth between our bedroom and his.  Benji moved from our room to his crib in the nursery at 4 weeks old so as to establish a healthy sleeping environment early on, which I do attribute to his excellent sleeping habits.  We depended on swaddling until about 4 months, and used a zipadee zip to transition him to a sleep sack between 4 and 5 months old.  He'll sleep wearing anything now.

The 4 month growth spurt/sleep regression was almost our undoing.  I would still argue this was harder than the newborn period in some ways.  Ben would awaken every 1-3 hours and absolutely nothing but nursing would soothe him.  I became a human pacifier - he has never taken to an actual pacifier and no amount of coaxing and pleading could convince him to give it a try.  If I attempted to put him down in his crib asleep, he woke right up crying.  We were both completely miserable, and because I was acting as a human pacifier Tom was unable to do much to help.  He needed to be nursed to sleep for naps as well during this period.  I tried the swing, the car, the bouncer, the rock n' play, rocking and singing... anything and everything we could think of!  I finally gave in to co-sleeping for a night or two which resulted in better sleep for Benji, but still virtually no sleep for me because I couldn't allow myself to relax enough to fall asleep.  And my typically cheerful baby was still content while awake, but he looked a little dazed and stopped smiling at anything and everything.

So I started researching sleep training and quickly identified a method that I liked called the SleepEasy Solution.  I downloaded and read that entire book within a 24 hour period, and it was the most wonderful resource for sleep I have come across (personally or professionally).  Yes, this is a modified cry it out version, which is controversial.  It was so instrumental in turning our lives around within about 4 days that I felt compelled to share the basics with you, but this is by no means enough information to completely skip the book....spend the $10, it is worth every penny!

Sleep Environment: create an ideal and consistent place for sleep.  For us, that meant adopting most, but not all, of the recommendations made by the authors.  Ben sleeps in his crib, with a small (breathable!) lovey, is placed on his back awake, has a loud white noise machine, and the lights are turned off.  Because he rolls over on his own he flips to his belly within about a minute of putting him down but (for SIDS safety) we always put him down on his back.

Sleep Schedule: we started sleep training around 4.5 months old, likely just below 15lbs.  The book outlined that a baby at this age and weight needs a total of about 15 hours of sleep per 24 hours.  He should sleep 11-12 hours overnight and 3-4 hours daytime.  Naps were to be spaced starting 2 hours after waking for the day, 2.5 hours between the end of nap 1 and 2 (and 2 and 3), and awake at least 1.5 hours before bedtime.  Feeding schedules are incorporated, as is bedtime routine (and mini bedtime routine for naps).  Our schedule continues to follow this pattern (although some days he takes two longer naps) and looks like this:

• 7am wake up
• 9am nap 1 (typically lasting 1-1.5 hours)
• 1pm nap 2 (typically lasting 1-1.5 hours)
• 5pm nap 3 (typically lasting 0.5-1 hours)
• 7:30pm bedtime  

Check Ins: this is the "cry it out" portion of sleep training that a lot of mom's are unable to stomach, and I can't blame them because my heart breaks when I hear my little man crying.  Professionally I have been in support of cry it out, a baby must learn to self soothe and it is the parent's responsibility to teach their child to sleep.  But most parents don't believe me or understand the importance of this when I explain, and months (or years) later ask in desperation how to correct bad sleep habits that have been in place since early infanthood.  It is possible to do, but more difficult, and sooner or later you do need to teach your child how to sleep.  Night one will be the hardest, night two a bit easier, and by night three or four you'll be done with the hard stuff, I promise.

A timer/stopwatch is seriously important to this step.  I found that 20 seconds of crying felt like 5 minutes, so I needed a reality check here.  If your baby begins crying start a timer for 5 minutes, and prepare to be in agonizing emotional pain (sorry mama).  If your baby is still crying after 5 minutes go into the room, do not touch them, but in a soothing voice reassure that you love them and it is time for sleep, and get back out of the room within 30 seconds.  The book goes into detail as to why this specific method is really important, and it made so much sense to me (think of touching as teasing them that you'll revert back to old and overall ineffective soothing methods).  In effect you are encouraging them to attempt, and eventually rely on self soothing instead of parental soothing to produce sleep.  After the first check in reset your timer for 10 minutes and repeat.  If needed, reset for another 10 minutes and so on.  

Our experience was great.  The longest Benji ever cried was the first night and maxed out at 17 (horrible) minutes before he learned to suck on his hand and fell back asleep all on his own.  Subsequent wake ups that night he cried for a few minutes (longest was 11 minutes) and then soothed himself with his hand and went back to sleep again.  In the morning when he woke up and started fussing I went in to him and he beamed up with me with a huge smile and squealed, at which point a promptly burst into tears in relief that my baby didn't hate me.  As mentioned, the next night went better, and the third night he put his hand in his mouth the second I put him down and never cried - seriously. 

Falling asleep all on my own

Overnight Feedings/Weaning: most babies are still waking up to eat overnight at 4+ months.  As long as they weigh at minimum 14 pounds (ideally 15) they don't NEED to eat, but awaken out of habit.  This being said, you should clear this with your pediatric provider before weaning all overnight feeds.  Because we went from nearly hourly awakenings to sleep training, I had to take an educated guess of how often he was eating vs. comfort nursing.  The book explains how to properly dreamfeed rather than allowing the baby to awaken and control their nursing patterns.  I decided to dreamfeed at 10pm, 1am, and 4:30am to start.  I set alarms and woke myself up and crept into his room to dreamfeed at those times, and timed how long he ate for over the course of the next few days.  If Benji awoke before I was to feed him, I would allow him to self soothe back to sleep (doing check ins if necessary) and make sure he was asleep for 10 minutes before I would go in to dreamfeed, so the timing wasn't always perfect, but very close.  After determining his patterns, I shortened the time he ate at the 1am feeding by 1-2 minutes every night until it was gone.  Then I did the same for the 4:30am feed.  I still dreamfeed at 10pm to date, but that's for me - both to keep my milk supply up (he has had some weight gain issues unrelated to sleep training), and I admit I love the cuddling before I go to bed.  Technically I could pump at 10pm and he could wean off of this feed too, and I will eventually.....

So there you have it.  The basics of sleep training using the SleepEasy Solution.  I've heard varying statistics on the effectiveness of sleep training, and ultimately it does not work for all babies.  But it does work for most.  And the benefits of having a well rested baby and parents are astounding.  Benjamin is hitting milestones at a faster rate now, he is ALWAYS happy, and he can be flexible with sleep when needed because he is an expert at self soothing now.  There will be set backs when traveling, teething, going through a growth spurt, or illness, but existing on little sleep is now our exception instead of our norm.  

Tips and Tricks for Home Healthcare

Because I feel for the parents that bring their kids into the office with a complaint that could be treated at home, I've been slowly compiling a list of issues we commonly see, and the at home solution you can try before hauling your family off to the doctor's office.

1.  Splinters.  My favorite and almost fail proof method involves a hot compress and Elmer's glue.  Soak or use a hot compress for about 10 minutes to soften the skin.  "Paint" on a layer of glue and allow it to dry completely.  Peel the glue off and out will come the splinter with the glue.  No tweezers, no needles, no pain. This works surprisingly well even on the big guys.  If it's really big, this should at least loosen it enough you can grab the end with tweezers and slide it out without discomfort.

2.  Warts.  These are painful to remove at the office because we freeze them, often more than once over a few weeks.  For a stubborn wart the freezing really is required, but for a lot of cases you can get rid of them at home over about a months time without any pain.  My preferred method is to suffocate the wart with duct tape.  It's actually great that it comes in fun colors now because kids seem to be into this treatment method.  Cut a small square of tape to cover the entire area of the wart and keep it in place except for bathing.  You'll have to switch out the tape from time to time to keep it sticky.  One day, you'll go to switch it out and notice the wart is gone (hooray).  My second favorite method is to use apple cider vinegar.  Using a q-tip dab a bit on top of the wart 3-4 times a day, for 3 weeks.  The wart should shrink down and dry up.  Apple cider vinegar can be irritating to the surrounding healthy skin, so be careful to only dab the wart.

3.  Fever.  Ok, I could speak on this one for days, so I will try to keep it short and to the point.  In young infants, take a rectal temperature, don't argue, don't think it's torture, just do it for the safety of your baby - accuracy is key for this age group.  Ask at an office visit how to do this if you're unsure, but it actually is the only accurate way to measure an infant's core temperature.  For toddlers take an axillary (armpit) temperature.  For school aged kids take an oral temperature.  Use the cheap digital thermometers.  A fever is defined as 101 degrees and above in kids over 4 months old.  100.4 and above in newborns.  Fever is not something to be feared alone and it is not a diagnosis, but rather a symptom.  It's proof the body doing what it is meant to and fighting something off - fever is good.  Treat the symptom, but don't panic.  Kids can have fevers for a week without any issue.  Schedule an appointment if they have had a fever over 101F for 3 days, or if they aren't drinking well, or if your mom instinct tells you something is seriously wrong.  But if your child is playing and drinking but has a temperature of 103.4, they're probably ok.  Judge small children's illness by their ACTIONS not their temperature reading on a thermometer.

4.  Croup.  A terrible viral illness that strikes at season changes typically, but can happen at any time. The distinguishing trait is a harsh, barky cough (actually sounds like a seal is barking).  An appointment is warranted if your child has a history of wheezing/asthma/respiratory distress, or is vomiting due to the cough, but otherwise this one can be rode out at home, even though the cough sounds really scary.  It will be worse at night and it will resolve more quickly with cold, moist air.  Traditionally people steam up a bathroom and that moisture can help - but cold air works better.  Run a cool mist humidifier constantly, but during bad coughing fits open your freezer and stick your kiddos head in there and let them breathe in that cold wet air.  Alternatively (and actually better), wrap them up in warm clothes and take them outside to breathe the cold outdoor nighttime air.  The spasm will calm once the air moves through the airway.

5.  Ticks.  Lyme disease is a real and serious illness.  But for a tick to transfer the disease through a bite, they typically have to adhere for about 24 hours, which rarely happens.  When the tick is removed its important to evaluate if it is engorged, or flat.  A flat tick doesn't have a great chance of transmitting Lyme, but may still leave a bit of a ring, or target around the site which terrifies parents.  Many providers will still proactively treat these bites with antibiotics "just in case", but the guidelines actually call for a watch and wait approach.  If a fever develops in this case, call for antibiotics.  If no illness symptoms, no fever, and a flat tick, it is ok to dab the site with some Neosporin and just wait it out.  Unnecessary treatment with antibiotics is actually pretty detrimental to their efficacy, so its nice to avoid it when we can.  When it comes to removing the actual tick, this tool is amazing.

6.  Rashes.  If it doesn't bother your child, don't let it bother you.  I know this one is hard, and hives definitely are an exception to the rule.  But most rashes are the product of minor irritation such as heat, contact with an irritant like perfumes or oils (plants, chemical, etc.), or environmental (dry air).  Nearly all of these rashes can be treated by either leaving them alone, or if you must do something, applying a super hydrating solution such as Vaseline to help seal the skin in and allow it to heal without any further irritation.  Don't put anything else on it.  A lot of parents try a variety of "treatments" and it becomes difficult to later assess if the rash we see in the office is the original rash or due to the attempted treatments.

I'm sure his list will keep evolving over time.  As I type this out I wish I had jotted down the common treatments I would discuss over the phone time and time again while I was working.  This is certainly a great post for you to post your questions about simple home remedies though, if you have any.  I personally love when parents and healthcare providers alike get creative about home treatments in order to avoid an office visit or medication, as long as their is evidenced based research to support it, OR like in the case of the splinter removal, no harm can be caused if it doesn't work.

Sadly headstands still don't cure hiccups

Allergy or Intolerance?

There is a lot of teaching that revolves around allergies - food, environmental, and seasonal.  But for today, I will try to be brief while I stress the importance of understanding the difference between an allergy, an intolerance, and a preference in relation to foods.

My kid doesn't like to eat.  On the surface, it's sort of a funny concept and one that a lot of parents struggle with, so its easy to laugh off.  And for most parents with kids who "don't eat", it's because they have preferences and are picky, so they hold out for what they like best.  For a few families, it's due to a sensory struggle, or oral motor delays, both of which make it very difficult for the child to mechanically put food in their mouth, chew, move it to the back of the mouth, and swallow.  I'm not yet sure which of the categories we fall into in our family.  I am highly suspicious of just pickiness, but unfortunately for us his strong will and food stand offs also come with the failure to gain weight.  Not to a dangerous level by any means, but he is slow to gain and burns off nearly every calorie he takes in as he's a bit of an energizer bunny. 

But to get to the point.... I've had a surprising number of parents ask me lately if I think he has food allergies and he's avoiding foods because of this.  Unfortunately, our little ones aren't that intuitive.  Newborns will sometimes scream and pull away when offered milk when they have allergies - either to cow's milk or something in mom's diet.  But rarely is this the only symptom in a true allergy.  More often than not, what we consider "allergies" in regards to food is an intolerance.  Now I do not mean to imply that your child's allergy is made up, or that they should ever be given foods that they have been deemed allergic to by a medical provider.  Cow's milk is actually a great example of this.

To keep the explanation simple I will try not to get too into the science jargon.  Cow's milk has very large proteins.  Proteins are hard to digest in general, but the larger they are, the harder the gut works, and this can cause gas, irritation or discomfort, changes in bowel movements, and sometimes traces of mucous in the stool if consumed in high volume.  The proteins in other alternate milk choices are much smaller, such as soy, almond, silk, or goat's milk.  Smaller proteins = easier digestion process = symptoms resolve.  Of course it's easy as a parent to now assume an allergy exists.  But please, if you think your child is allergic to cow's milk (or any food for that matter) advocate for them to be formally tested at either your pediatrician's office (simple blood draw believe it or not), or at a pediatric allergist specialist.  Because here is where the difference lies between an allergy or an intolerance.  An allergic child is at risk for physical damage, and yes sometimes death in severe cases, if they consume or come in contact with the allergen.  This includes all forms of the allergen that may not be known to the average person.  In the example of cow's milk, all labels have to be read intensely to rule out casein, and whey too.  If peanuts were the problem, beyond the peanuts and peanut oil it's important to know if pink peppercorns were used in a restaurant dish, because those are in the same nut family and have been a hidden trigger.  An allergy is serious medical condition and should be treated as such.

Intolerance is common, and should still be treated with respect.  Avoiding foods that your child is intolerant to is important, but should they accidentally become ingested, or if they are given in small quantities, no real harm should come to your child.

Bottom line, if your child is "allergic" to milk, "but can have ice cream" you are also confusing your child.  They need to clearly understand the importance of an allergy too so that they can speak up for themselves in time.  I have had a child in my office tell me they were allergic to chocolate, and I looked up to see the parents giggling behind him and confided in me later that this is how they keep him from eating junk food.  The American College of Asthma, Allergy, and Immunology states that only 5% of kids under the age 5 have a food allergy.  Now how many families do you know who tell you their kids are "allergic" to some foods?  It would be easy for me to say Ben was allergic to foods rather than stubborn, but that's far from the truth.

Allergies change very frequently up through about age 5 years, especially for wheat, cows milk, egg, and soy allergies.  If your child has previously been diagnosed with an allergy, ask if they can be retested at their annual physical.  It is true that it's common for children to grow out of allergies, so even if they have a rough start, have hope!

He prefers his food on the floor rather than in his belly.....sigh.

And the last bit of wisdom....it is ok for your child to be diagnosed and treated for food allergies at your primary care pediatric office.  As a parent, of course you want to see the specialist, but in all honesty you're going to wait a long time, and/or pay more to receive the same information in most cases.  If your child is diagnosed with multiple or high grade (4 or 5 out of 5) a follow up can easily and quickly be arranged at the allergist.  A good provider does communicate with these specialists and a phone consult on our side is often far more effective for all involved.

The scoop on poop

Lets be honest, you had no idea how excited you would be about poop until you became a parent.  Through practicing as a PNP I have known that to be true for a few years, but it wasn't until I became a mom myself, that I finally got to know the level of anxiety or joy that your baby's poop can elicit.  And what's even better (well better might not be the best word here), is that other parents get it.  Which means poop becomes a constant topic of conversation somehow, and at some point or another you realize you forgot to filter your discussion over a meal as other patrons glance your way with unhappy looks.

In starting this blogging venture, I always knew that poop would be featured.  But when I get down to it, there are so many aspects of this that I want to share with you, so consider this to be part one of the poop discussion.  I can't believe I just typed that...

Lets talk newborn and infant poop.  The first week or so you'll see a transition from the thick tarry dark meconium to a green pasty substance, and finally ending up with something that is thin, watery, often seedy, and can be anywhere from pale tan to pea green in color - but most often somewhere in the yellow section of the color wheel.  Or so you're told to expect.  Here's the thing, as long as your baby is pooping on a regular basis, and you are working from something thick towards something thinner (pasty is fine still), and the poop is not black, white, or red - you're baby is very likely fine.  Lots of parents look at pictures in books or on the internet or wherever (I don't want to know to be honest) and come in panicked with a dirty diaper in hand asking about why their baby's poop isn't just right.  But poop is not a goldilocks thing, so if your baby is pooping, you're doing fine.

But what if your baby isn't pooping?  Or is in pain when they poop?  It's natural to assume that they are constipated, and often that they are in pain associated with constipation.  But try not to jump to that conclusion just yet.  Children and adults should poop at least once a day, ideally a few times a day.  Infants don't follow these rules.  The hospital may have told you that your baby needs to have X number of wet diapers and Y number of dirty diapers a day to confirm they are being fed.  That's not how nutrition is measured any longer, and instead we look at weight gain, but the hospitals are slow to change their habits.

Formula fed baby's (and combination breast milk and formula fed baby's) will poop pretty regularly, sometimes multiple times daily and sometimes once every 1-3 days.  Their poop may continue to vary on the spectrum of "normal", or they may develop a very routine looking poop.  The reason for the variation has to do with the constantly developing and changing gut flora, or healthy bacteria that we all need to aid or digestive process.  When you're new, so is your gut flora, and as it develops you will naturally digest differently over time, even if you are only eating the exact same formula day after day.  Formula fed baby's do tend to experience constipation more than breast milk fed baby's, but this even is more rare than most parents think.

In an infant (before solid foods).... constipation is not straining alone.  Constipation is not infrequent pooping.  Constipation is hard, often dried and cracked, small balls of poop.  Think rabbit pellets.  Sometimes they can get backed up enough to have quite large stools instead of the small pellets, and these will definitely be cracked and dry.  This is certainly a reason to ask for an appointment with your healthcare provider.  It is not a reason to switch formulas quite yet.  And it is definitely not a reason to assume that your child is allergic to dairy and switch to soy (soy actually IS constipating by the way).  Do make sure you are mixing your formula correctly with the right water to powder ratio, but do not add extra water beyond the directions for your specific product as this will dilute the nutrients they need to grow and thrive.  Some helpful home remedies to help with constipation (and gas) include warm baths, massaging the belly in a circular motion, and bicycle motions with the baby's legs.  Gas is often confused with constipation (the straining is more often than not gas, rather than poop), so frequent burping and slow flow nipples help to reduce gas build up too.

Breastfed infants can poop ten times a day, or once in ten days. Yes, you read that correctly.  I was personally blessed with a once a week pooper and trust me, it was something to be celebrated, not stressed over.  Ben's longest stretch without pooping was actually 22 days.  Because we were seeing a GI specialist for his jaundice already, I discussed this with them at some length and I was reassured that he was fine because he was gaining weight and peeing like a champion.  Here are the two things to remember about breastmilk: there is very little waste, and it acts as a laxative (if there is solid waste to be produced).  Obviously if an adult didn't poop for 22 days they would be in the hospital, likely for bowel obstruction, but my little man was just fine and we were blessed without many dirty diapers until solids start.  All bets are off once they receive food other than milk.

The above information is hard for a parent to trust and to stomach themselves, and I get that.  By all means I want you to call your medical provider and get the reassurance you need on this - whether through an appointment, a phone consultation, or a weight check with a nurse.  But hopefully hearing this information helps you to accept that your baby doesn't have to poop when you poop.

So there you have it, the first installment of the poop series.

Teething!.....or maybe not....?

I frequently saw patients at work who told me at the 2 month well child check up about how their kiddo is already teething.  Sometimes this would come as excitement (ooh something new!), but most commonly parents seemed very distraught at the idea of having to deal with teething so soon.  And at the 4 month visit, it's one of the topics on everyone's mind.  One thing was for sure though, if a parent decided their child was teething, they were 100% absolutely sure that this was fact.  Attempting to disagree with teething progress hurt my relationship with the families I saw as they felt I didn't trust them or were trying to undermine them.  With time I learned to develop a different approach to addressing early teething and educate about the unlikely reality that teeth would be appearing any time soon because so many other exciting (well not to me, but maybe to you) changes are happening in the mouth first!

Above is my favorite guide to teething that I provide to parents.  By no means do teeth follow rules.  Some babies indeed will pop a tooth at 3 months, while others reach their birthday with gummy smiles still.  And some babies erupt teeth in the oddest of patterns with little regard for symmetry or the "correct" order.  But, this image does help give a concrete visual to parents as they try to observe what is happening in their own baby or toddler's mouth.  

But before the teeth.... drool!  And hands in the mouth!  And fussiness!  Some healthcare providers refer to this as "pre-teething".  I suspect this term was made up to appease the parents who came to appointments informing their provider that their child was teething, when in fact they were not.  At birth, only about half of the saliva glands are active, so while your baby's mouth should be moist or wet, they very rarely are slobbering all over you in the newborn stage (if they are, bring it up to your provider as in rare occasions that can indicate a smaller airway for a variety of reasons, making swallowing difficult).  The other half (ok, it's not really a 50/50 thing here, but for an easy to follow generalization I hope that you're all ok with this basic explanation) are turned on like a light switch around 3 months old.  So boom, drool.  Lots of it.  And with drool comes new sensations, so they put their hands in their mouth.  And then, oh my gosh what is this fantastic toy at the end of my arm that is in my mouth!  Chewing on fingers, putting EVERYTHING in the mouth, and some fussiness starts.  Why fussiness?  Because not all new sensations are pleasant.  

What about the white specks or lines you sort of see in their gums?  Well, when those saliva glands become active the gums naturally thin out a bit and sometimes the ridge of the gum's connective tissue can be seen.  This is a sign to look for to help gauge of the process of teething might be starting, but this is still at the early end of the spectrum.  When the teeth are actually coming, those gums will get very swollen, red, and tender to the touch.  Most kids don't readily open wide for you to take a look, so catch a glimpse when they are laughing, or crying (silver lining?), or better yet stick a clean finger in their and feel around.

When teeth cut through, you may see blood.  For some reason this note doesn't make it into most resources on teething, and a lot of healthcare providers forget to mention it too.  Some kids might spot a bit of blood, others (like mine) may bleed a lot, and still others might never bleed at all.  Often times I didn't know Ben was getting a tooth until we brushed his teeth and we had a bloody toothbrush to show for it.  Gross, I know, but being squeamish and being a parent don't go hand in hand so well, so I'm assuming you can all take that imagery.  

So when your kid starts drooling, you've reached the first step - saliva glands are activated!

When your kid starts sticking hands in the mouth - woohoo, I have hands!  They taste good and feel interesting in my mouth!

When you think the gums look funny and might have white underneath them - the saliva glands aren't blocked (hooray) and less fluid is stored in the mucosa tissue.

When you think the gums look swollen and red - teeth are finally coming!  But they could be here in days or weeks...be patient.

When a tooth cuts through - you may see blood, but your baby has near instant pain relief and life will soon be easier.

The whole process DOES last about 3-4 months from first drool to first tooth in most cases.  I don't care one bit if you refer to the whole process as teething, but if your doctor (hopefully gently) tries to correct you, at least now you know why.

And please, if your baby is in pain from teething, provide them relief!  You're not imagining anything, teething pain is worse at night.  This one has a pretty simple explanation behind it, there are no distractions in the middle of the night, so all of the focus goes to the pain.  I am a big fan of Motrin (over 6 months old) and Tylenol myself, but I know not all parents want to go that route initially.  My professional advice on amber teething necklaces is that there is not enough scientific evidence to support use.  But....my kid wears one, and anecdotal stories from parents are worth something to me too.  He drools less and is happier while he wears it, so placebo or not we stick with it.  Orajel scares me both personally and professionally - please don't use it.  The concept behind the product is to numb the area.  Well how can you guarantee that the saliva doesn't carry this to the back of the throat and numb the throat?  Huge choking hazard, and I have treated little ones who aspirated their own saliva and didn't have a cough reflex causing pneumonia.  Teething tablets...they contain a similar ingredient to the Orajel actually, so I'm not a huge supporter, but they don't seem to have as big of a risk.  My kiddo never took a pacifier, but I have heard from moms that they have had great success with making milk popsicles for their children using an ice cube tray and a pacifier.  Frozen waffles are favorites over here, as well as chewing/sucking on frozen washcloths.  If you have any other remedies for teething pain, please leave them in the comments.  I always ask parents what works for their family, and love to pass off that information to others who are struggling with the more common routes of treatment.  

Happy teething to you all!

Happy and wearing his amber necklace on the day tooth number 12 showed up

BreastMILK Jaundice

Not to be confused with it's common friend breastFED jaundice, breastmilk jaundice is pretty rare and was a source of great frustration during Ben's first 4 months of life.  As a PNP I had heard of breastmilk jaundice, but in truth because this is a diagnosis confirmed by a pediatric GI specialist, as a primary care PNP I had not encountered it in practice.  So when my baby boy started glowing orange (like serious glow worm status) just days after he was born I expected the "normal" round of tests and treatments for a jaundice baby.  He had blood work taken and my colleagues/his doctor reviewed the hospital lab work for both Ben and myself.  We ended up back in the hospital for about 24 hours while Ben screamed his innocent little head off under the UV lights, which brought his glow down to a just-back-from-vacation-at-the-beach status.  But, our follow up the next morning revealed that his levels were quickly climbing back up, which shouldn't happen.  It was very likely at this point that he had breastfeeding jaundice.

Breastfeeding jaundice is a fairly common occurrence, and as a primary care provider we don't panic too much with this one and simply monitor the situation through frequent assessments and lab work.  Typically until levels are declining and a good eating pattern has been established for the baby.  In most cases there is no need to substitute breastmilk with formula as long as the baby is eating more than 8 times a day and dirtying diapers well.  However, in some persistent cases, or levels that continue to creep higher, providing formula for 48-72 hours (pump and save that breastmilk!) will quickly help bilirubin cycle out of the body, and this method can be diagnostic to confirm that breastfeeding was the source of the issue.  In either case, after a few weeks of life the issue should have resolved and levels shouldn't rise significantly once breastfeeding is resumed.

Back to our personal journey....  Beyond the frequent check ups and blood draws, we were referred to a GI specialist (Ben's levels just hovered at a high level that warranted a double check by the liver pros), and we were given the instructions to give only formula for 72 hours.  Sure enough, Ben's levels dropped back down some immediately following that diet change - yay!  And unfortunately, as soon as breastfeeding resumed he jumped right back up to those almost dangerous levels - ugh (even thinking about this now makes me sigh audibly).

This is AFTER treatment at 4 weeks old...his color actually looks quite good here

Everyone's suspicion now pointed at breastmilk jaundice.  While breastfeeding jaundice can be resolved by increased consumption and stooling, breastmilk jaundice actually gets worse because these babies have an increased biliruibin reabsorption from the gut.  There is something in the breastmilk itself - interestingly while numerous theories exist regarding exactly what this is, there is no conclusive answer to the mystery "ingredient" - that keeps the elevated bilirubin circulating in the blood.  The more milk that is consumed, the more stable those levels are.  The good news is that there are virtually zero cases of these elevated levels harming the baby and there is no reason to discontinue breastfeeding.  For us, Ben remained jaundice (or as we like to say, tanned) for 4 months.  We had frequent blood draws and we did have his liver examined with imaging to rule out any other abnormalities, and those moments were hard for us.

Today, at 16 months old he still nurses 3 times a day.  There have actually been a few times here and there where I thought he looked a tinge orange, but his GI doc assured me that while this is possible for the duration of my time nursing him, there is no reason to check his levels unless it is a drastic or prolonged change.  I was so thankful for the supportive team of doctors and nurses we worked with while figuring out the answer to Ben's colorful start.  I suspect many moms quit breastfeeding when a diagnosis of breastmilk jaundice comes about, because frankly it is frightening to hear that your milk is causing something to go wrong within your baby.  But breastmilk continues to be the best nutrition possible (should you be able and interested in providing it!) and I know Ben and I have both benefited from continuing our breastfeeding journey despite this struggle.

Introductions

My name is Christine.  I am a Board Certified Pediatric Nurse Practitioner.  And, I am a mom.  For the first few months of my son's life, I was a working mom.  Now, because of a move to Chicago (for my husband's career) that had taken longer than expected, I unexpectedly became a stay at home mom.  First and foremost, I have to give sincere credit to you stay at home moms.  This job is tough.  My husband, Tom, travels very frequently for his job and that leaves me as the sole caregiver for our baby (and dogs and home) a lot of the time.  To his credit, he is an amazing father and provider for our family and he spends as much time with Ben as possible when he is in town.  We have now finally made it to Chicago and once my state licensure comes through  I know that I will return to the workforce, ideally remaining in the primary care setting and working two to four days per week.  I would love the opportunity to split time between career and family and I know it will take work to perfect that balance.

Many of our friends are in the same stage of life - married for a few years and starting families.  These past two years in particular has been full of babies, and Ben is going to be fortunate to grow up with kids his age when we all get together.  As our kiddos grow older, I've noticed that I'm asked for advice more often than when the babies were newborns.  While everyone overall seems to be happy with their primary healthcare providers, their seems to be a trend of lack of communication between families and their pediatric office staff.  Perhaps this is because the well child check up visits are spaced with greater frequency after the 6 month old mark, or perhaps they observe how crazy busy the providers are in the office and take note of the packed waiting room and don't want to "bother" the providers.  Whatever the reason, I've found people asking my advice with greater frequency lately.  I miss work, so I don't mind this at all (with a friendly reminder that I can't actually diagnose or treat their kids, so they do need to go to their provider too!).  I really enjoy educating others and I like to explain the "why", that often gets left out during a rushed appointment.

So that's where this blog idea came about.  I'd like the opportunity to share a bit of knowledge about the "why's", as well as some of the basics about common well and illness care for little ones.  If you've been told not to give your child cough medicine until they are school age, did anyone take the time to explain why?  If not, I don't feel like it's completely fair to wag a finger at a parent when they're desperate to soothe a miserable child at 3am and give them a dose anyways.  I'm open to questions and comments, and am always interested in learning something new myself.  I plan to tie the content of these posts to my own experiences as a mom as well.  Having a child has certainly opened my eyes and changed my perspective on how to utilize my education and healthcare practice. We are fortunate to have a healthy son, but our journey hasn't been without a few bumps and concerns.

So please, feel free to ask for advice, clarification, or resources to help you on your parenting journey.   I will do my best to provide these tools from a combined professional and personal perspective.  But remember, this information is not to replace your relationship with your own healthcare provider.  My hope is that it will lead you to feel comfortable to pick up the phone and call your child's provider and ask more questions.  We really do welcome phone calls and appointments, no matter how busy the office might seem.