Thursday, April 25, 2013

The Poop series: Chapter #1 Baby poop

updated April 2017

The poop series.

I joke about it, but it is quite true that part of my job seems to involve talking about poop several times a day.  I don't just get to talk about it, many of my email poop questions now come with photos...

Today's post is the first of a four part "poop series"  

Today's topic is 
*Basic baby poop/ the first couple of months

Watch out for future topics which will be: 
*the changing stools once kids start eating,
*Toilet training tips
*General constipation for older kids
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Most folks don't realize when they sign up for this "parenthood" gig that poop is going to be the frequent subject of many conversations. I am not kidding when I tell you that I have poop related phone calls every single day. It helps to know what is normal so that you don't worry.
I remember as if it were yesterday, my husband Sandy's first real experience changing a poop laden diaper. He soon became an expert, but that first one was a disaster. Lauren's little feet managed to get covered in poop, and before he knew it there was poop all over the place, including most of the baby and part of the walls. 
When babies are first born the stools are very dark and tarry. This is called meconium.
The meconium is very sticky and can be a bit challenging to clean. Vaseline, Aquaphor or Cerave ointment can help you gently remove the meconium from your child’s gentle skin.
Once babies start to successfully feed, the stools will gradually transition to a lighter color.
Normal colors range from yellow, orange, green or brown. I rarely pay much attention to color unless it is accompanied by a fussy baby or other symptoms that are telling us that something is off.
Those first bowel movements help signal us that the system is working and that the baby is actually getting milk. We certainly want to encourage breast feeding, but I understand that it is not an option for everyone. If you can make nursing work, there are a lot of benefits. If it feels overwhelming, try to give it at least 2 weeks before you give up. Take advantage of the excellent lactation assistance that is out there.
One of the real challenges for a nursing mom, is that It is harder to track the milk intake for the breast fed babies. It can be hard for new parents to be certain that the baby is successfully nursing. The baby might be hanging out on the breast for hours, but not reliably transferring adequate milk. The not-being-able-to-know-for-sure how much the baby was getting drove me nuts with my firstborn. Listening for swallowing and watching mom's breasts to see that the milk is coming in will give important clues, but when we see those first yellow stools I always want to give mom a big congratulatory hug. Yellow stools are proof that the baby is getting milk. If a baby is fed from a bottle, then of course we can track how much they are eating fairly easily.
Normal breast milk stools are very squirty and yellowish. Some may have little seeds. Think Mustard. (You may want to change your plans for having lunch at the deli today)
It seems that almost every new parent gives me a call to make sure it is okay for the stools to be so runny. Yes it is. Diarrhea would be clear watery stools with only flecks. Baby poop is routinely very liquidy. Remember, they are not eating any solid food, liquid in/liquid out!  Some babies seem to have loud squirty poops every time they eat (or as soon as you have put a fresh diaper on them). As long as it has a color, it is likely fine.
There are many factors that can impact the color. Stools from a formula fed baby tend to be a bit greener than the yellow ones we get from breast milk. Grippe water can also make stools greenish, as can the lack of hind milk. (see the colic post)
If blood is noted in the stool, we certainly want to be notified, but most of the time it is not something I am alarmed about as long as the baby looks good...(Is their color fine? The belly nice and soft? Are they eating well?)
Red blood is usually fresh and comes from near the anus. It can be caused by the gentle skin down there getting irritated.
Darker blood is not as fresh and comes from higher up in the digestive tract. My first question will be about mom's nipples. If they are very sore, it is likely that there was some bleeding and the blood we are seeing in the stool is mom's blood. (I know, yuck.)
If stools are mucousy with some fresh blood it can also be connected to mom’s diet. Often removing dairy completely will alleviate the issue.
Once we see that the baby is gaining weight and having a regular pooping pattern we are no longer concerned about monitoring the frequency.
It is quite common for babies who used to have frequent poops, to suddenly shift to way less frequent stools.
As long as the stools remain soft it is not something that concerns us. Some babies go as infrequently as once a week.
It is also quite normal for babies to grunt, groan and turn bright red as they work on a bowel movement.
It is considered constipation when the actual stool is hard, formed and pellet-like. If that is the case, check in with your doctor's office. This is very unusual for a breastfed baby. I have found some organic formulas to be the culprit.

A pooping baby tends to be a happy baby. If you have one of those infrequent poopers it is hard to watch them struggle.
Massage their tummy. Go on youtube and search out some Infant Massage techniques. A good belly massage can help stimulate peristalsis (which is the movement within the intestines that moves the poop along.)
The tummy may be the most important area, but doing an entire body massage will help them relax. 
Don't forget their little hands! Take your thumb and make firm little circles on their palms. This is a reflexology technique that grandmas have been practicing for generations.
You can also bicycle their legs. Let gravity help them out. Hold them in an upright position and pull their little legs up to a squat position. Nobody poops as easily in a reclining position.
Sometimes a little rectal massage will also help. To do this you can put a dab of KY jelly or Vaseline on a Q-Tip and stick it a tiny bit of the way (just the cotton tip worth) into the butt. In the office when we take a rectal temp, more than half of the time this will make the baby poop right on the thermometer.
The Windi is another gentle way to stimulate pooping and help relieve gas at the same time.
There is no intervention needed for infrequent stools as long as you have a happy baby.
If it has been many days in between poops, your baby seems quite uncomfortable and massage has not helped, our next step will be glycerin. With the glycerin you have 2 options.
Glycerin suppositories are little sticks of glycerin (over the counter in most drugstores.) You break off a piece and stick it into the butt (KY jelly helps.) This stimulates the babies to poop fairly soon.
The other option is a product called Pedialax. These are little bulbs full of liquid glycerin. You pull off the cap and insert the pre-lubricated tip into your baby's butt and squeeze the liquid in. These works really well. The box says that these are for babies 2 and over, but I have found them safe and quite effective for younger folks.
Often just going out and buying glycerin will make your kid poop. It is a useful product to have on hand. Someday within the next couple of years it will come in handy.
Baby poop is a fairly benign substance. This will change.....
Next week’s post will address the changing stools as solids are introduced. )

Thursday, April 18, 2013

Is your child getting enough iron?

  Please see updated post February 2017


If nursing is working well for you, breast milk is of course the perfect food and the iron in it is very well absorbed.
If your baby is on formula it is important that you use one that is iron fortified.

Babies are actually born with maternal iron stores that start to diminish sometime between 4-7 months.

Once the baby is six months or so, I would suggest starting solids and making sure that the baby is getting adequate iron.

Infants from 4-12 months require 11 mg/ day

Toddlers need 7-10 mg

When your child becomes a teenager the iron needs go up along with the rapid growth that is taking place.

Iron is essential for energy, growth and brain activity. Did you know that there is a strong connection between insomnia and anemia? 

If your child is having trouble sleeping, one of the first things I would look at is the diet!
Anemic kids can also have head aches, restless leg syndrome, low energy, and trouble focusing. They may have cold hands and feet and look pale. Children who have low iron levels also tend to put non food items in their mouths more than other kids. Older kids might love chewing on ice.

If you have concerns about anemia at any age, give us a call and we can see if it makes sense to order a CBC.

In our office, most of the doctors will give you a lab slip to get your iron level checked around the 1 year exam. ( I suggest getting a lead level done at the same time)

There are two components in the CBC ( complete blood count) that give us most of our information about your child's iron level
The Hemoglobin is part of the red blood cell that carries oxygen. Your body needs iron in order to have a normal hemoglobin level

The normal range for a young child is 11-16

The Hematocrit is a measure of what percentage of the blood is the Red blood cells
The normal range for a child 6-month-2 years is 33-40%

These ranges can vary from lab to lab and I have seen lots of goofy lab results over the years that have terrified parents needlessly. If we ever get an extreme result of any sort the first action should be to repeat it..


Iron rich foods can be divided into two groups
Heme versus non heme

Heme Iron is much more easily absorbed. Animal sources like meat, poultry,eggs and fish contain Heme Iron.
The dark meat chicken and turkey are higher in iron than the white meat.
The egg yolk is a better source than the egg white.

Non Heme iron can be found in dried fruits, beans, tofu, enriched cereal and dark green leafy veggies.

Cooking in cast iron pans is actually a great way to get some extra iron into the diet.


Iron is a fairly tricky mineral when it comes to absorption. Some foods may actually be high in iron but are also high is something called phytic acid which block absorption.

Iron loves Vitamin C but doesn't absorb well with milk.
Because of this, kids who drink more than 24 ounces of milk once they have hit the one year mark have a higher incidence of anemia.
For you anemic adults out there I hate to pass along that coffee and tea also are a problem with it comes to helping the iron do it's job.


Hopefully you can offer enough food choices that you can get adequate iron from your diet.
If you have a very fussy eater and the lab shows that the iron level is low, you may need a supplement.

Unfortunately, Iron supplements can cause constipation and the drops can cause some tooth discoloration ( so brush those teeth)

Some of the supplements that come in a yummy chewable or gummy form are easy to take, but MUST be kept in a child proof area. Too much iron ( if you little one gets a hold of them) can be very toxic.

One of my favorite brands is Floradix for kids. Read the label, but for most toddlers the dose is 1 teaspoon/ day.


Some common iron rich foods

Chicken liver 3 oz                                      11.0mg
Lentils 1 cup cooked                                   2 ½ mg
Ground beef 3 oz                                        5 ½ mg
Tofu ¼ cup                                                 3 ½ mg
Beans ½ cup cooked                                  2 mg
Spinach ½ cup cooked                                2 ½ mg
Potato with skin, white, baked ½ medium     2 ½ mg
Prune juice ½ cup                                        1 ½ mg
Broccoli ½ cup                                             ½ mg
Enriched baby cereal ¾ cup                           4-18 mg
Tortilla 1 average                                           1 mg
Molasses 1 Tablespoon                                  0.9 mg
Raisins     ½ cup                                             1.6 mg

Other things good options are nuts, and seaweed snacks. Become a good label reader!

When your little one eats their iron rich foods give them positive reinforcement, feel their muscles and tell them that all that healthy food is helping them grow big and strong.

Monday, April 8, 2013

Lead

PLEASE SEE UPDATED POST 3/2016


Ideally our children will have no lead in their systems. Unfortunately many of us live in environments where our kids are in fact getting exposed.

Between the ages of 9-15 months, many doctors will suggest a routine blood test. Most often we will order a CBC ( complete blood count) which will check their iron level and a lead level.
Typically the lowest report that we get from most labs will be < 3. It is rarely reported as an actual 0.
Anything over 3 means that there is some measurable lead exposure.
No result over 5 should be ignored.
A level higher than 10 is cause for concern.
A level higher than 45 needs urgent medical attention.

As of this year 2013:
If your child in San Francisco has any measurable lead level the city will send out a public health nurse to help you explore your environment and see if they can figure out the source.

Common Sources can include:

*paint chips. (House built before 1978 are most at risk)
*lead pipes (run the cold water for a minute or so before drinking) 
...Use the initial water for watering plants or something

*keys ( don't let your child chew on them)

*Brightly painted pottery or toys ( beware of things imported from different countries The brighter the color, the more apt they are to have lead)

*Antique furniture varnish

*Some lipstick brands

*Some candies imported from other countries

*some computer cables ( of course chewing on cables is not a good idea no matter what)

*Dirt and sand that get tracked in from outdoors


Most of the lead gets into your child from the hand to mouth route. They either chew on something directly, or put hands that have been in contact with lead dust into their mouths.

Prevention is the best defense!
Do the best you can to make sure there are no obvious lead sources inside your home.
Consider having a 'shoes off' policy to avoid tracking lead dust inside.
Make sure your kids get in the habit of frequent hand washing, especially before meals and snacks

A nutritious diet is VERY important. Iron, calcium and Vitamin C compete with lead for absorption.

If you have any concerns about your home, regardless of whether or not your child has been tested, call the SF lead program to arrange a public health nurse visit.

The SF department of Public health lead prevention program phone number is 415-252-3888
The public health nurse is Margarita Herrera 415-252-3897

Below is a link to information regarding lead for Pregnant women



Friday, April 5, 2013

Dealing with Colic

Please see updated post on this topic October 2015

I think the most common calls I get are about fussy, gassy babies. ( although I sure do talk about poop a lot, perhaps it's a tie). Often these colicky kids have wretched periods during the late afternoon and early evening when it seems to be especially hard to settle them ( I refer to this as the witching hours)

With most of my patients this usually seems to improve at least a little once you hit the 3 month mark ( keep your fingers crossed)
If one of those gassy babies is yours and you are breast feeding, the first thing I will ask is about your diet. I know that not everyone agrees that there is a connection, but in my case I swear to you that if I even looked at cabbage my kids cried for a week.
The biggest culprits in my opinion are:
coffee
caffeine ( in tea and chocolate among other things)
dairy
gassy foods (like cabbage, onions, broccoli)
spicy foods

What I suggest you do is see if you can establish a connection between an extra fussy day and something that you recently ate.
Hey look, I have some moms that know perfectly well that coffee is a problem but drink it anyway because they can't face the day without it.

As always, it is a balance. It is worth finding out if there is a connection between your diet and your babies gassiness but then make whatever choice works best for you.
The other thing that breast feeding moms should pay attention to is hind-milk. The milk that the babies get as they empty a breast is helpful with digestion. Sometimes greenish stools ( not necessarily something that I worry about) and increased gas issues are because they are switching breasts too soon and never getting to the hind-milk.

If you haven't found any magic cures from a diet elimination, it is perfectly find to experiment with some different colic remedies
*Simethicone is the ingredient found in most of the OTC gas drops that you can get at a drug store. Some of the name brands are Mylicon or Little Tummies. Simethicone drops are very safe and helpful in about 70% of my patients. They are certainly worth a try.

*Homeopathic colic remedies come in a few products. I am most familiar with Coccyntal drops

http://www.boironusa.com/products/cocyntal/(made by the Boiron company) and colic tablets by Hylands
These seem to help about 60 % of the time. I consider them fairly harmless if used properly. They too are worth having in your arsenal.
*Grippe Water is an herbal remedy that can be found in many health food stores or Whole foods. I find this helps about half of the time. Stools might get a touch green with this (not to worry)

*Brew some chamomile tea, add a few grains of sugar and give a dropperful or two to your baby. This also helps about half of the time.
(You may have a couple of months of colic ahead of you, you will have plenty of time to try all of these)

*Don't forget about massage! Go on line and check out baby massage techniques on You-tube.
( there is a book called itsy bitsy yoga that gives you some yoga poses for your baby that might help with colic)
 

*Get up and dance. Hold your baby over your shoulder with their knees tucked up in fetal position. Give firm pats on the back. Sway, bounce and sing. ( I teach the "shuffle" at my baby boot camp class)

I read a study some where years ago that postulated that kids with lots of colic symptoms ended up with higher IQ's
Hold that thought....
As with everything, this stage will pass. Enjoy the calm moments.

~Nurse Judy