Pediatric Manual
owners manual
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Table of Contents
About our office 7
Office locations 8
Office hours 8
Routine scheduling 8
Sick visits 9
Emergency/After hours 10
Fees, billing, insurance 10
Immunization fees 12
Well Days (Normal Newborn Care)
Philosophy of modern pediatrics 15
Normal newborn care 17
First Day Home 17
What is Normal? 17
Newborn Rashes 20
Jaundice 21
Stools 21
Sleep 22
Some Things You’ll Need for a New Baby 20
Thermometer 23
Medicine spoon/dropper 23
Infant aceteminophen drops 23
Car seat 23
Poison control number 24
Plug-in outlet adapters 24
Diapers 24
Patience and a sense of humor 24
Feeding your baby 25
Breastfeeding 25
Formula feeding 34
Beginning solid foods 36
Frequently asked questions by new parents 39
Clothing 39
Crib 39
Room temperature 39
Skin and hair care 39
Cradle cap 40
Circumcision 40
Colic 41
Dental care 42
Diaper rash 43
Hernias 44
Immunizations 44
Pacifiers 49
Spitting up 49
Sun exposure 50
Teething 50
Thrush 50
Travel 51
Travel vaccines 51
Sick Days
Common infant & childhood ailments 55
Fever 55
Dosage Charts 57
Diarrhea 59
Vomiting 62
Food poisoning 63
Constipation 63
Common Colds 64
Cold Sores 65
Cough 65
Ear Pain 67
Sore Throat 68
Conjunctivitis (“Pink Eye”) 68
Chickenpox 69
Lice 70
Poisoning 71
Minor Accidents 72
Cuts & Scratches 72
Abrasions & Scrapes 72
Puncture Wounds 72
Animal Bites 73
Human Bites 73
Nosebleeds 73
Head Injury 74
Burns 74
Choking 75
Accident Prevention 77
Car Seats 78
Riley Hospital for Children Safety Store 80
Epilogue & Index
Epilogue 83
Recommended Reading 84
Useful Web Sites 84
Index 87
About our office
Southern Indiana Pediatrics, an Indiana University Health Southern Indiana
Physicians practice, was formed in 1995 when Drs. Laughlin, McDaniel,
and Malone joined forces to erect a new office building and recruit more
pediatricians for the growing population in this area. Since that time we have
expanded our practice with both additional providers and locations in both
Bloomington and Bedford. In 2011, we joined IU Health Southern Indiana
Physicians to further strengthen our ties with our local hospital and the IU
Health system, including Riley Hospital for Children.
Each pediatrician normally sees his or her own patients to provide continuity
of care. However, when one of us is out of town there is always another
pediatrician in the same building with access to patient records to easily
assume any patient’s care when needed. We feel this provides the “best of
both worlds” for our patients. We also have pediatric nurse practitioners who
can see patients and provide care. All of our physicians and pediatric nurse
practitioners are board certified by their respective credentialing boards.
Office locations
Bloomington - West
350 S. Landmark Ave.
Bloomington, IN 47403
4935 W. Arlington Rd.
Bloomington, IN 47404
Bloomington - East
651 S. Clarizz Blvd.
Bloomington, IN 47401
1614 25th St.
Bedford, IN 47421
Regular office hours
Monday – Friday, 8 am – 5 pm
Monday – Friday, 8 am – 7 pm
Monday – Friday, 8 am – 5 pm
Appointments may be scheduled during these times. These are also the best
times to call with routine questions, medication refills, etc.
(See page 10 for Urgent Care Clinic and for Emergencies and After Hours care)
Routine scheduling
We always let you know at the end of each well child visit when your child will
be due back for the next check-up and attempt to schedule the appointment
for you. The American Academy of Pediatrics recommends the following
schedule of routine well child physical exams:
■■ Birth
■■ Within First Two (2) Weeks
■■ Two (2) Months
■■ Four (4) Months
■■ Six (6) Months
■■ Nine (9) Months
■■ Twelve (12) Months
■■ Fifteen-Eighteen (15-18) Months
■■ 2-18 years of age – Yearly exams
If your child has a medical condition, which requires more frequent visits, such
as asthma, diabetes, ADHD or other chronic conditions, the above schedule
will be adjusted accordingly. Starting in middle school, athletes are required
to have yearly exams to maintain eligibility. If your child is current with his/her
yearly well child exams, forms for sports participation, daycares, camps, etc.
can usually be completed without a separate examination. Please remember it
is your responsibility to keep your child current with his/her physical exams and
On occasion, certain problems arise that can’t be resolved during a “routine”
visit. Extended visits may be scheduled to more effectively take care of these
Our primary goal is to work WITH you to provide for the optimum health and
development of your child. Please communicate any concerns you may have so
we can achieve that goal together.
Sick visits
If your child is ill and needs to be seen, please call us after 8 am. We will
always see you that same day, if necessary.
If you are uncomfortable with treatment suggestions we make over the phone
and would like an appointment for your child instead, just let us know and we
will work you in. If your child has been seen for an illness and isn’t responding
as he/she should to treatment, please let us know. The only way of knowing a
complication may be arising is for us to communicate with one another.
If your child attends a daycare or babysitter’s, it is important that these
providers communicate with you if your child is sick so you may make
arrangements to have him/her seen during office hours. (Please note: we do
offer after hours appointments 365 days a year in our “Urgent Care Clinic”
located at 350 S. Landmark Avenue in Bloomington.)
In case of emergency/After-hours care
We do provide an after-hours “Urgent Care Clinic” that is open 365 days a year
for problems that can’t wait until the next day. The Urgent Care Clinic is located
at the Bloomington office at 350 S. Landmark Avenue. Urgent care is by
appointment only. To make an appointment, please call us at 812.335.2434.
Saturday and Sunday afternoon appointments are available for urgent care in
our Bedford office. To make an urgent care appointment in Bedford, please
call 812.277.0118.
We feel our Urgent Care Clinic offers a more cost effective and less threatening
alternative to the use of hospital emergency rooms or acute care centers not
dealing exclusively with children.
Note: There is an additional after-hours charge for services provided through
the Urgent Care Clinic. This charge may or may not be covered by your
insurance plan and is your financial responsibility.
We feel we provide extensive availability to care for your child by having
our office open for your healthcare needs throughout the day and evening
seven days a week, 365 days a year. Calls after hours should be reserved for
emergencies only. If you need to call after hours, please call the office and you
will be referred to our pediatric registered nurse call service. These nurses will
assist you in arranging for the emergency care you need, or in providing advice
to help you with your problem. Please use this service for emergencies and
acute problems you do not feel can wait until the office is open. Please do not
use this service for routine questions, prescription refills, medication changes,
formula changes, appointment scheduling, or to settle arguments with spouses
or relatives.
Fees, billing, insurance
Please feel free to ask the receptionist about any fees before or after your visit.
These fees include physician services and occasionally laboratory services
or immunization fees. We recognize the high cost of medical care and make
every effort to keep your medical costs down. For this reason, we request that
you pay for medical services at the time of your visit. This will help cut down
markedly on billing costs so these savings may be ultimately passed on to you.
We do recognize that unexpected medical expenses are not always budgeted.
If necessary, a monthly payment program may be arranged. Also, we do accept
MasterCard, Visa, Discover and American Express as a courtesy to our patients.
We have agreements with some insurance carriers and will bill them directly
for services provided in our office and at the hospital. If your insurance requires
a co-payment for each office visit, we ask that you pay this at the time of
your visit. For those insurance carriers for which we do not have provider
agreements, it is your responsibility to pay for our services provided at the time
of your visit and submit your claim for reimbursement. We will provide you with
a “superbill” at each office visit. This bill can be attached to your own insurance
form so claims can be filed with minimal difficulty.
If your insurance has not responded to claims within 60 days, the balance
becomes your responsibility. We are more than willing to work with families to
set up payment plans. Please call our direct billing line at 812.335.2436.
We have in the past, unfortunately, encountered numerous problems in being
reimbursed for services in cases of children whose parents are divorced.
Because of this, we ask that the parent bringing the child in to the office
be responsible for payment that day, then collect reimbursement from the
appropriate party if indicated in the same way patients with insurance do. We
realize this can be a difficult situation and we appreciate your cooperation in
this matter.
Feel free to call the office with any questions about routine illnesses, office
policies, etc. We are happy to help you in any way possible!
Immunization fees
We recognize that immunizations are quite costly. While we prefer to follow
your child for well care and medical problems, if your insurance does not cover
the cost of immunizations and you prefer to receive these at the well baby
clinic, we can provide you with a prescription listing which vaccines your child
is due to receive at the end of the check-up appointment. You then simply take
the prescription to the clinic and the immunizations may be given there. The
Well Baby clinic is able to provide this service through their participation in an
immunization program funded by the state.
Well days
Normal newborn care
Philosophy of Modern
The role of the pediatrician is not only to see your child for acute illnesses but
to also provide comprehensive well child care. During the first two years of life,
your child will be seen frequently. Growth and development will be followed
closely and immunizations will be given. A TB test may be given to check for
exposure to tuberculosis and your child will be checked for anemia or lead
exposure. In the first two years we will also discuss proper nutrition and help
you with other problems such as discipline or sleep problems, etc. so that you
and your child can build a solid and healthy foundation for future growth and
Older children should have yearly checkups. During these visits, a physical
examination will be done to catch any potential problems early in order to treat
them early. Also, any problems with bedwetting, school or learning problems,
nutrition, etc., will be discussed. Check-ups are scheduled every two to three
months during the first two years of life, yearly until school age and then every
one to two years unless needed more often for sports participation.
Normal newborn care
Let us examine the new baby, head to toe, so that we can become familiar
with activities and features that make your child unique, normal, and the most
beautiful baby on earth! Please note that not much of your “friendly” advice will
come from our office. It will come from grandparents, relatives, friends and the
person behind you in the checkout line at the grocery. Please use this office as
your “objective” guide to baby care.
First day home
It is amazing how most babies instantly transform from being beautiful, quiet,
perfect infants in the hospital to demanding and crying babies the second they
arrive home. It is true, however, that babies become more alert and hungrier
24-48 hours after birth. The first few days are a major adjustment for baby and
parent alike. This can be a difficult time, but it is also a time to finally settle
down and start to get acquainted with one another. You will find your baby
loves to be handled. Babies are comforted by gentle, firm handling and prefer
to be wrapped snugly in a light blanket and cuddled.
What is normal?
Let’s face it. Babies are STRANGE. They burp, sneeze, spit up, pass gas,
make faces, grunt and cross their eyes on a daily basis. All these things are
NORMAL for them. They can turn red in the face and make horrible sounds
in the process of having a perfectly loose stool and this won’t mean they are
Your baby’s head may have undergone some “molding” during the birth
process. It may look a little lopsided and have some bruising. The skull bones
may also overlap slightly. This is all normal and gradually goes away in a few
days. All babies have “soft spots” where the skull bones come together. The
biggest one is on top of the head in the front. This area may even pulsate,
which is normal. It is not a tender area and may be washed thoroughly.
Your baby’s eyes may have some swelling or discharge in the first day or two
after birth due to irritation from the antibiotic ointment placed in the eyes at
birth to prevent infection. Any discharge should be rinsed away with water
and a clean washcloth. If the discharge doesn’t clear within a few days, call
the office during office hours. Many babies have tear ducts that don’t function
well in the first few months of life. These babies collect mucus in their eyes
until the tear ducts start to drain. This is NOT an infection. Treatment involves
keeping the eyes rinsed with warm water and massaging the tear ducts. This
technique can be demonstrated in the office. Contact our office during regular
hours if your infant has persistent eye drainage. We usually treat this problem
conservatively and most of the time the drainage resolves by six months of
After the first few days, your baby will begin to open his eyes more and look
around. Babies can’t focus well or follow moving objects at birth. However, they
can see short distances and like bright colors. Over the first two months, they
begin to focus better and begin to track moving objects. They may occasionally
look cross-eyed and this is not a cause for concern unless it persists longer
than four months.
Your baby’s nose may become congested with mucus, particularly in the first
few weeks after birth. Use a bulb syringe to clear this. If the congestion isn’t
relieved with your baby spontaneously sneezing or use of the bulb syringe, you
may use saline nose drops. These can be purchased over-the-counter at any
pharmacy (Ocean Spray, Ayr, etc.) or you can make up your own by mixing 1/4
teaspoon of table salt in four ounces of tap water. Use two to three drops in one
nostril, then suction after a few minutes for best results. Repeat on the other
side. If the stuffiness doesn’t interfere with your child’s breathing or feeding,
try not to let it bother you. Some babies sound more stuffy than others. Simply
propping up your baby in an infant seat may help. Persistent congestion is
often related to exposure to cigarette smoke or wood heat.
Many babies have nipples that appear raised and swollen. They may even have
a milky discharge. This is due to hormonal changes and will normally subside
in three to four months. Don’t squeeze or rub medication on the nipples as it
will only irritate them.
The genitals of both boys and girls may be swollen at birth. Girls commonly
have a white discharge with some blood streaks from the vagina for up to one
or two weeks after delivery. Boys often have a swollen scrotum, which usually
contains fluid (a hydrocele); this normally resolves on its own during the first
few months of life. However, if the swelling comes and goes or worsens, it may
indicate a hernia. Call the office if this occurs.
Most babies have bowed legs or feet after birth. This is not a cause for alarm
and almost never requires treatment. It is usually due to how they were
“packaged” while in the womb and straightens out in due time. If you are able
to passively move your baby’s legs or feet into a neutral position, they will get
there on their own eventually.
Your baby’s umbilical cord will drop off at some point during the first two to
three weeks of life. It is normal for there to be a few drops of blood when this
happens and there may be some drainage intermittently for several days.
Clean the area with alcohol or hydrogen peroxide when you notice blood or
discharge. If the area develops red streaks on the skin or a foul odor, call the
office. If your baby appears to have an “outie” or protruding umbilicus after
the cord is off, no special treatment is needed. (See section on “Umbilical
Sudden movements, bumps and noises produce startle reflexes (jerky
movements, throwing arms and legs out wildly). Babies also jerk or twitch
for no apparent reason, even while asleep. Gentle, firm handling and calm,
reassuring voices are easily sensed by your baby. As your comfort and
confidence levels increase day by day, your baby will also be more calm and
will overreact less often.
Newborn babies often have a rather irregular breathing pattern while sleeping.
You will notice breathing may vary over 10 to 20 seconds from being very
shallow and quiet, increasing in intensity to being deep and strong. This is
called periodic breathing. Babies also appear to “sigh” and “catch their breath.”
They occasionally sound “rattly,” especially during or after feedings. This is due
to secretions above their airway and the babies will not act bothered by this. It
will only bother us parents, as we would like to have them “clear their throats,”
but they don’t! This is normal.
Newborn rashes
1. Stork bites - Flat, pink birthmarks may be present at the bridge of your
baby’s nose, eyelids or the back of the neck. About half of all newborn
babies have some form of these. You may notice the spots becoming
more pronounced when the baby is crying and fainter when the baby is
quiet. The spots on your baby’s eyelids (sometimes called “angel’s kisses”)
will usually fade away in the first three to four months of life. Spots on
the forehead or nose often take longer to fade and may not entirely fade
away. Spots on the neck usually don’t fade but are covered up as the hair
Mongolian spots - These are bluish flat birthmarks seen most commonly
in dark skinned babies on the back and buttocks. They may be present on
any part of the body and usually appear less noticeable after the first two
to three years of life.
Milia - These are tiny white bumps seen on the face of about 40 percent
of newborns. They are basically plugged skin pores and usually open up
and disappear by one to two months of age. No ointments should be
applied to them.
Erythema toxicum - Over half of all newborn babies develop red blotches
in the first week of life, some with a small white lump in the center. These
can literally appear and disappear before your very eyes but they are NOT
hives and do NOT mean your baby is allergic to anything in particular.
“Drooling rash” - A rash may often appear on the chin or cheeks due to
excess drooling or contact with stomach contents after a baby spits up.
Some of this can be helped by placing a clean towel under your baby’s
face during naps.
Most babies develop some degree of jaundice (yellow/orange skin color). This
is not present at birth but becomes noticeable at two to three days and usually
peaks at five to seven days. It is usually seen more with breast-fed babies and
may persist to some degree for two to three weeks. Notify our office during
office hours if you notice jaundice and:
Excessive sleepiness
Poor feeding
Less than three to four bowel movements in 24 hours
Less than three to four wet diapers a day
If your baby has jaundice but is feeding well, urinating and stooling, it is
usually not a problem. Call us if you are concerned and we can see your baby
and/or obtain a bilirubin level. Treatment is usually simple observation and
occasionally phototherapy (usually done at home).
Newborns usually have at least three to four bowel movements in 24 hours by
the third or fourth day of life. If your baby is breastfed and is not having at least
three to four stools (“scoopable” poops, at least one tablespoon) in 24 hours by
three or four days old, you should call our office for an appointment to weigh
him and evaluate how breastfeeding is going . Breastfed babies may stool as
many as 10 times in 24 hours. By one to two months the pattern changes, and
babies may not stool for a week or more at a time.
Newborn babies usually sleep more during the day than at night for the first
couple of months. You may try placing your baby skin to skin with you during
the day to try to get him to wake more during the day to feed, and sleep more
at night. This may take several weeks to work, so enjoy taking naps during the
day when he is asleep and keep visits with friends and family short for the first
week to get some rest.
Your baby should wake up at least eight times (eight to 12 times for breastfed
babies) in 24 hours to feed. If you have a “good” baby who does not wake up
at least eight times in 24 hours to feed, awaken your baby every three hours
(one four hour stretch of sleep is fine) to feed. If you are breastfeeding and he
falls asleep in less than five to 10 minutes, call our office for an appointment to
evaluate how breastfeeding is going. You may try having him skin to skin with
you on your chest (this encourages your baby to wake up naturally within 20
minutes or so) or take his clothes off and gently rub his back or head to help
him to awaken to feed.
If at all possible, your baby should sleep in his/her own crib and own room.
Babies normally are very noisy when they sleep. For your baby’s safety, under
no circumstances should you sleep with him/her in your bed.
Babies should sleep on their backs or propped to the side. Crib death (Sudden
Infant Death Syndrome) has been shown to occur only half as often when
babies are positioned in this way. By five to six months, many babies can roll
back to front and positioning is no longer an issue. Keep the crib free of pillows
or items that could cause suffocation until 12 months of age. Consider using
a sleeper outfit instead of a blanket. If you do use a blanket, place the baby
with his/her feet to the foot of the crib and tuck a thin blanket around the crib
mattress, covering only as high as his/her chest.
Some things you’ll need
for a new baby
A glass or digital thermometer is fine. The “ear thermometers” currently in
vogue are fine for babies over three years of age but a rectal temperature
with a glass or digital thermometer is more accurate and a more important
issue in infants during the first two months of life. The ear thermometers
have the advantage of being very quick to use but the temperatures can vary
significantly. The thermometer strips available to be used on a child’s forehead
are NOT RECOMMENDED! They’re okay for aquariums, but unreliable for
children. The pacifier thermometer tends to underestimate the temperature on
average 0.5°F, and it needs to stay in your infant’s mouth at least three and
a half minutes. Thus, if a fever is highly suspected, a rectal temperature is the
most accurate option.
Medicine spoon/dropper
Kitchen teaspoons and tablespoons are not accurate for the measuring of
medications so a medicine spoon or dropper, preferably one that measures in
both teaspoons and milliliters, is needed.
Infant Aceteminophen drops (Tylenol/Tempra)
Call before giving these to a child under two months of age. After two months,
feel free to use this as directed for fever, teething pain, etc.
Car seat
This is one of the most important items to obtain for your child. Never
purchase a used car seat for your child. Most seats are now safety tested
to meet government standards. Do not use a car seat that is: 1) too old
(some manufacturers recommend their seats be used only five to six years),
2) was in a crash, 3) has any cracks in the frame or is missing any parts 4)
does not come with instructions, or 5) does not have a label with the date of
manufacture and seat name or model number.
Poison Control number
If your child eats or drinks a potential toxin (plant, medication, etc.), first call
Poison Control at 800.222.1222. Ipecac is no longer recommended as a
routine poison treatment intervention in the home. Existing Ipecac in the home
should be disposed of safely.
Plug-in outlet adapters
Small plastic adapters to plug into empty electrical outlets are important once
your baby begins to explore.
Either cloth or name brand disposable diapers are fine. Generic brands or off
brands of disposable diapers do tend to create more problems with diaper
Patience and a sense of humor
Enjoy your baby!
Feeding your baby
You’ve decided to breastfeed – a wonderful way for you to nourish and nurture
your baby! Breast milk is a living fluid and protects your baby while her
immune system is developing. It changes as your baby grows, meeting her
changing needs.
Breastfeeding is the normal way humans were designed to feed their babies,
but it is a learned process for both of you, similar to learning to dance. It may
take up to a couple of weeks for you and the baby to learn this new dance
Feeding cues
Signs of your baby’s readiness to feed include hand-to-mouth movements,
smacking lips, eye movement in light sleep, clenched fists, and movements
of the arms and legs. She is really ready to nurse when she begins to “root”
toward anything that comes close to her face. Nurse your baby every time she
shows any of these signs. Crying is a late sign of hunger. Keep your baby in the
room with you at least until breastfeeding is well established so that you nurse
before she is hungry enough to cry.
Frequency of feedings
Breast milk is made “on the spot” as the baby suckles at the breast and
stimulates the nipple. This sends signals to the pituitary gland to make milk.
Therefore, babies need to be breastfed at least eight to 12 times in 24 hours
in order to gain weight and stimulate your milk supply. Interestingly, the more
frequently you nurse in the first two weeks, the more milk you will produce at
four to five months. Remember that breast milk is easily digested, so infants
who are breastfed nurse frequently.
Length of feedings
Some babies nurse every one and a half to three hours, while others “cluster
nurse” several times in a row and then sleep for four hours. Feedings may vary
in length – as long as your baby is actively breastfeeding – that is, suckling
with long, drawing sucks, she should be allowed to stay there. Your baby may
nurse for five to 20 minutes on each side, or may nurse on only one side. What
is important is that you are physically comfortable, and your baby is getting
enough to eat. If your baby is “hanging out” at the breast (not actively sucking
to feed), you don’t need to burp her – just gently lay her down. Or, you can try
burping her when finished with one side to see if she awakens to nurse the
other breast as well.
If your baby is hungry before the feeding (fists clenched, actively rooting for
the breast) and satisfied at the end of the feeding (fists unclenched, arms
relaxed), and stools at least three times in 24 hours, things are probably going
well. However, if she is feeding for only a few minutes, or for over an hour at
most sessions, is hungry immediately or frequently after the feeding, or is a
“good” (too quiet, not demanding) baby, call our office for a weight check and
breastfeeding evaluation. The good news is that most babies fall into a more
predictable pattern by the time they are five to six weeks old, with occasional
days when they will nurse more frequently, i.e. during growth spurts.
All newborn babies lose weight during the first days of life, whether breastfed
or formula-fed. They are born with extra fluid because it takes a few days
for the full volume of milk to “come in.” The first 24 hours of life, your baby
will get about three tablespoons of colostrum, a clear substance containing
antibodies and all the calories she needs. The second day, she will get about
13 tablespoons, and by day three to five your breasts will fill with more milk.
The exclusively breastfed infant usually loses up to seven percent of birth
weight, and will usually regain to birth weight by 10 days of life. Breastfed
babies gain quickly once the milk is in, usually a half to one ounce per day. The
number one reason women give up breastfeeding or supplement with formula
is the perception that they do not have enough milk. If you have any questions
about whether your baby is getting enough milk, please call our office for an
evaluation of how breastfeeding is going.
The latch
The latch is the way the baby takes the breast and transfers milk into the
mouth. A good latch is crucial to breastfeeding success! It prevents sore
nipples for the mother (the number two reason women stop breastfeeding),
ensures that milk is being transferred from your breast to the baby, and
stimulates continued milk production.
Tickle your baby’s upper lip with the nipple, and WAIT until she OPENS WIDE,
and then latch her on with your nipple pointing to the roof of her mouth. Your
baby should take a BIG mouthful of breast tissue to get a deep latch. This
protects your nipple by placing it in the back of her mouth where it is soft. She
should not make “clicking/slurping” noises, and her cheeks should not dimple
when she sucks.
While your baby learns to nurse, it is common to have to “de-latch” her several
times before getting a good latch. Do this by placing your finger deep into her
mouth to break the suction, then move her away from your breast and try
latching again. If your baby is having difficulty latching, call us or a Lactation
Consultant immediately for assistance.
Proper positioning of the baby at your breast is important for her to get a good
latch. Make sure she is tucked in to you, “tummy to tummy.” Have pillows
available to support your arms and hands. Relax your shoulders. There are
several positions for breastfeeding your baby. The cradle and football hold
are commonly used until your baby has learned to latch easily. The side-lying
position allows you to rest lying down while she nurses.
Maintaining a good milk supply
The most common cause of early weaning is thinking you don’t have enough
milk. Since you can’t measure how much milk the baby is getting in ounces,
you need to know how to make sure she is getting enough milk.
■■ Keep a diary of feedings and bowel movements for the first few days
at home.
■■ Your baby should feed eight to 12 times every 24 hours.
■■ Your baby should stool three to four times every 24 hours. The stools
should be changing from black to brown to green and then should be
loose, seedy and yellow.
■■ Your baby should have four to five wet diapers every 24 hours in the early
days (six or more wet diapers by six days).
■■ Watch for long, drawing sucks and listen for swallowing sounds.
Spitting up
Babies can spit up frequently. This is usually more of a “laundry issue” than
anything concerning. However, if you baby “projectile” vomits (spits up most of
his feeding and it shoots out of his mouth) more than once in 24 hours, or if
you have concerns about how frequently your baby is spitting up, call our office
to make an appointment to have him evaluated.
Going out
It is best to begin expressing/pumping and storing your milk after
breastfeeding is well established. Pump no longer than 15 minutes each
session. Some women find that hand expression or a manual pump works well.
You can rent or buy a double electric breast pump at Indiana University Health
Bloomington Hospital or at your WIC office. The person from whom you rent
or buy a pump should make sure the flanges fit your breasts. A little olive oil
applied to the inside of the flange helps with comfort while pumping.
Going back to work
Indiana has a Lactation Support in the Workplace Law (SEA 219). The law says
state and government offices, and employers with more than 25 employees,
must try to provide a private space and cold storage for employees who pump
their breast milk. Introduce a bottle with breast milk when your baby is about
one month old, or a month before going back to work. If he doesn’t like the
idea at first, here are some things you can try:
■■ Feed your baby the bottle when he is sleepy
■■ Have someone other than his mother feed him while she is away.
■■ Offer the breast milk in a different container – a syringe or even a tiny
cup, or a “sip cup” if he is a few months old.
Collection and storage of breast milk
■■ Wash equipment in hot soapy water with a bottle brush. Sterilizing it is not
■■ It is best to store milk in plastic (BPA-free) or glass bottles. Plastic milk
storage bags are acceptable for occasional use. Some components of
breast milk “stick” to the plastic bag.
■■ Freshly expressed breast milk may be kept at room temperature (75
degrees) for eight to 10 hours if necessary, stored in the refrigerator for
five to seven days, and in the back of a freezer that is separate from the
refrigerator for five to six months. If you aren’t going to use the milk for
several days, it is best to freeze it as soon as possible.
■■ Do not add fresh warm milk to frozen milk.
■■ To defrost, place milk in lukewarm water until it reaches room
temperature, about 20 minutes, or defrost it in the refrigerator. Do not
microwave or defrost in hot water – this can change the properties of the
■■ Breast milk separates when standing because it is not homogenized.
Shake it gently to mix.
■■ If your baby does not finish his bottle of breast milk, you may place it back
into the refrigerator but it must be used within four hours.
■■ Do not add fresh breast milk to what is left in a bottle of unfinished breast
milk. Let him finish what is left and then finish his feeding with a new
bottle of breast milk.
Common breastfeeding challenges
Breastfeeding should never hurt beyond some tenderness during the early
latch. Please call our office or a Lactation Consultant if breastfeeding is in any
way painful.
Sore nipples
Treat tender nipples by applying breast milk or lanolin cream after nursing.
Start nursing on the least sore side first. If your nipples are too sore to allow
your baby to nurse for longer periods of time (i.e. for comfort), find other ways
of comforting him.
If you have sore nipples beyond the first week, or if you feel a burning sensation
during or after breastfeeding, you or your baby may have a yeast infection
(“thrush”). This is more common in babies and mothers who were treated
with antibiotics. Call our office for an appointment. This condition needs to be
evaluated and treated with an anti-fungal agent. Your nipples do not need to be
washed, except during your routine shower.
Difficulty with the latch
Try placing your baby skin-to-skin between your breasts. This may calm the
baby who is fussy trying to latch, or help awaken the baby who is too sleepy to
latch. Try expressing your milk from the nipple and touching it to your baby’s
upper lip. If she is too sleepy, try gentle waking techniques (undress her, tickle
her feet, wipe her face or back with a cool cloth). Watch closely for feeding
cues, and completely avoid pacifiers until she has learned to latch well and
breastfeeding is well established.
If none of these techniques work, begin pumping every two and a half hours
for 10 to 15 minutes, or expressing your milk by hand. You may not get much
milk at first but anything you get should be saved and given to your baby.
Supplemental feedings, whether breast milk or formula, should be offered with
a small cup (a shot glass works well) or syringe if possible to avoid confusion
between a bottle nipple and your nipple. However, sometimes a bottle is used if
your baby is too sleepy or is not gaining weight well enough.
Engorgement, a sense of fullness in the breasts, occurs usually on days three
to five when your body is still trying to figure out how much milk to make. Your
breasts may be so full that they become firm and it is difficult for the baby to
latch. Try taking a warm shower or massaging your breasts to get the milk
flowing and soften your breasts for your baby to latch. Don’t use hot water
for long periods – this can increase the swelling. After nursing, applying icy
cold compresses can help relieve some of the warmth and discomfort. Freeze
a water-soaked diaper, or use bags of frozen vegetables. Nurse your baby
frequently - your baby, if latching well, is the best help to relieve engorgement.
You may also hand express or pump your breasts just until your breasts are soft
enough for your baby to latch. Ibuprofen and acetaminophen can help you feel
better until your body adjusts the amount of milk to make for your baby and
the engorgement resolves.
Fussy baby
Babies are often gassy and fussy the first few months, with evening hours often
being the worst. This is not necessarily due to low milk supply or something you
have eaten. If your baby is fussing more than usual, try avoiding caffeine intake
or eliminating cow’s milk protein for two weeks. Nurse frequently, wear your
baby in a sling and walk around, give him a warm bath, drive him around in
the car, or enlist a family member to help soothe your baby and allow yourself
to take a break. It may be tempting to give formula, but it can cause more
problems than it relieves. Check to make sure your baby’s fussing isn’t from
being too warm or cold, having a wet diaper, or simply needing a change in
the way he is held. Fussiness usually diminishes by two months and resolves
by three to four months. Call our office if your baby is inconsolable, has
intermittent bouts of screaming, or has signs of illness such as a fever.
Frequently asked questions about breastfeeding
Do I have to eat any special foods while I breastfeed?
Current research does not indicate that any special foods are needed or to be
avoided to “make good milk.” You should eat a well-balanced diet and drink
when you are thirsty for your own health.
Should I put my baby on a schedule?
Some books advocate placing babies on a schedule to help them learn to
“sleep through the night.” This does not meet the needs of the helpless
newborn, and can interfere with growth and milk production. Babies begin
sleeping through the night when they are developmentally ready.
“I think my baby may be using me as a pacifier. She wants to nurse a lot.”
How frequently your baby nurses depends on her growth and developmental
stage at any given time. The length and frequency of feedings varies from baby
to baby and day to day. On days when she feeds more frequently, she is likely
experiencing a growth spurt.
Breastfeeding on demand ensures that she is getting enough milk and that
your body keeps producing enough for her to grow adequately. If your baby is
a few months old, she could be feeding more frequently because her sleep
patterns are changing, she is experiencing discomfort from teething, or
something in her routine has changed (i.e.: travel). Infants and older babies do
nurse for comfort, and if their “non-nutritive” sucking needs are not met at the
breast they will often suck on blankets, a pacifier, or their thumb. The comfort
and nurturing you offer by nursing is as important as your milk!
My medication insert states “Consult your doctor if pregnant or nursing.”
Most medication inserts err on the side of caution. Most medications are
safe for you to take while breastfeeding, and those that are not can most
often be switched to ones that are. That being said, antihistamines and
pseudoephedrine can decrease your milk supply. If you have to take them,
drink plenty of fluids. Birth control pills, shots and implants can also decrease
your milk supply. Call us to ask us about any medication you are considering
taking – we will refer to Medications and Mother’s Milk by Dr. Hale, which
contains the most up-to-date research and drug information for breastfeeding
mothers. If anyone tells you that you have to stop breastfeeding, call our office
or a Lactation Consultant immediately.
How long should I continue to breastfeed?
The American Academy of Pediatrics states “exclusive breastfeeding is
sufficient to support optimal growth and development for approximately the
first six months of life and provides continuing protection against diarrhea
and respiratory tract infection. Breastfeeding should be continued for at least
the first year of life and beyond for as long as mutually desired by mother
and child.” The American College of Obstetricians and Gynecologists and the
American Academy of Family Physicians have similar recommendations.
Can I breastfeed and formula-feed?
Yes. The benefits of breast milk are “dose-dependent.” This means the more
breast milk your baby gets, the more your baby benefits, and that even a
little bit can keep your baby healthier. Many women decide to breastfeed at
night because it’s easier not to have to prepare the bottle of formula, or to
breastfeed before work and in the evening.
Will breastfeeding change my breasts?
The changes your body goes through during pregnancy includes your breasts,
so it is not breastfeeding but pregnancy that changes the breasts.
I want my partner to be able to participate in feeding my baby.
Until breastfeeding is well-established, your partner can help by holding your
baby skin to skin, burping her, soothing her by allowing her to suck on a clean
finger if she is finished feeding, and giving YOU a neck massage to help you
relax while feeding! Later on your partner can feed her pumped breast milk
from a bottle.
Call our office for more resources.
Formula feeding
It is important to use a formula that suits your baby’s needs. Some formulas
are made from cow’s milk, and some from the soy plant. Hypo-allergenic
formulas are made of partially digested proteins. The formula you choose
should be fortified with iron. Formulas come in powdered, liquid concentrate
and ready-to-use formulations. We can discuss which formula is the best type
of formula for your baby.
Frequency of feedings
Feed your baby about every two to four hours, but not on a schedule – watch
for cues that indicate he is hungry (hand to mouth motions, sucking on his
hand). Wake him if he has been sleeping for four hours.
How do I know if he’s getting enough?
Your baby should have at least one soft stool a day and six or more wet
diapers every 24 hours. Call us if he has hard stools or trouble having a bowel
In the first few days, your baby will take one to two ounces, and by one week,
he will take two to three ounces each feeding. Let the baby decide how much
to take. If there is some formula left in the bottle that is a good sign that
he took what he needed. Do not make him finish the bottle. This can cause
overfeeding and weight gain problems. If he gulps his feedings and looks like
he is trying to catch his breath, take frequent breaks during the feeding to let
him catch his breath. Stop several times during the feeding to burp him, more
if you find that he spits up after or between feedings.
Always hold your baby while feeding him. Never prop his bottle. Feed him in
a semi-upright position to prevent formula from getting into his inner ear and
causing an ear infection. Switch arms when feeding him – this helps him to
use both eyes while he looks at you while feeding.
Feeding time is not just about nutrition, it is also about interacting and
learning. If your baby takes his bottle quickly, cuddle him and talk to him
Preparing formula
■■ Shake the can of formula before opening. Wash the top of the can with
hot soapy water.
■■ Follow the directions on the can exactly. If it is mixed to be too strong or
too weak it can make your baby grow poorly or get sick.
■■ Once the formula is opened or mixed it must be kept in the refrigerator at
40 degrees or lower. Formula mixed from concentrate or is “ready-to-feed”
must be used within 48 hours. If mixed from powder it should be used
within 24 hours (powdered formula is not sterile).
■■ Warm bottles of formula under running water. Never heat in the
■■ Once formula it taken out of the refrigerator it must be used within one
hour of reaching 40 degrees. After that it must be thrown out.
■■ Distilled water is the safest water to use to mix infant formula.
■■ Never use the scoop from one brand of formula to mix a different brand of
■■ Do not put the scoop back into the can once you have handled it, because
this can contaminate the powder. Keep the scoop in a plastic bag when
not using it.
■■ Write the lot number of the formula can down, in case there is a recall of
that product.
■■ Bottles and nipples should be washed in hot soapy water or through a
dishwasher cycle in the top rack. There is no need to sterilize bottles or
nipples if your baby is doing well.
Going out
Make sure to pack formula you have already mixed in a cooler that keeps the
formula cold enough until it will be used, or bring sterile water to mix powdered
formula, or “ready-to-feed” formula which is sterile until opened (but is more
Please call our office if your baby is having any difficulty with formula feeding
or have any questions about formula feeding your baby.
Beginning solid foods
For some reason, friends and relatives tend to fixate on when a baby has his
first water bottle and first bowl of cereal! Any pediatric allergist will tell you,
however, the most important factors in avoiding the development of food
allergies are breastfeeding and delaying solid foods. Breast-fed babies are
afforded some degree of protection from food allergies, and the longer a child
is exclusively breast-fed, the better.
The sooner solid foods are introduced, the more chance there is of developing
allergies over time.
Our goal is to delay solid foods until somewhere between four to six months of
age. This will vary from baby to baby, however. We can’t realistically expect a
baby with a birth weight of 10 pounds to be ready for solids at the same time
as a baby whose birth weight was five pounds! If your baby is breastfeeding
and sleeping through the night, don’t start solids. If, however, she has been
sleeping eight hours at night and is now waking for two additional night
feedings, she may be ready for solids.
If your baby is bottle feeding and taking more than 32 ounces of formula in a
24-hour period, you may give a solid feeding supplement if she’s still hungry
after the 32 ounces. Rice cereal is a good choice for your baby’s first solid
food. It may be mixed with breast milk, formula or apple juice until quite thin,
then fed to your baby with a spoon. Do not use an infant feeder! These lead to
overeating, potential choking or aspiration and defeat the purpose of teaching
your baby about eating solid foods.
After several weeks on rice cereal, you can begin to slowly introduce your baby
to different solid foods. A good rule of thumb is to introduce solids slowly,
using one new food for five to six days before trying another. Most pediatricians
recommend cereals first, followed by either yellow vegetables or green
vegetables, and then fruit. After six months, meats may be introduced. Juices
should be treated as fruits (but no orange juice until around 12 months of age)
and should be diluted to half strength with water. Babies should not have more
than four ounces of juice per day.
Some foods, including eggs, orange juice, and peanut butter should not be
given to children during the first year of life. These foods are considered “high
risk” in terms of developing food allergies, especially if received early in life.
Honey should not be given to children during the first year of life because raw
honey can contain spores causing botulism in young children. These foods can
be discussed in more detail during office visits.
Frequently asked questions
by new parents
Clothing should be loose-fitting and allow for easy movement. Don’t overdress
your baby. Dress him as you would yourself. Your baby’s hands and feet may
feel cool, but if his body is warm, he is fine. Cotton material is best. Wool may
irritate your baby’s skin. Wash new clothing before putting it on your baby for
the first time. Dreft detergent is a good choice for washing clothes and diapers.
Softeners and anti-statics are best avoided for the first year, as they frequently
cause skin irritation.
Your baby’s crib slats should be no more than 2 3/8 inches apart and the
surface should be free of splinters and painted with a non-lead based paint.
The mattress should be the appropriate size for the crib. Don’t permit hanging
toys or window curtains within reach of your baby.
Room temperature
Ideal room temperature for your baby is 65-70 degrees (no different than you
probably keep it anyway!). Additional humidity during winter may be provided
by central or room humidifiers. Be sure to clean frequently to prevent the
spread of mold.
Skin and hair care
Your newborn’s umbilical cord should be kept clean and dry. Cleansing with
alcohol around the base of the cord during diaper changes is sufficient. Once
the umbilical cord is off and, if you have a circumcised boy, once the plastic
ring is off the circumcision, the baby may be bathed in the tub (or sink). Until
then, sponge your baby with warm water only or with a very mild soap such
as Dove or Neutrogena for “real messes.” Babies don’t need to be bathed
daily, just when dirty. (Once or twice a week is often enough during the winter.)
Again, plain water or a very mild soap (Dove or Neutrogena) are all that are
The skin of newborn babies often appears dry and flaky. You do not need to
apply lotion or oils to your baby’s skin. Beautiful new skin is growing under
the layer that is flaking off. However, if the skin is very dry, you may apply an
unscented baby lotion, olive oil or baby oil to the dry areas – your baby may
even enjoy the massage he gets as you apply the lotion!
Hair should be washed with a mild baby shampoo. You may wash around the
outside of your baby’s ears with a Q-tip or soft washcloth. Do not insert Q-tips or
other objects into your baby’s ear canal.
Cradle cap
If your baby has oily, yellowish scales and crusts on his scalp, he probably
has “cradle cap,” a common condition in young infants. Applying baby oil to
the crusts before shampooing will help soften them so they are more easily
removed. Use Selsun Blue shampoo and an old toothbrush to scrub the scales
up and clear the problem fairly easily. Use the Selsun Blue daily until the scales
have cleared, then once or twice a week to keep the problem from flaring up
The decision as to whether to have a newborn son circumcised is no longer
considered a medical one. While statistically there is a slightly higher chance of
urinary tract infection in an uncircumcised male, the chance is still extremely
low (1%). And, new research suggests that circumcision can reduce the risk of
contracting HIV. Most physicians do not inflict their personal feelings, pro or
con, on families but allow the families to make their own decision on this very
personal issue.
If you wish your newborn son to be circumcised, this can be performed in
the newborn nursery prior to discharge from the hospital. A local anesthetic
is injected to numb the area. “Plastibell” circumcisions are most commonly
performed in this part of the state. This means there is a plastic ring that
remains on the tip of the penis for a few days following the procedure. The
area should be cleaned with warm water until the Plastibell detaches. If the
ring appears to be slipping down the shaft of the penis, contact the office.
Otherwise, the Plastibell should detach on its own within five to seven days
after leaving the hospital. It is normal for a moderate amount of yellow mucus
to be present when the ring is detaching. If you have concerns about this or feel
the area looks red or infected, call the office.
If you do not want your newborn son to be circumcised, no special care of the
foreskin is needed. Just clean the tip of the penis. Do not try to retract the
foreskin forcefully. It will retract naturally as your child gets older (usually by
five to 10 years of age).
Colic is seen in 10 percent of healthy, well-fed babies and usually begins
around the third to fourth week of life. It ends (hopefully) by the third month.
These babies have an excessive amount of fussy crying and appear to be in
pain. There may be multiple causes for what we presently term “colic,” but
nobody is sure exactly what the causes are. It is seen in both breast-fed and
bottle-fed babies. It is not the result of inadequate parenting so don’t blame
yourself if your child has this problem!
There are several things to try to help the crying spells.
Rhythmic, soothing activities -- Try carrying your baby in a front pack or
pouch. An automatic baby swing, rocking cradle or buggy ride may help.
Sometimes a drive around the block in the car may help. Putting the baby
in an infant seat on top of the clothes dryer and then running the dryer
with some sneakers in it will sometimes soothe the baby. (Be sure the
seat is secured so it won’t jiggle off onto the floor!)
Some babies are calmed by sucking a pacifier. If your baby has eaten in
the past two hours, don’t feel you must feed him. Colicky babies aren’t
usually hungry.
Warming the baby with a warm water bottle or warm towel on her tummy
or swaddling her may help.
Soft sounds may calm your baby. Soft music or a recording of sounds
from mother’s womb may be used.
If your baby is dry and has been fed, it is perfectly all right to close the door to
his room and let him cry for a while. Check on him periodically, but try setting a
timer for 20 minutes and use this time to do something YOU want to do! Colic
can be very frustrating and exhausting for parents if you don’t take “time out”
occasionally. New mothers in particular should try to take at least one nap
each day. You can also try to increase the amount of time your baby sleeps
at night by not allowing her to sleep more than three to four hours at a time
during the day.
Dental care
Your child’s gums should be massaged daily with a wet washcloth until the
first tooth erupts. You may then change to a soft toothbrush with plain water or
just a pea sized amount of toothpaste on the brush. Fluoride is important for
preventing tooth decay but TOO MUCH fluoride can discolor your child’s teeth.
Your child will need help with brushing until about school age. Younger children
aren’t coordinated enough to maneuver the toothbrush everywhere it needs to
Most dentists like to begin seeing children as early as their first birthday for
routine dental care. Check with your family dentist as to his or her preference.
If your family dentist does not see young children, we can refer you to a
pediatric or family dentist who does.
The leading cause of tooth decay in children under two years of age is taking
a bottle in bed at night. Breastfeeding at night has not been shown to cause
dental cavities. Studies show that components in breast milk may act against
the bacteria that cause dental cavities.
The city water supplies in Monroe, Lawrence, Owen, Brown and most
surrounding counties have adequate amounts of fluoride. If you have well
water, a kit for testing the amount of natural fluoride in your water may be
obtained from your county health department. Request a WAF (Water AnalysisFluoride) kit. The kit comes complete with all instructions and a mailing label.
If your water source is found to be deficient in fluoride, a prescription can be
given through our office or your dentist’s office.
Monroe County residents:
Lawrence County residents:
Monroe County Health Dept.
119 West 7th
Bloomington, IN 47402
Lawrence County Health Dept.
2419 Mitchell Road
Bedford, IN 47421
Diaper rash
Diaper rash is a common problem among babies. You can help prevent it by
keeping your baby’s diaper area clean and dry. At each diaper change, the area
should be cleansed with water and a soft cloth or with diaper wipes that don’t
contain alcohol, oils or perfumes. Once a day, wash the diaper area with warm
water and soap. Allow your baby’s bottom to air dry before putting diapers back
on. Air drying with a hair dryer on a cool setting can be very soothing.
If your baby develops a diaper rash around the rectal area, a barrier cream
such as Desitin or Vaseline should be used. If the area is very red and “scalded”
looking, your baby’s stools may be somewhat acidic. Applying Maalox (Yes, like
you drink!) and then covering with Vaseline will speed the clearing of the rash.
If your baby has recently been on antibiotics, diagnosed with thrush or has
developed red bumps over the front of the diaper area, she/he may have a
yeast infection causing the rash. Lotrimin cream used twice daily should clear
this. (Lotrimin is now available over-the-counter.) If unsure, call the office during
regular hours.
lnguinal hernias appear as bulges or swollen areas in your child’s groin (or
scrotum, in males). The bulges often change in size, becoming larger or smaller
in the course of a day. They may be slightly tender. If you notice any swelling in
your child’s groin (boy or girl), notify the office. Hernias appearing in the groin
area do require surgical repair, although usually on an outpatient basis. It is
only an emergency if the baby is very fussy, the area won’t reduce (become
smaller) with mild pressure or if the area is discolored and the baby is not
feeding or is vomiting.
Umbilical hernias occur when a weakness in the muscle around the “belly
button” causes it to protrude outward. These are very common and usually
cause no problems. When a child cries, the umbilicus will protrude more, but
it won’t break! The hernia usually resolves on its own by school age without
treatment. Taping a quarter over the area won’t make things go away any
sooner and babies can develop allergic rashes from the tape.
This vaccine protects your child against diphtheria, pertussis, and tetanus. A
tetanus booster is given every five to 10 years after entrance into school. Your
child may experience fever, irritability and pain or swelling at the injection
site in the 24 to 48 hours following this vaccine. Acetaminophen and cool
compresses usually help any discomfort. There have also been rare reports of
cases of encephalopathy (nerve and brain damage), usually temporary, in one
of every 100,000 to 300,000 children following DTaP immunization. With the
newer generation of acellular vaccine (DTaP) we rarely see any side effects at
Flu vaccine
Any child over six months of age may receive the influenza vaccine, and it
is now recommended not only for high-risk children, such as children with
asthma, diabetes or other chronic conditions, but for all healthy children over
six months. There is an intranasal influenza vaccine now available for healthy
children two years and older. This protects against infection with the influenza
virus, which causes a week-long illness of headache, sore throat, fever, muscle
aches and dry cough. Epidemics of influenza occur each winter and each year
a flu vaccine is “custom made,” based on a prediction of which strains of virus
will be predominant in the coming winter months. The vaccine is best given in
the fall months to allow time for immunity to develop before “flu season” hits.
Hepatitis A (HEP A)
Hepatitis A is a virus that can cause liver disease. Hepatitis A is spread through
contaminated food and water. The vaccine for hepatitis A is a two-dose series
given six to 18 months apart. It is recommended for all children beginning at
one year old.
Hepatitis B (HEP B)
This vaccine provides protection against the Hepatitis B virus, which can be
transmitted across the placenta at birth or later in life via blood or sexual
contact. The first injection is given at birth. Side effects are minimal, with
usually just some tenderness at the injection site. The Hepatitis B series is now
a required immunization for all children entering public schools for the first
Hemoglobin/Lead screen
These tests may be indicated at around nine to 12 months to screen for
anemia or exposure to lead in the environment. We will discuss at the well
child visit whether these are indicated for your particular child.
Each child receives three or four doses as indicated. This vaccine protects your
child from infection with the bacteria Haemophilus Influenza type B, which
causes epiglotitis and meningitis in childhood. Side effects are rare and include
fever and redness at the injection site.
This vaccine provides protection against the human papilloma virus (HPV),
which can infect the genital area of men and women. It can cause warts and
cancer of the penis in men and abnormal Pap tests, warts, and cancers of the
vagina and cervix in women. A vaccine to prevent HPV infection with strains
causing 70 percent of cervical cancers and 90 percent of genital warts is
recommended for males and females nine to 26 years old. These HPV types
are spread by sexual contact and 80 percent of men and women will be
infected at some time in their life. Protection is best when the vaccine is given
before becoming sexually active. We suggest beginning the three-dose series
at the 11 or 12 year check-up, with a second dose in two months and the third
dose four months later.
This vaccine can prevent four types of meningococcal disease, including two of
the three types most common in the United States. Meningococcus is a serious
disease caused by bacteria and is the leading cause of bacterial meningitis
in children two to 18 years of age. Meningococcal vaccines cannot prevent all
types of the disease, however, they do protect many people who might become
sick if they did not get the vaccine. The vaccine protects about 90 percent of
recipients and because meningococcal disease is so serious, prevention is
better than treatment. Two forms of the vaccine are available depending on the
child’s age and risk factors.
The measles, mumps and rubella (German measles) vaccine is given in two
doses. Reactions to this don’t occur until one to two weeks after the vaccine is
given. There may be fever, rash and aching joints. During this time, your child
is NOT contagious to others at all. Acetaminophen or ibuprofen will help make
your child more comfortable. Getting the MMR vaccine is much safer than
getting any of these three diseases.
Polio vaccine (IPV)
Polio is a disease that can paralyze. The vaccine is now an injectable killed
virus and is given in four doses. There are very few side effects.
A TB skin test is recommended in the event of a TB exposure. If any family
member is diagnosed with TB or develops a positive skin test or any immune
deficiency, it is important to let us know as this will change the schedule for
your child’s testing.
This vaccine helps protect infants and toddlers from diseases caused by the
streptococcus pneumoniae bacteria. These include meningitis, bacteremia,
pneumonia and ear infections. Prevnar is given in a series of four doses and
has side effects similar to those seen with other childhood vaccines.
Rotavirus is the most common cause of vomiting and diarrhea in the United
States. Nearly every child will be infected in the first two to three years of life.
The vaccine for rotavirus is a liquid that is swallowed at the two and four month
check-ups. Vaccination prevents severe forms of the illness that may lead to
dehydration and the need for hospitalization.
This vaccine was licensed in 2005 and is the first vaccine that protects
adolescents against all three of the following serious diseases: Tetanus,
Diphtheria and Pertussis. Tetanus, diphtheria, and pertussis are all caused by
bacteria. Diphtheria and pertussis are spread from person to person. Tetanus
enters the body through cuts or wounds. Adolescents 11 through 18 years of
age should get a booster dose of Tdap every five to 10 years.
At 12 months or older, this vaccine is nearly 95 percent effective in preventing
severe chicken pox. Side effects include some fever and pain at the injection
site. Also, two to four weeks after receiving the vaccine a child may actually
develop a few spots like the chickenpox. No special precautions are needed
in a child who develops these spots, as the odds of passing the virus on to
otherwise healthy people are very slim. However, they should avoid people with
known immune deficiencies or who are on chemotherapy. A second dose of
varivax is given at four to six years of age.
Childhood Immunization Schedule
Hep A
Hep B
2 mo.
4 mo.
6 mo.
9 mo.
12 mo.
15 mo.
18 mo.
4-6 yrs
11-12 yrs - Meningoccocal, Tdap, HPV series
We give immunizations according to the current American Academy of
Pediatrics guidelines. These may change as new vaccines become available or
depending on when immunizations are started.
Most pediatricians don’t have strong objections to the use of pacifiers in infants
who seem to have a strong need to suck. A properly shaped pacifier is less
damaging to the developing mouth than sucking on a thumb or finger. Pacifiers
should be of a one piece design to avoid the possibility of an infant swallowing
or choking on a part of it. Pacifiers should not be placed on strings tied around
a baby’s neck or any string used that is long enough for a baby to strangle on.
Spitting up
Spitting up is very common in newborn babies and is due to a weakness of the
muscle at the upper end of the stomach. It improves with age and has usually
cleared up by the time a baby starts walking. Most spitting up has nothing to
do with what formula your baby is on so formula changes after leaving the
newborn nursery are rarely indicated. Please call the office before changing
your baby’s formula.
Giving your baby slightly smaller feedings more frequently and avoiding tight
diapers will help somewhat. Although burping during feedings is important, a
baby should be burped only when he or she pauses in feeding. Sucking should
NOT be interrupted. Burping is less important than giving smaller feedings.
If your baby is still having a significant amount of vomiting despite these
measures, call the office and we can discuss possibly thickening the feedings
with cereal or other measures.
Most “spitters” start having problems during the first week of life.
If your baby has not had problems in the past but suddenly begins to vomit
during the third or fourth week of life, be sure to call the office during regular
office hours.
Sun exposure
In the summer your baby’s skin will need to be protected when he is outdoors,
even from indirect sunlight. Babies should be shielded from direct sun
exposure when possible. PABA free sunscreen lotions of a 15 rating or greater
are recommended routinely for babies over six months of age who will be have
any sun exposure to provide maximum sunburn protection. Skin cancer is on
the rise. Studies have shown each case of sunburn increases this risk.
Teething may cause a baby to be fussy or have a low-grade fever (usually not
over 100). Teething may cause loose stools and some irritant diaper rash.
Teething does not cause high fever.
To make your baby more comfortable during teething episodes, give
acetaminophen just as you would for any other type of pain. Children’s Motrin
(ibuprofen), now available over the counter, is often even more effective for
teething pain for infants older than six months. You can also try one of the
water-filled teething rings that can be placed in the refrigerator or freezer
for cooling. Teething biscuits, raw carrots or other foods that can break off
into chunks and choke your baby should not be used. Teething gels, which
contain xylocaine are not recommended. These can cause toxicity with heart
arrhythmia if swallowed in sufficient quantities.
Some babies enjoy chewing on nipples (including Mom’s) or pacifiers while
teething. Others actually begin refusing nipple feedings (even the breast). If this
happens, try giving acetaminophen or ibuprofen about an hour before feeding
time or using a sipper cup for fluids.
Thrush appears as white, curd-like plaques coating the gums, tongue and sides
of baby’s mouth. It can’t be washed away. Normally this is seen in young babies
who are still nursing or on bottle feedings. Occasionally it is seen in an older
child after a course of antibiotics. It is caused by a fungal (“yeast”) infection. If
you think your child may have thrush, call the office during regular office hours
and a prescription can be phoned in to treat it.
Anything that comes in contact with the baby’s mouth should be boiled for 20
minutes. The medication prescribed should be continued for three days after
the thrush appears to be totally gone.
Infants generally travel very well. Plan ahead to allow more frequent stops for
feeding and diaper changes. Infants should ALWAYS travel in APPROVED car
seats. For those babies taking airplane rides, the only precaution needed is to
have the baby nursing or sucking on the pacifier during takeoff and landing.
This allows for equilibration of ear pressure during changes in altitude.
Travel vaccines
For those patients traveling out of the country, we do offer immunizations
for plague, typhoid fever, hepatitis A, etc. Dr. McDaniel is registered with the
Centers for Disease Control and Prevention (CDC) as a “Yellow Fever Center,”
the only such center in southern Indiana providing Yellow Fever vaccine for
young children. We also have available computer software to help provide
information on health conditions in the country you will be visiting along
with general information. Our software is updated monthly so you can take
advantage of the latest information regarding epidemics, etc. in the country
you will be visiting. Be sure to contact us as early as possible if you are
planning a trip! It sometimes takes several weeks to complete a course of
recommended immunizations prior to leaving the country.
If your child has upper respiratory symptoms (i.e., common cold) without a high
fever (104°), he or she may still receive immunizations without rescheduling
for a later time.
Sick days
Common infant &
childhood ailments
Repeat after me, “Fever is our friend (unless my baby is under 2 months old, in
which case I will call the doctor immediately!).”
Fever is present if the oral temperature is greater than 100 degrees Fahrenheit
(37.8 degrees Centigrade) or the rectal temperature is 100.5° degrees
Fahrenheit or greater. Axillary temperatures (temperatures taken under the
arm in the armpit) are variable but usually a fever is present with an axillary
temperature over 99-100 degrees Fahrenheit. A child may “feel hot” without
having an actual increase in body temperature so if you think your child may
have a fever and are concerned, use a thermometer to check the actual
Types of thermometers
There are many types of thermometers available. Acceptable choices include
glass thermometers and digital thermometers. Thermoscans (thermometers
which take the temperature in the ear) are fine for older children (over three
years of age). If a child under two months of age is felt to have a fever, we
request you check a rectal temperature using a glass or digital thermometer
before calling us. The thermometer strips available for use on a child’s
forehead are notoriously inaccurate and not recommended. Be sure to tell us if
you don’t take the temperature rectally.
Mild fevers may be caused by too much clothing, recent exercise, hot weather
or hot foods. A fever is expected after certain immunizations and is a normal
reaction of the immune system to the vaccine.
Pediatricians as a group are very concerned about fever in infants under two
months of age. This is because their immune systems are still developing and
they often don’t give clinical signs of severe illness other than fever at a young
After two months of age, we consider fever a normal response to infection. It
should be treated only if your child is uncomfortable or the fever is fairly high
(over 104-105°).
Call IMMEDIATELY if your child has fever associated with
any of the following:
■■ Age under two months
■■ Constant crying as if in pain
■■ Fever of 105° or higher NOT responding to medication
■■ Stiff neck
■■ Purple spots on the skin
■■ Difficulty breathing (other than a stuffy nose)
■■ Your child is becoming difficult to arouse, confused or delirious
■■ Your child appears extremely ill or has other signs that worry you
Call the office during regular hours if:
■■ Your child complains of sore throat or ear pain
■■ Your child complains of pain with urination or is voiding frequently or
wetting the bed
■■ Your child has a significant cough or any other symptoms along with fever
persisting beyond 48 hours.
Ways to treat fever
Either an acetaminophen product (Tylenol) or ibuprofen (Motrin), if over six
months, may be used to treat fever. The ibuprofen products are particularly
effective but may cause stomach upset in some children and should not be
given to children who are vomiting or having severe diarrhea. The practice of
alternating fever reducing medication is no longer routinely recommended
since the potential for errors is so great. Thus, to prevent confusion and
possible over-dosage, choose either acetaminophen every four to six hours with
a maximum of five does in 24 hours or ibuprofen every six to eight hours. Base
the dosage on your child’s weight, NOT age.
Fever reducing medicine dosage charts
ACETAMINOPHEN (Tylenol/Tempra)
Every 4 hours as needed; No more than 5 doses/day
6-7 lbs.
1 ml
8-10 lbs.
1.5 ml
11-14 lbs.
2 ml
15-16 lbs.
2.5 ml
17-19 lbs.
3 ml
20-22 lbs.
3.5 ml
23-25 lbs.
4 ml
26-27 lbs.
4.5 ml
28-31 lbs.
5 ml
32-33 lbs.
5.5 ml
34-36 lbs.
6 ml
37-39 lbs.
6.5 ml
40-42 lbs.
7 ml
43-45 lbs.
7.5 ml
46-48 lbs.
8 ml
49-51 lbs.
8.5 ml
52-54 lbs.
9 ml
55-57 lbs.
9.5 ml
58-60 lbs.
10 ml
61-63 lbs.
10.5 ml
64-66 lbs.
11 ml
67-69 lbs.
12 ml
70-72 lbs.
12.5 ml
Greater than 72 lbs.
15 ml
IBUPROFEN (Motrin/Advil Children’s)
Every 6 Hours as needed
15–17 lbs.
3 ml
18-19 lbs.
4 ml
20-21 lbs.
4.5 ml
22-23 lbs.
5 ml
24-25 lbs.
5.5 ml
26-28 lbs.
6 ml
29-30 lbs.
6.5 ml
31-32 lbs.
7 ml
33-35 lbs.
7.5 ml
36-38 lbs.
8 ml
39-40 lbs.
8.5 ml
41-43 lbs.
9 ml
44-46 lbs.
10 ml
47-48 lbs.
10.5 ml
49-50 lbs.
11 ml
51-52 lbs.
11.5 ml
53-54 lbs.
12 ml
55-57 lbs.
12.5 ml
58-59 lbs.
13 ml
60-61 lbs.
13.5 ml
62-63 lbs.
14 ml
64-65 lbs.
14.5 ml
66-68 lbs.
15 ml
69-70 lbs.
15.5 ml
71-72 lbs.
16 ml
73-74 lbs.
16.5 ml
75-76 lbs.
17 ml
77-79 lbs.
17.5 ml
80-81 lbs.
18 ml
82-83 lbs.
18.5 ml
84-85 lbs.
19 ml
86-87 lbs.
19.5 ml
Greater than 88 lbs.
20 ml
Two common reasons for the lack of response to fever-reducing medication
are: 1) not waiting long enough to see the effect, which may take up to 60 to
90 minutes, and 2) under-dosing. But it is better to err on the side of underdosing if the weight of your child is not accurately known.
Sponging in a bath with lukewarm water may initially lower the temperature
but its effects are not lasting and it may actually trigger the body to conserve
and raise its temperature due to the goose-bumps, shivering, and other
mechanisms it causes. Therefore, the bathing should be abandoned if a child is
expressing discomfort.
Note: Fevers are normal the first 24 to 48 hours after a DTaP vaccine and five
to 15 days after MMR.
Babies usually have mushy, somewhat loose stools. Diarrhea is defined as a
sudden increase in the number of stools and looseness of stools compared
to your baby’s normal pattern. Breast-fed babies may have anywhere from 10
loose stools per day to one stool per WEEK and practically any consistency is
normal for a breast-fed baby. (They usually resemble mustard water with a little
curd thrown in!) However, if your breast-fed baby has a sudden increase in the
usual number of stools, acts sick, has vomiting, fever or weight loss, then there
is reason for concern. While bottle-fed babies tend to have some more formed
and less frequent stools, the same basic rules apply.
Diarrhea is usually caused by a viral infection or occasionally a bacterial
infection. It usually lasts several days, sometimes as long as one to two weeks.
Infections cause diarrhea by causing temporary injury to the intestines which
causes incomplete digestion and absorption.
Children who are otherwise alert and active and having only mild diarrhea do
NOT necessarily require any dietary changes other than limiting juices and
sugar-containing fluids. Although it may help to limit milk, it is usually safe and
recommended to continue milk during a diarrheal illness.
If your child is becoming listless and having moderate to severe diarrhea, some
simple dietary changes may be necessary, as follows:
Breast-fed babies
Breast-fed babies continue to nurse. An electrolyte-containing supplement
(such as Pedialyte or Kaolyte) should be given in small amounts between
feedings to replace the electrolytes lost in the diarrhea stools. These
supplements can be found near the infant formulas in groceries and
pharmacies. As long as your baby is having wet diapers, a few additional fluids
should be all that is needed. Once stools have begun to improve, solids may be
added back if your baby had been taking them prior to the diarrhea. Stick with
the “ABC diet” - applesauce, bananas, and rice cereal - for a few days. Yogurt,
toast and crackers are other bland foods that don’t irritate diarrhea in most
children. Boiled or baked potatoes without added butter and baked chicken
may be added as well.
Bottle-fed babies
Bottle fed babies should receive an electrolyte supplement ONLY for the first
24 hours of significant diarrhea.
Good choices for electrolyte supplementation
■■ Pedialyte or Kaolyte, or a similar commercially prepared electrolyte drink.
These are available near the infant formulas in groceries and are usually
in ready-to-feed form.
■■ Gatorade may be diluted to half strength with water and used until you are
able to get to the store for a premade electrolyte drink. Any flavor is finewhatever color stool you want to clean up from the diaper! Many children
over 12-18 months find this very palatable.
■■ Jello water is not the first choice as a “clear liquid” in a child with diarrhea
but will do in a pinch until you can get to the grocery. Just mix a box of
jello with water as you normally would when making jello, then don’t chill
it but feed it at room temperature.
Bad choices for a “clear liquid” diet for diarrhea
■■ Boiled skim milk - Boiling milk is dangerous because it causes an elevated
salt content in the milk.
■■ Kool-Aid and juices - These contain too much sugar, which can worsen
diarrhea. They also don’t contain the appropriate electrolytes.
■■ Soda pop - Carbonated beverages often aggravate diarrhea, particularly
if they contain caffeine. The electrolytes needed to replace losses from
diarrhea are not present, once again.
■■ Water - Water alone can alter a child’s electrolyte status and aggravate
salt and electrolyte depletion caused by the diarrhea.
REMEMBER: When we say “clear liquids,” we don’t mean every liquid that is
After 24 hours on a “clear liquid diet,” your child should be advanced to half
strength formula. Mix his formulas as usual, then add extra water to each
bottle so the formula is only half as strong as usual. After one day of half
strength formula, you should be able to increase the formula back to the usual
After your child is tolerating formula, the “ABC diet” may be resumed if he
has been taking solid feedings in the past. (Applesauce, bananas, rice cereal,
yogurt, crackers, dry cereal, toast, plain baked potato and baked chicken.)
During this time stools may temporarily seem to worsen but should begin to
thicken and decrease in frequency over the next few days.
If your child’s diarrhea worsens as the diet is advanced, call the office during
regular hours for advice.
Older children follow basically the same plan; that is, clear liquids for 24 hours,
followed by an ABC diet and avoiding juices or milk for a few days. Raw fruits,
vegetables, bran products, beans and spices may aggravate the diarrhea as
well. If your child continues with diarrhea after several days without milk, you
may want to resume his milk intake but with Lactaid drops (available over the
counter) added to the milk or with a lactose-free milk.
Medications are rarely recommended to slow diarrhea; these usually just
prolong the symptoms. If your child has had prolonged or severe diarrhea, this
may be an option but always check with a pediatrician before using any antidiarrheal medication.
You should call the office if:
■■ Diarrhea is severe (e.g., bowel movement every hour for over 24 hours)
■■ Stools don’t improve after three to four days on the special diet
■■ Mild diarrhea lasts over two weeks
■■ You see mucus in more than one stool
■■ Your child develops signs of dehydration (a decrease in the number of wet
diapers/voids, dry tongue and mouth, increasing lethargy or refusal to
■■ Your child’s breathing becomes fast or labored
■■ Your child has severe abdominal pain
We should see your child if he or she has:
■■ Bloody diarrhea
■■ Persistent abdominal pain for more than two hours.
■■ Less than three wet diapers in a 24 hour period
■■ Stools every hour for over 24 hours
See within 24 hours if:
■■ Diarrhea for more than two weeks
■■ Fever for more than three days
The most common cause of vomiting is a viral infection of the GI tract.
Vomiting usually stops within 12 to 24 hours. It is best treated with clear
liquids in small amounts. Wait one to two hours after your child’s last episode
of vomiting, then begin with just one to two tablespoons (½ - 1 oz.) at a time
and gradually increase the amount every 20 to 30 minutes. Refer to the list of
acceptable “clear liquids” listed in the diarrhea section for examples. There are
also electrolyte popsicles available now, usually in the formula section near the
electrolyte drinks (e.g. Pedialyte, Freezer Pops).
After eight hours without vomiting, your child may begin the “ABC diet” as
discussed in the diarrhea section, then gradually resume a regular diet. In
occasional instances, a suppository for vomiting may be prescribed but these
don’t always work and can have significant side effects. For the most part,
small amounts of clear fluids by mouth are the most effective and safest
treatment of vomiting.
You should call the office if:
■■ Your infant vomits for more than 24 hours or your older child vomits for
more than 48 hours
■■ Your child develops signs of dehydration (decreased number of wet
diapers/voids, dry mouth and lips, increasing lethargy, refusal to drink)
■■ Your child becomes confused or difficult to arouse
■■ Blood appears in the vomitus
■■ The vomitus becomes dark green in color
■■ Your child develops SEVERE abdominal pain or mild abdominal pain for
more than 24 hours.
■■ Any other symptoms appear which bother you.
Food poisoning
Vomiting, abdominal cramps and diarrhea occurring two to four hours after
eating unrefrigerated meat, dressings, pastry or cream sauces may be due
to food poisoning. Treatment is supportive with clear liquids and symptoms
usually resolve in about six to 12 hours.
Constipation is never an emergency and should not be a reason for after-hours
calls. (Please see the information on normal stool descriptions in “Well Days”
Babies often grunt, strain, grimace and exhibit great effort in working up
to a good bowel movement. A breast-fed baby may actually seem to be
uncomfortable for one to two days before his/her “explosion” of a weekly
bowel movement.
Apple juice or prune juice may help soften hard stools. Usually one to two
ounces a day in infants over two months of age will do the trick.
If your infant is very uncomfortable, you may use ½ of a glycerin suppository
(available over the counter) to help the passage of any stool. Insert rectally
after lubricating the rectal opening with Vaseline.
If your child has chronic constipation, please contact the office during regular
office hours.
Common colds
Most children get around six colds per year, twice that many if they’re in
daycare. Colds (upper respiratory tract infections) are caused by direct contact
with a person who has one. They aren’t caused by cold air or drafts. Usually,
fever lasts for two to three days and the runny nose, sore throat, etc. last for
about seven to 10 days.
Over-the-counter cold medications are not particularly effective as a rule,
especially in young infants. In the first few months of life, it is better to avoid
medications in favor of using a bulb syringe to suction mucus from the nose.
Using a hot shower in the bathroom at bedtime may help to “break up” any
mucus in your baby’s nose so it drains more easily. You can also use saline
drops to help loosen secretions in your baby’s nose. These are available overthe-counter (Ayr or Ocean Spray drops, etc.) or can be made at home by mixing
¼ teaspoon of table salt with four ounces of warm water. Place two to three
drops in one nostril at a time, then suction with a bulb syringe after waiting two
to three minutes to be effective. This is most effective if done before feedings
and at bedtime and naptime.
Antibiotics do not help the common cold, and left over antibiotics should
be properly discarded. Decongestants can cause excitability or irritability in
some children and should be avoided. A cool mist vaporizer may be helpful,
particularly in the winter.
Your child should drink lots of fluids, particularly juices. Believe it or not, even
chicken soup has been shown to have some beneficial effect on the common
cold. (Grandma was right!)
If cold symptoms have lasted more than seven to 10 days and/or any of the
following signs appear, you should call the office.
Please call the office if:
■■ Your child’s fever lasts more than three days
■■ Your child’s eyes become matted
■■ Your child complains of ear pain
■■ Your child coughs up yellow mucus for more than 24 hours
■■ Your child’s breathing becomes labored
■■ Your child develops thick, green drainage from the nose after having cold
symptoms for more than seven to 10 days
Cold sores
Herpes virus of the lip (“cold sores”) is transmittable to infants and children
and can cause serious disease. Do not let anyone with a cold sore kiss or
handle your baby.
Coughing is a normal reflex to clear the lungs of mucus and protect them
from pneumonia. During the winter months, viral respiratory infections of the
trachea (windpipe) or bronchial tubes can result in a dry cough which persists
for two to three weeks. Some children develop “cough variant asthma” with a
persistent dry cough instead of wheezing. Chronic, loose night time coughs are
often present with sinus infections in older children or may be seen in children
with allergies.
There are several things you can do to make your child more comfortable
during these coughing episodes.
■■ Humidity - Dry air tends to make coughs worse. Your child should drink
plenty of fluids. A hot shower in the bathroom at bedtime will humidify the
air somewhat and may help coughing. You should NOT use Vicks or any
medication in a vaporizer if your child is under age two.
■■ No smoking - No one should smoke in the house or car around your child.
This means no smoking indoors, even in another room of the house where
the child isn’t present. The smoke still gets into the air space in the house
and eventually finds the child! Multiple studies have shown that passive
smoking aggravates chronic cough, asthma, respiratory infections and ear
infections in children. If you would like a handout specifically addressing
passive smoking and children, ask at the office and we will gladly provide
you with one.
■■ Medications - If the cough is causing your child to lose sleep, call the
office and we can prescribe a medication for use at bedtime. During
the day, it is best not to suppress the cough as it serves as protection
against developing infection in the lungs. However, in some children a
bronchodilator (e.g., albuterol) may be prescribed for use during the day.
This won’t suppress the cough but will make it more effective in clearing
any secretions from the lungs.
You should call the office if:
■■ Your child has fever for more than three days with his cough.
■■ Your child coughs up yellow mucus for more than 24 hours.
■■ Your child’s cough lasts longer than three weeks.
■■ Your child seems short of breath.
■■ Your child’s cough worsens despite treatment.
■■ The cough causes your child to miss school.
Note: If your child awakens at night, with a very BARKY COUGH and noisy
breathing, place him in the bathroom with a steamy hot shower running. If he
or she has croup (a viral infection of the trachea) this should help. Sometimes
taking a child out into the cool night air will also help. If these measures don’t
improve your child’s breathing within 10 minutes, you should call for more
instructions. Also, if your child is having severe throat pain with drooling or high
fever, CALL!
Some fever is expected, but if the fever is above 104°F, schedule an
appointment the same day or the next morning to rule out bacterial infection in
addition to croup.
Ear pain
Ear pain is common in children and may be due to middle ear infections, outer
ear infections (“swimmer’s ear”) and pressure from colds. It may also be seen
in cold weather in a child who suddenly comes indoors; this is usually not due
to infection but rather the sudden warming of air in the middle ear causing the
air to expand, putting pressure on the ear drum. Infants will often pull on their
ears not only from ear pain, but also when they are tired or teething.
If your child has a stiff neck or has had a pointed object placed in the ear
immediately prior to complaining of pain, he should be seen immediately.
Otherwise, he should be seen within 24 hours.
Call the office during regular hours if you think your child may have an ear
infection. Signs include increasing irritability and not sleeping well at night
after having had a cold for three or four days.
Until your child is seen in the office, give acetaminophen or ibuprofen (see
dosage tables under “Fever” section), elevate your child’s head, and use
a heating pad or warm towel compresses to the ear. This should keep her
comfortable until she can be seen. If all these measures aren’t helping, call for
a prescription for pain medication until your child can be seen.
Sore throat
Sore throats may be caused by viruses or bacteria (e.g., strep throat). Hot salt
water gargles, cool foods, humidified air, acetaminophen or ibuprofen and
lozenges for older children will help the pain.
Your child should be seen during regular office hours if:
1. Sore throat has been present for more than two to three days
2. Swollen or tender lymph nodes are present in the neck along with abdominal
pain or a rash
3. There has been recent exposure to strep throat or impetigo
4. White spots are present in the back of the throat
Please do not use leftover antibiotics if your child has a sore throat. The
antibiotics may be too old to do any good. Also, they don’t help viruses. If we
diagnose strep throat in your child, we will treat with an antibiotic at that time.
After 24 hours of medication, your child may return to school or day care.
Conjunctivitis (“pink eye”)
Conjunctivitis is inflammation of the white part of the eye and membranes
lining it, with or without mucus production. Viral conjunctivitis (“pink eye”)
usually presents with no other symptoms. Bacterial conjunctivitis usually
presents with more mucus, cloudy nasal drainage, cough and possibly fever.
Initial treatment at home should be washing the eye with warm water and a
washcloth to remove the mucus.
If your child is complaining of ear pain or showing signs of bacterial
conjunctivitis, call the office during regular office hours and we will help you
decide if your child should be seen.
Epidemics of chickenpox occur frequently. These appear first as small, red
bumps resembling insect bites. Within 24 to 48 hours, they change to thinwalled blisters, then open sores and finally dry crusts. Repeated crops of these
sores occur for four or five days and they may be present on any skin surface,
even in the mouth. Your child will probably have a fever with the chickenpox.
They usually develop two to three weeks after exposure to a contagious person.
A child may catch chickenpox from an older person with shingles, as shingles
represent basically a reactivation of the chickenpox virus.
Chickenpox can often be diagnosed by an experienced parent or grandparent
so an office visit isn’t needed. If unsure whether your child has the chickenpox,
call the office and we will arrange to see him or her outside of the regular office
area to avoid exposing other children in the office.
Please call immediately if your child becomes difficult to arouse, confused or
delirious, or complains of a stiff neck or severe headache.
Otherwise, your child can be managed at home. Cool baths will help the itching
and WON’T spread the chickenpox. Oatmeal soap is soothing and helps itching.
Calamine lotion applied to the chickenpox will also help the itching. Keeping
the Calamine cool in the refrigerator seems to make it more soothing.
Please note: CALADRYL is not recommended in children with chickenpox!
The Benadryl in that particular product is absorbed through the broken skin
in children with chickenpox and can result in toxic levels of Benadryl in the
system. For the same reason, Benadryl sprays or any topical form of Benadryl
is not recommended. If your child has severe itching, Benadryl MAY be given by
If your child develops sores in the mouth, popsicles, milk shakes and cool
liquids are tolerated best. Acidic and salty foods (soda pop, juices, pretzels,
etc.) should be avoided until the sores have healed. Your child’s fingernails
should be kept trimmed and hands washed often to decrease the risk of
infecting the chickenpox from scratching. If you suspect the pox may be
infected (if they become soft and golden and drain pus), call the office. Fever
may be treated with acetaminophen. Your child will no longer be contagious
after the chickenpox have scabbed over (i.e., about six to seven days). He or
she may return to school or day care after a week and needn’t wait until the
scabs have all fallen off.
Nits are pearly white in color and attach firmly to the hair shaft and are not
easily removed like dandruff. Lice bugs are 1/16 inches long and are difficult
to see. Lice crawl; they do not jump or fly. They are often found around ears and
the back of the neck.
Treatment recommendations:
■■ Nix cream rinse – Shampoo with any shampoo, then apply Nix and leave
in for 10 minutes. Rinse. If the nits are strong, you can use ½ strength
vinegar to help loosen them. Then, comb out with a fine tooth comb that
comes in the package.
■■ Ovide lotion – It is available only by prescription and is applied to the
hair, left to air dry, then washed off after eight to 12 hours. Avoid fire or
cigarettes. Ovide is flammable when wet.
■■ Mayonnaise (not fat free) – Apply to entire head and sleep in a shower
cap all night. This will smother the lice. Olive oil works too, but is more
expensive and harder to get out of your child’s hair.
General measures:
■■ Combs and brushes should be rinsed in Nix.
■■ Combs and brushes should be placed in the freezer overnight.
■■ Sheets, pillowcases, hats should be run through the wash.
■■ After being treated, your child can return to school.
■■ Most schools do require that all nits be removed, even if dead, because it
is too hard for the school nurse to be sure all nits are killed.
■■ Items unable to be washed should be tied up in a plastic sack for three
Poisoning is one of the most common medical emergencies. Each year
about 500 children in the United States die from poisoning. Most, if not all,
poisonings are preventable.
Children are naturally inquisitive and curious and will open drawers and doors
where toxic materials may be stored. Make sure that anything potentially
dangerous is locked up and away from your child. Kids are especially bad about
getting into Grandma’s purse, too! Make sure purses are empty or unavailable.
The most common ingestants are medicines, gasoline and other petroleum
products, furniture polish, household washing products, and Drano-like
products. All are potentially lethal and should be safely stored high and away
from children. Don’t store dangerous material in “friendly containers” (i.e.,
gasoline in coke bottles).
If your child does get into a toxic material and swallows some, follow these
steps to help ensure your child gets the help he needs.
Identify the drug or chemical that was ingested. Have the bottle next to
you when you call and estimate the amount taken.
Call the Poison Control Center at 800.222.1222
Or call:
IU Health Bloomington Hospital Emergency Department: 812.353.9515
IU Health Bedford Hospital Emergency Department: 812.275.1381
Keep these phone numbers on an emergency list by your phone.
Ipecac is no longer routinely recommended for poison treatment intervention
in the home. (Safely dispose of any syrup of Ipecac currently in your home.)
Minor Accidents
Cuts and scratches
Wash for five minutes with an antibacterial soap (i.e., Dial, Safeguard) and
water. Cover with a bandage or gauze. Don’t use alcohol, hydrogen peroxide
or Methiolate on open wounds; they sting and can cause tissue damage. If
bleeding hasn’t stopped after 10 minutes of continuous pressure with gauze
or cloth, or if the wound edges are gaping and you think the child may need
sutures, call for advice. If the wound begins to appear infected, with pus or red
streaks around it, call for advice. If your child’s immunizations are up to date,
no tetanus booster will be needed. If your child hasn’t had a tetanus booster
within the past 10 years, call the office during regular office hours to arrange
for a booster. This should be done within 24 hrs.
Abrasions and scrapes
Wash for five minutes with soap and water. Remove any dirty particles from
the wound with tweezers. If there is tar in the wound, it can be removed with
Vaseline. Cut any loose pieces of dirty skin away with sterile scissors. If the
wound is small, leave it open to air. If large, cover with a Telfa pad for 24 hours.
Acetaminophen or ibuprofen may be given for pain. If a very large area of your
child’s body is involved, call the office.
Puncture wounds
It may be helpful to make the wound re-bleed initially. Then soak it in hot,
soapy water for 15 minutes. These soapy water soaks should be continued
twice daily until healing occurs. A sterile dressing should be applied between
soaks. If the wound begins to look infected, call the office. If your child is up to
date on immunizations, an additional tetanus booster is NOT needed, as it is
present in the DPT vaccine. If you child is 15 years of age or older and hasn’t
had a recent tetanus booster, it may be time for one. Call the office during
regular office hours to arrange for a booster within 24 hours of injury.
Animal bites
The wound should be washed immediately with Dial or Safeguard
(antibacterial) soap. Peroxide can be used to clean if desired. It may then be
left open to air or a loose dressing applied.
Watch for signs of infection (such as red streaks or drainage at the site of the
bite). If your child is not up to date on immunizations he should come in within
24 hours for a tetanus booster. Antibiotics are needed only if the wound is very
large, requires sutures, or penetration of bone, tendon, or joint has occurred.
Also, cat bites often cause infection and usually need antibiotics. Any wound
involving the hand, foot, face, or genital area should be seen by a physician.
If the animal appears healthy, is up to date on vaccines, etc., it needs to be
watched for 10 days to be sure that it doesn’t start acting sick. If the animal
was already acting sick, it needs to be checked by a vet and still isolated and
observed for 10 days to be sure it does not exhibit any signs of rabies. If the
animal was a stray or wild animal, the police or local animal control should be
contacted to attempt to catch the animal immediately so that it can be isolated
for 10 days. If the animal is unable to be located, then the rabies series needs
to be given. Animals most likely to transmit rabies are: bats, skunks, raccoons,
foxes or large wild animals. Mice, rats, gerbils, hamsters, gophers, chipmunks
and rabbits are usually considered free of rabies. Rarely, squirrels have carried
rabies so if a squirrel was the culprit and seemed sick, further investigation is
needed. You must also call the county health department to report the attack.
Human bites
These are treated basically the same as animal bites with two exceptions:
1. Because human bites are actually more likely to become infected,
antibiotics are more often prescribed. Call the office for advice.
2. The human (in most cases) does not need to be caged up for 10 days.
These are common with trauma and during the winter when the air is dry.
During a nosebleed, pinch your child’s nose shut for 10 minutes by the clock.
Have him breathe through his mouth. This may be repeated once if the
bleeding hasn’t totally stopped following the first 10 minutes. If bleeding still
hasn’t stopped after a second attempt, call the office.
Head injury
If your child doesn’t lose consciousness, chances are no major harm was done.
Your child should be kept awake for one hour after significant head trauma;
after this, he or she may nap. Your child should be aroused every two hours
during the night following a significant blow to the head to be sure his or her
pupils are equal in size and that no unusual signs (listed below) are present.
Call immediately if your child develops:
■■ Persistent vomiting (more than twice), stiff neck or fever
■■ Unequal sized pupils or a pupil that doesn’t get smaller when you shine a
flashlight on it
■■ Confusion or unusual drowsiness
■■ Seizures or loss of consciousness
■■ Stumbling, problems talking or using the arms and legs
■■ Significant bleeding or leakage of fluid from the nose
■■ Headaches not relieved by acetaminophen or ibuprofen
If in doubt, call, especially in children under six months of age.
Very large burns, burns of the face, neck or genitals or burns encircling an arm
or leg should be seen as soon as possible by a physician. Any electrical burns
should also be seen as soon as possible.
The burned area should be rinsed immediately (don’t take time to remove
clothing) with cold water for 10 minutes. No butter, ointment or creams should
be applied.
Extensive burns should be wrapped in a wet sheet or towel and brought to the
office or emergency room.
Minor burns (red with only a few blisters) may be managed at home. They
should be washed with antibacterial soap twice daily. Blisters should NOT be
opened; the outer skin protects against infection. Small burns need not be
covered. Acetaminophen may be given for pain. Cold compresses may also be
used. If your child is unable to sleep because of pain, call for advice. If several
blisters are present, we will probably want to see the burn in the office and will
probably recommend an antibiotic cream. Bacitracin and Neosporin are both
available over-the-counter and work well for minor burns.
Any foreign body in the airway may be life-threatening. If your child is choking
but can make noise and speak, do NOT pound on his back but do seek
immediate medical attention. If the choking child is unable to breathe or make
a sound, turn her face down over your knees and forcefully give four or five
back blows with your open hand. If this fails, deliver rapid thrusts to the chest.
Repeat en route to an emergency facility if there has been no response. If you
can actually see the object, you may try to remove it with your fingers, but
only if you can actually SEE it! If you are comfortable performing the Heimlich
maneuver, this is very effective in older children.
Accident prevention
Accidents are the number one cause of death in children between the ages
of one and 16. Most accidents are preventable. Start “child-proofing” at six
Do’s and Don’t’s for Prevention of Accidents
Keep crib sides securely fastened.
Use restraints in baby feeder, carriage, stroller, car seats, etc.
Never prop baby bottles.
Do not hang or tie toys to the crib (Your baby may become entangled in
the string).
Avoid use of pillows.
High chairs should have a broad base to prevent tipping, a safety strap,
and a latch on the tray.
Teach your child the meaning of the word “HOT”
Use gates on stairways to prevent falls.
Windows should open from the top or have guards attached.
10. In the kitchen area, be alert for spattering grease, keep pot handles
turned inward, keep hot containers in the middle of the table at mealtime.
11. Always check bath water temperature; never run hot water first, as child
may fall in.
12. Be alert for small objects - peas, buttons, popcorn, beads, nuts.
13. Be sure broken glass and razor blades are safely disposed of.
14. Use safety plugs in unused wall sockets; be sure electric cords are not
frayed and secure electrical cords so lamps cannot be pulled over.
15. Be careful when using plastic bags, especially dry-cleaner bags.
16. Make sure that your child can’t got into the Drano, oven cleaner, furniture
polish, medicines, alcohol or any other toxic substance. Keep them locked
up. If you are using one of these items, put it away in a secure place
before answering the phone or doorbell.
17. Always use a car seat or seat belts, even when in someone else’s car.
18. Turn water heater temperature down lower than 130° so even the hottest
faucet water won’t burn as much.
19. Don’t use a lawn mower when children are playing nearby.
20. No peanuts or popcorn in the house until your youngest child is four or five
years old, raisins and gum until three years old.
21. Don’t turn your back on your baby when he’s on the bed, table or
bathinette. Never leave the baby alone in the bath, even for a few seconds.
22. Keep your baby away from loose cords (Venetian blind cords). Make sure
no cord hangs in or near your baby’s crib.
23. Never tie a pacifier around your baby’s neck.
24. Consider a smoke alarm near the children’s sleeping area. Develop and
practice escape routes with children in case of fire.
25. Discourage your child from running with food in his mouth.
26. Teach road safety, i.e., never run into the street, look both ways before
crossing, etc.
27. Teach bicycle safety. Require bicycle helmet use.
28. Teach water safety. Never consider a child “water-safe.”
29. Never leave your baby alone in a room with pets, no matter how gentle.
30. Put plants up and out of reach.
31. Use safety latches for cabinets.
32. Wood stoves are a leading cause of winter burns. Use safety screens.
33. Curling irons are a leading cause of burns. Keep them out of reach of your
Car seats
Automobile accidents are the leading cause of accidental death in children. For
this reason, utilization of a car seat each time your child rides in the car is an
absolute requirement. Unrestrained babies and children become flying missiles
during a collision. Their flight is stopped not usually by a parent, but rather by
the dashboard or car window. Don’t bring your child to our office unless he/she
is properly restrained!
Use of the car seat should start on your baby’s first ride home from the
hospital. You will find that children accept car seats very well. Car rides are
much more enjoyable and relaxing when children know they must be in a car
seat when riding in a car.
Car seats must be approved by the National Highway Traffic Safety
Administration and must be used as directed. If you have questions about a
particular car seat, please contact the office.
Indiana State Law requires all children from birth to age eight be properly
fastened by a child passenger restraint system. Children eight to 16 years must
use child restraints or seat belts in all vehicle types. The safest place for a child
under 13 years of age is in the back seat.
Infant Safety Seats
■■ Indiana law requires children up to 20 pounds and one year old to be in
a rear-facing car seat. The American Academy of Pediatrics recommend
infants stay rear facing until the age of two.
■■ Always face rearward
■■ Always follow manufacturer’s instructions
Convertible Child Safety Seats
■■ For infants and children up to 40 pounds
■■ For infants, recline and face rearward
■■ For toddlers, upright and forward facing
■■ Always follow manufacturer’s instructions
■■ Check to see that you have the vehicle safety belt in the right place
Booster Seats
■■ For toddlers who have outgrown convertible safety seats and weigh
approximately 35 pounds and over.
■■ Shield boosters have not been certified for use by children who weigh
more than 40 lbs.
■■ Always follow manufacturer’s instructions for use with shoulder harness or
with lap belt only.
Remember to always wear a safety belt and wear it properly. Children should
wear a lap belt low and snug. The shoulder belt should be properly adjusted
across the chest. Do not allow children to sit on a pillow, or wear a safety
belt under their arm, across the neck, over the face, too loosely or over bulky
clothing. If a safety belt cannot be fit correctly, use an approved booster seat.
Children should stay in child safety seats until they are 40 inches tall and weigh
40 pounds.
Riley Hospital for Children Safety Store
The Riley Hospital for Children Safety Store offers low-cost child safety products
and injury prevention education. The store provides an environment where
parents feel comfortable to shop, learn, and ask questions about their child’s
Products available include:
Smoke detectors
Bike helmets
Cabinet locks
Appliance locks
Baby safety gates
Window cord wraps
Gun locks
Fire smothering blankets
Riley Safety Store staff are trained to teach you and your family how to properly
use and maintain safety products and practice child safety. Staff are also ready
to answer any questions you may have about what you can do to prevent child
Bloomington location
Southern Indiana Pediatrics
651 S. Clarizz, Blvd., Bloomington
812.353.KIDS (5427)
Open Mondays & Wednesdays, 12 - 6 pm
Epilogue &
We don’t receive training to become parents. This is unfortunate because
our first child is always our “experiment.” As parents, we must be willing to
adjust to our children and learn from them while teaching them what we can.
Children thrive and excel when they are brought up in a positive atmosphere
of acceptance, happiness and approval. All children are different and need to
be treated as individuals. No two are alike! This makes parenthood extremely
interesting, challenging and, at times, frustrating.
Please make use of every opportunity to talk to and be with your child, read to
your child and play with your child. The greatest gifts we can give our children
as parents are our love, our acceptance and our time. They will then grow up to
be more confident and loving.
Most behavioral problems that children manifest are simple attempts at
getting attention. If we parents spent more time giving positive attention,
children would have less motivation to seek the negative attention they usually
get with these behaviors.
Make efforts to read parenting books and special topic books that relate
to your particular concerns. You will find your unique problems are actually
universal problems. This helps us parents realize we are not alone in our
parenting endeavors.
Finally, parenting is much easier when both parents are on the same
wavelength. Effective parenting requires, to a large degree, effective
communication between spouses.
Remember - take time to have fun along the way!
Recommended reading
Touchpoints: Your Child’s Emotional and Behavioral Development; by T. Berry
Brazelton:Addison Wesley, 1992
Caring for Your Baby and Young Child: Birth to Age 5; American Academy of
Pediatrics: Editor- in-Chief, Steven P. Shelov:Bantam Books, 1991,1993,1998,
Useful websites
Indiana University Health
Southern Indiana Pediatrics,
Indiana University Health Southern Indiana Physicians
Indiana University Health Bloomington Hospital
Indiana University Health Bedford Hospital
Indiana University Health Morgan Hospital
Indiana University Health Paoli Hospital
Riley Hospital for Children at Indiana University Health
Health, nutrition & safety
American Heart Association - Nutrition Information
CDC Travel Site
Childhood Obesity
ASK - Answers for families of kids with special needs
Children’s Hospital of Philadelphia - A resource for child safety seats and child
passenger safety
Food and Allergy Network
Healthy Kids
Indiana Perinatal Network
In Source - Indiana Resource Center for Families with Special Needs
Mothers of Asthmatics
National Network for Immunization Information
Pertussis Web Site
Safety Belt Safe U.S.A. The national non-profit organization dedicated to child
passenger safety
Blue Cross/Blue Shield
Hoosier Healthwise
Indiana Health Network (IHN)
Private Healthcare Systems (PHCS)
Sagamore Health Network
Abrasions and scrapes, 72
Crib, 39
Accident prevention, 77
Cuts and scratches, 72
Acetaminophen, 56
Advil/Motrin dosage chart, 58
Animal bites, 76
Dental care, 42
Diaper rash, 43
Diapers, 24
Barky cough, 66
Diarrhea, 59
Billing, 10
Drooling rash, 21
Booster seats, 79
Bottle feeding, 34
Bowed legs or feet, 19
Ear pain, 67
Breastfeeding, 25
Electrolyte supplementation, 60
Breathing pattern, 20
Emergency/after hours, 10
Burns, 74
Epilogue, 83
Erythema toxicum, 20
Eyes, 18
Car seat, 23, 78
Chickenpox, 69
Choking, 75
Fees, 10
Circumcision, 40
Fever, 55
Clothing, 39
First day home, 17
Cold sores, 65
Food poisoning, 63
Colic, 41
Common colds, 64
Conjunctivitis, 68
Genitals, 19
Constipation, 63
Cough, 65
Cradle cap, 40
Head, 17
Head Injury, 74
Office locations, 7
Hernias, 44
Our office, 7
Human bites, 73
Pacifiers, 49
Ibuprofen dosage chart, 58
Pink eye, 68
Immunizations, 44
Plug-in outlet adapters, 24
Immunization fees, 12
Poisoning, 71
Immunization schedule, 48
Puncture wounds, 72
Insurance, 10
Rashes, 20
Jaundice, 21
Recommended reading, 84
Riley Hospital for Children
Safety Store, 80
Lice, 70
Room temperature, 39
Routine scheduling, 8
Medicine spoon/dropper, 23
Milia, 20
Sick days, 55
Minor accidents, 72
Sick visits, 9
Mongolian spots, 20
Skin and hair care, 39
Sleep, 22
Smoking, 66
Newborn rashes, 20
Solid foods, 36
Nipples (baby), 19
Sore throat, 68
Nipples & breastfeeding, 30
Spitting up, 28, 49
Normal newborn care, 17
Stools, 21
Nose, 18
Stork bites, 20
Nosebleeds, 73
Sudden Infant Death Syndrome, 22
Sun exposure, 50
Office hours, 8
Teething, 50
Thermometer, 23
Things you’ll need, 23
Thrush, 50
Travel, 51
Travel vaccines, 51
Tylenol/Tempra dosage chart, 57
Umbilical cord, 19
Urgent Care Clinic, 10
Vomiting, 62
Well child care, 17
Well days, 17
What is normal?, 17
Bloomington - West
350 S. Landmark Ave.
Bloomington, IN 47403
4935 W. Arlington Rd.
Bloomington, IN 47404
Bloomington - East
651 S. Clarizz Blvd.
Bloomington, IN 47401
1614 25th St.
Bedford, IN 47421
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