Friday, July 19, 2013

How loud is too loud?

Please see the updated post July 2017

Mammals are born with lots of very tiny and delicate hair cells in their inner ears. These cells help to amplify sound.
Exposure to loud noises over our life time damages these cells. ( the high frequencies are the first to go) 
Your baby's ears are more sensitive than those of an adult. Not only do they have thinner skulls, but they also have a full complement of these little hair cells, so sounds will have full amplification. 

Your baby's hearing actually starts to develop between 24-28 weeks of gestational age. It is thought that the noises they hear are slightly muffled (imagine what it feels like when you are under an inch or so of water)
They can certainly hear well enough that they seem to recognize the voices of those who have been talking to them while they were in utero

So yes, we need to make sure that we protect our baby's hearing, but the fact is that all of us need to pay attention to loud noises that can lead to hearing loss.

We pay attention to two different factors

The frequency is measured on the Hertz scale.
The lower tones are the lowest numbers
People with the sharpest hearing may be able to hear frequencies ranging from sounds with tones as low as 20 hertz and as high as 20,000 Hertz
A sound higher that 20,000 is known as ultrasonic
Some animals, dogs for instance, can hear much higher frequencies than humans
Human speech tends to fall between 1000-5000

Because as we get older many of us lose the ability to hear the higher frequencies, some brilliant marketers have taken advantage of this. 
There are now actually ring tones out there for teens only.  Most adults over the age of 20 have no idea when they ring. 

The second aspect of sound that is relevant is the loudness
Sounds are measured in units called decibels.

To give you an idea of how loud various sounds are, take a look at the following list
30    Whisper
            60 normal conversation
      80 Telephone dial tone
      85 traffic noises from inside a car
      90 Bart train ( average...actual sounds range from 73-99) 
      107 power mower
     110 stereo headset
     125 sand blasting or rock concert
     140 gun shot

The longer the exposure to loud noises the more damage that can be done
OSHA has guidelines set for safe exposure on the job.
 85    for 8 hours
       88 for 4 hours
       91 for 2 hours
       94  for 1 hour
       97  for  30 minutes
      100  for 15 minutes
      103  for 7.5 minutes

For those of you who recognize a pattern, good for you
for every 3 decibels over 85, the safe exposure time gets cut in half


Okay, so what do we do with the above information?  
Make sensible choices.
Make sure that all headphones that your kids use are turned down to a reasonable level.
Avoid environments where your child will be subjected to PROLONGED long noises.
That BART platform is probably not going to cause any trouble unless you spend a lot of time down there.
If you know in advance that you will be in a super noisy place, consider some of the new baby friendly headphones that will cut about 20 decibels.
( Ear plugs are a little problematic, because they are a choking hazard and it may be hard to see if your baby pulls them out)

I have actually had parents call me to ask if it is okay to take their baby to a rock concert.

My "NO" possibly reached 100 decibels.


Have your child's hearing tested on a regular basis once they are over the age of  3 or 4 (sooner if you have concern)
You may not know this but most babies in this country are given a hearing test before they leave the hospital after birth.  

When we do a routine hearing test in our office a child who can hear a 25 decibel sound  in frequencies from 500-4000 will pass.

Any in-office hearing test has the risk of being inaccurate, especially for patients under the age of 4.
I will often have a patient who flagrantly failed the test but when I tell them I have a secret question, stand behind them and whisper, " would you like a sticker?" They answer, "yes please".
If you are concerned about your kids' hearing (and remember there is a great big difference between hearing and listening),
play a whispering game with them and see how they do.  
If there is a concern about your child's ability to hear the next step will be a visit to an audiologist for a much more accurate exam as well as a visit to the ENT specialist.

Friday, July 12, 2013

Vitamin D/ Is your child getting enough?

 Please see the updated version of this post September 2015

The American Academy of Pediatrics recommends that all breast fed babies start getting 400 iu of a Vitamin D supplement within the first few weeks of life. They should continue to get supplemented until they are assured of getting adequate amounts from other dietary sources.
Children over the age of one and all adults, should make sure they are getting at least 600 iu daily.  
( iu stands for international units, which is a common way that Vitamin D is measured)

Occasionally, some of our families find out about this and are surprised that it wasn't brought up at one of their well child exams. Frankly, in our office we sometimes simply forget to discuss it.

Here's the scoop about Vitamin D.

Years ago, Vitamin D deficiency was most associated with Ricketts (a disease that causes very soft bones) More and more recent studies are finding that Vitamin D levels are also very important well beyond good bone health . Deficiencies are linked to multiple illnesses including diabetes, cancer prevention, heart disease and even mood disorders. There are also current studies going on to see if there is a link between low Vitamin D levels and increased allergies. 

At the same time that scientists were stressing the importance of this vitamin, they were also discovering that many folks are surprisingly quite Vitamin D deficient without being aware of it. The segment of the population who test the lowest for Vitamin D are the pregnant and  breast feeding women.  

Supplements added to milk and orange juice, some fatty fish and cod liver oil  are the main dietary sources of Vitamin D but the fact is that historically much of our vitamin D is/ was from sun exposure.
Folks with paler skin or those who live in sunny climates generally have higher levels.
Being out in the sun, unprotected for 30 minutes 2 or 3 times a week will give most people the amount they need.
But wait!! Do we really want to expose ourselves and our children to the risks associated with sunburn?
It is hard to find the right balance here.

In fact, our recent healthier sun screen practices are quite likely the cause of our lower Vitamin D levels.

Quality infant formulas do have vitamin D in them.
Babies who get 1000 ml of formula per day have their needs covered. ( there are 30 ml in an ounce, so this is about 32 ounces)

But what about the majority of our babies who are partially or completely breast fed? Instinctively it is hard for me to wrap my brain around the concept that breast milk is not a "complete source" for all of your baby's needs.
It comes down to the mom.
If a mom doesn't have adequate Vitamin D herself, her breast milk will be deficient in this one regard.
On the other hand, if mom is taking her prenatal vitamins and is quite certain that her vitamin D level is fine ( The only real way to tell is with a blood test) then I think the baby's level is most likely fine without a supplement. 

If you do end up giving your baby Vitamin D supplements, one of the most common brands is the 
Enfamil D-Vi-SOL that gives the daily dose 400iu/ dropperful.

Babies seem to tolerate this well.
There are some other forms out there that give 400iu/ in each drop. That is quite a difference.
It is very important that you pay attention to the form that you are giving.

If you are giving your baby a multi vitamin supplement like Poly-Vi-Sol, that already has the D in it. Be a label reader!
 Vitamin D is one of the fat soluble vitamins. You cannot get "too much" from sun or diet. But, as with any supplement, too much can cause some toxicity. 
Most studies suggest that the upper limit for safe supplementation  is 1000 iu/ day for babies or 2,000 iu for adults. ( I know that there are some folks advocating taking much higher doses, but I am not familiar with any real science to back of those claims) 

I do believe that the sweeping suggestion that all babies get vitamin D is meant to protect the smaller percentage that actually needs it.
If you are one of the many folks out there who has a low level, it is very important that your baby get the Vitamin D that they need. ( and yourself as well!!!!) 
Even if your level is fine, giving your baby a daily vitamin D supplement is certainly harmless if giving the proper dose.
If you choose to skip the Vitamin D recommendation, consider getting a blood test to see what your level is. It is worth knowing for your health as well.

Friday, July 5, 2013

Crib safety

Crib safety

The phone call starts like this.

" Our baby can sometimes turn onto his/her tummy during the night and can't turn back over, what should we do?"

For generations, babies were put into their cribs on their tummies. Grandmothers are a wise bunch. They knew that babies do tend to sleep more deeply when they are on their bellies.

Ah, but now the experts say that it is actually safer for babies to be having lighter sleep for the first couple of months.

The "Back to sleep" movement began in 1992.

The claim is that the incidence of SIDS has decreased 50% since babies have been going to sleep on their backs (or on their sides as a second choice).

The statistics are compelling so even though we are seeing  more flat heads than we used to, we accept the recommendation that putting your child to sleep on their back is the correct action.

Because the sleep isn't quite as deep, if they have a need that needs to be met, they can more easily wake up and let you know about it.

Also, for very young babies who have poor head control, having them on their back is the safest position so that they don't get their little face planted into a soft mattress.

Okay, but now the baby is rolling over!

It is NOT reasonable for you to stay up all night and watch them, or even wake up every couple of hours to check on them or turn them.

My best suggestions are:

Make sure your crib is as safe as can be

(scroll down to see some consumer reports pointers on crib safety)

Do plenty of tummy time during the day. Make it fun and pleasant. Your baby will be able to work on their head control as well as other motor skills. Soon they will master rolling in both directions.

By the time they are in control of their bodies and able to roll at will, they will get themselves in whatever position they choose, regardless of how you put them in the crib.

Do try to switch the positions as much as you can to avoid having them lay on the same exact spot. It is okay to put them on their sides and switch up the direction.

Here is a tip to help you with positioning. Make an inexpensive and safe positioner by filling a men's large tube sock full of rice. Seal it up and then put the other sock on there in the other direction.

Tuck this in front of your baby so that if they end up flopping over it will be onto their back, not their tummy. You can use more than one. Place these below the nipple line, not up near the face.


 Below are some guidelines from consumer reports on how to make sure your crib is as safe as it can be.


If possible, avoid buying or accepting a used crib. Older models might not meet current safety standards or might be in disrepair. By law, the production date of a crib must be displayed on it and on its shipping carton.

A crib is one baby item you definitely want to buy new. That's the only way to be sure you'll get one that meets the latest safety standards. We recommend you purchase a JPMA-certified, full-sized crib with stationary sides. This guide will help you find the perfect one so the whole family can rest easy.

Basic is best


The safest cribs have simple lines and no scroll-work or finials. Infants can strangle if their clothing gets caught in such detail work. Following this advice will get you a safer crib and save you money. Consumer Product Safety Commission regulations for full-sized and portable cribs as of 2011 required the elimination of drop-side models, which have been connected to at least 32 deaths during a few years prior. (Drop-side cribs let parents raise and lower one side to get the baby out. They are no longer considered safe.) The standards also include rigorous new durability testing and require improved warnings and labeling. Consumer Reports' tests, which are based on the new mandatory safety standards, address such issues as mattress support, slat strength, and structural integrity.


Even when you're buying a new one, be on the lookout for safety hazards. Bring a ruler with you when you shop to check the spaces between the slats and other places on the crib. If they're greater than 2 3/8 inches wide, they're too far apart. If you buy a crib online, measure any openings immediately when it arrives at your home.

Check for sharp edges and protruding screws, nuts, corner posts, decorative knobs, and other pieces that could catch your baby's clothing at the neck. Buying a new crib could protect your baby from such hidden dangers as drop sides, slats, or hardware that might have been weakened by rough use, as well as loose hardware or glue joints caused by changes in humidity during storage.

Check construction and workmanship


One or more stabilizer bars--metal rods fastened to both end boards beneath the crib--can help to make the frame more rigid. The simplest in-store test is to shake the crib slightly to see if the frame seems loose. But be aware that display models aren't always tightly assembled. Without applying excessive pressure, try rotating each slat to see if it's well secured to the railings. You shouldn't find loose slats or spindles on a new crib, or any cracking if they're made of wood.

Buy the mattress at the same time


Pair the mattress and crib you plan to buy to make sure they're a good fit. (Mattresses are typically sold separately.) By law, a mattress used in a full-sized crib must be at least 27 1/4 inches wide by 51 5/8 inches long and no more than 6 inches thick. Still, do a quick check. If you can place more than two fingers between the mattress and the crib frame, the fit isn't snug enough.

Make sure to check all the hardware carefully when your crib is assembled, and periodically tighten or replace anything that's missing or loose. Missing and loose parts are a leading cause of accidents and death, because they can create gaps where a baby can wedge his head and neck and suffocate or strangle. Tighten all nuts, bolts, and screws. Check mattress support attachments regularly to make sure none of them are bent or broken. If you move a crib, double-check that all support hangers (which hold the mattress up) are secure.

Use the proper sheets


When buying a mattress, make sure you also buy crib sheets designed to fit tightly. If a sheet isn't the correct fit, your baby might pull it up and become entangled. Hand-me-down sheets can be great, but make sure the elastic at the corners is still strong. Test the sheet, whether new or used, by pulling up on each corner to make sure it doesn't pop off the mattress corner. Blankets, quilts, and pillows also pose a suffocation hazard and should not be used in the crib. Instead keep your baby comfortably warm and safe in a swaddle wrap or blanket sleeper. Resist the urge to put those adorable stuffed animals in the crib for the same reason.



Cribs are shipped unassembled, so if you're not sure you can put one together correctly (it's usually a two-person job that requires up to an hour from unpacking to complete assembly), ask a handy friend or relative for help or see if the retailer can send people to assemble it in your home. The latter can cost an extra $70 or more, but it can give you peace of mind. Besides saving tempers and fingers, having people sent by the store to set up your crib allows you to inspect it on the spot and reject it if you discover flaws.

Adjust the mattress to the right height


Most cribs let you adjust the mattress height; some have three levels, some have more. The higher levels make it easier to take your infant out of the crib, but they're dangerous when your child is able to pull herself to a standing position. Before your child reaches that stage--about 6 months--the mattress should be at its lowest setting. Bumper pads and large toys can help your little escape artist climb out, which is another reason they don't belong in the crib.

Place your baby's crib away from windows, window blinds, wall hangings, curtains, toys, and furniture so that they can't get to anything dangerous. Make sure any baby monitors (and cords) are also out of reach.



Crib bumpers are fairly controversial. The question comes up at many of my safety classes. I have done a lot of searching on the topic and can't find a definitive answer.

I would try to do without them, but there are some babies who are constantly whapping their heads against the rails that might benefit from a set. On the other hand, if you have a climber that is going to use them to help climb out of the crib, they are more hazard than help.

If you do choose to get bumpers, make sure they are the breathable mesh kind.


Another option that wasn't around when my kids were little are the high tech motion sensors and video monitors that have been coming onto the market lately.

With any monitor, expect some false alarms and growing pains until you get comfortable with it. Read all directions. A monitor that is not used properly is useless and can offer false reassurance.

Sweet dreams.