https://www.bbc.com/news/uk-scotland-47803975

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As I’ve said elsewhere, the greatest gift you can give your newborn baby is to breastfeed exclusively until the introduction of solids. This is not mumbo jumbo, touchy-feely, tree hugger advice. This is based on plenty of hard science about the long term health benefits of breastmilk. The World Health Organisation currently recommends exclusive breastfeeding to 6 months of age, based on studies done in the late 90’s, but in the past decade it’s been shown that from an allergy point of view one can start any time from 4 months, so this has become the general advice of paediatricians throughout the world. This piece looks at when, what and how to start solids in your baby.

New parents today are bombarded with massive information overload. This is particularly true when it comes to advice about when to wean your baby onto solid foods. In days gone by you’d just follow granny’s advice. Now everyone has a list of rules, and mother and baby magazines are full of do’s and don’t’s with solids, and hardly anyone agrees with anyone else.

So when you’re trying to make head or tail of a flood of conflicting information, my general advice is to take time out for a reality check. For thousands of years mothers all over the world have been doing what their mothers told them, and their children grew up fit and healthy (providing of course that food was available). If you bear in mind that what granny told them is quite different in every part of the world, then it makes sense that there can’t be a right way and a wrong way because they all work.

With this in mind, here are some thoughts about how to introduce solids into your baby’s diet…

When?

It’s interesting that your newborn baby’s digestive system can probably break down and absorb ( i.e. digest) any food that hits the stomach. So why don’t we start them on steak, egg and chips from birth? Well, there are a few reasons…

Babies can’t chew.

The occasional baby is born with one or two teeth (‘witches teeth’), but most have none, so they can’t grind solid food into a paste that can be swallowed. In days gone by before we could puree food, this may have been the main reason for not starting solids until baby had teeth.

Babies can’t swallow.

Newborn babies have immature nervous systems which develop at a rapid pace after birth. So they can’t sit, stand, walk or talk. And they can’t swallow even pureed food. Being able to swallow mashed up food is a developmental milestone, just like sitting, and all milestones have a range of normality. So in the same way that normal babies start to sit anywhere between 5 months and 8 months, normal babies can swallow pureed food between 4 and 6 months.

Allergy issues.

In the last 10 years, research has shown that the time to start exposing babies to foreign proteins in the form of solids is between 4 and 6 months of age. If you start before 4 months (as was often the case 30 or 40 years ago), there’s a higher risk of baby developing food allergy. And more recently it’s been shown that if you delay solids well after 6 months, there’s also a higher risk of food allergy developing.

The bottom line?

Start solids between 4 and 6 months of age when baby shows signs of being ready…

• baby seems hungry most of the time, feeds more frequently and wakes more frequently at night to feed.
• baby isn’t gaining weight as well as before.
• baby shows obvious interest in your food, starts lunging at your food when you’re eating.

What?

Once again, everywhere in the world does it differently, so there’s no right and wrong way. It’s been shown that the food you eat in your pregnancy flavours the amniotic fluid, which the baby swallows and tastes in the womb. So if you’ve been eating a good mixed healthy diet while you were pregnant, those are the foods that baby is likely to prefer. The local habit is to start with rice cereal, but a pureed fruit or vegetable would be fine. There’s nothing wrong with commercial baby foods like Purity, but home cooked and liquidized food may be better because of the probiotics it contains, which will help to build the baby’s immune system.

The basic rule is to start with foods which are low allergy risk like simple fruit, vegetables and cereals. Once baby is on a fairly wide range of these, you can get going with animal protein like chicken, meat, fish and egg containing foods. If baby reacts to any new food (rash, cramps and vomiting, stuffy nose or tight chest), make a note and leave this out for a later challenge after a year of age.

I should mention that the thinking about food allergy has changed quite a lot in the past few years. If you had a lot of allergic conditions in your family, doctors used to advise that you completely avoided all foods likely to cause allergy. The thinking these days is that it’s better to expose babies from these families to tiny amounts of the common allergy-causing foods in the first year of life so that they can develop tolerance to these foods. This makes it less likely that they have sever food reactions later in childhood.

Please remember that there are no hard rules. I get frantic calls from moms who can’t remember what the magazine said about the right age to start butternut. There is no right age – just because it appeared in print doesn’t make it one of the Ten Commandments!

How?

Slowly and steadily. Start with one or two teaspoons to see if baby is ready to swallow mushy food.  If it’s a disaster and baby spits it straight back at you, try again in a couple of weeks.

If it goes well, build up fairly quickly to the equivalent of a Purity 1 jar (about 80ml). If baby completes one full meal, start a second meal of something different. When baby completes the 2nd meal, move on to the 3rd. Your goal is 3 meals a day (breakfast, lunch and supper), with breastfeeds in between, and you should reach this goal 4-6 weeks after starting.

Never try anything new at night (this is a general rule for baby things). A vomiting baby always looks worse as the sun is setting! Try new things in the morning when help is at hand if there’s a problem.

Only introduce one new food every few days so that if baby reacts, you know what the likely culprit is.

What to watch out for.

• Weight gain – too fast or too slow. It’s difficult to calculate exactly what combination of breastfeeding and solids is ideal for a baby, so be guided by the weight chart, and adjust your plan as necessary.
• Constipation – if baby’s stools become firm or putty like, use a stool softener for a few days and concentrate on high fibre vegetables and fruit rather than cereals.

I hope you find this helpful. Obviously if you run into problems, contact your health care professional.

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Translation: “During childbirth, a woman experiences so much pain, that she can almost imagine what a man feels like when he has a cold.”

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Along with provision of clean water and breastfeeding, vaccination is by far the most important health care advance for children in the past 100 years.

Why are vaccines important?

• Vaccines prevent an estimated 6 million deaths every year
• Vaccines reduce the need for antibiotic treatment, so they help with preventing resistance to antibiotics (superbugs)
• Vaccines improve productivity, reduce health care costs and promote economic growth

Remember that a mass vaccination programme is huge expense for a country like South Africa which is on a tight budget, so the government will only add a vaccine to the schedule if it makes economic sense, and the return on investment (ROI) for vaccinations (12-18%) has been shown to be even better than the ROI for education, which is quite something!

So if that’s the case…

Why are some people opposed to vaccination? 

My personal view? Because people in the developed world have been allowed to forget what the world looked like before vaccinations. Have a look at the graphic below, which shows the number of cases of vaccine preventable illnesses in the USA before and after the introduction of vaccines.

Then there’s an expectation in the developed world that we are entitled to a risk free life, and if anything goes wrong, someone is to blame. The emergence of the internet also means that any vaccine scare, real or imaginary, will spread rapidly throughout the world, as I’m sure happened with the recent incident of the HPV vaccine in Cape Town. Once again there is absolutely no proof that the vaccine had anything to do with that child’s condition, but this will not affect the negative feeling the story generates about vaccination.

So the perception is that vaccine preventable illnesses no longer exist, and therefore any real or even unproven side effect of a vaccination is unacceptable.  Is this reasonable? In other words…

Are Vaccine Preventable Illnesses still out there?

Well, yes, they most certainly are. This is shown every single time vaccine coverage (the percentage of a population which has been vaccinated) drops, either

• By design, with vaccine scares, like whooping cough in the UK in the 70’s and measles in the UK following the autism scare. The difference here was that the old (whole cell) whooping cough vaccine actually caused fairly dramatic side effects in some cases, something which the new (acellular) vaccine does not. On the other hand, the link between the MMR vaccine and autism has been proven to be false.  Either way, when the coverage drops, the number of cases rises, as does the number of deaths, and this results in the public once again accepting vaccines. The graph below shows how the number of whooping cough cases increased when the coverage dropped after the scare, and decreased again when the coverage returned to normal.

Closer to home, the outbreak of 18 431 cases of measles in 2010 saw 552 children  sick enough to be admitted to Red Cross Children’s Hospital, 18 of whom died. Worldwide, measles still causes about 134 000 deaths every year.

• By default, when chaos caused by war and social upheaval prevents vaccination from taking place. Examples would be the re-emergence of diphtheria in the Russian Federation following the collapse of the Soviet Union (this is an illness not seen for decades, which then caused more than 150 000 cases and 5000 deaths in the 1990’s), and the recent outbreaks of polio in Nigeria and Pakistan (in Nigeria Boko Haram targeted health workers, claiming the polio vaccine was a western plot to make Nigerians sterile, and in Pakistan the Taliban banned polio vaccination, killing 63 health workers).

So the illnesses are there and we are protected from them by vaccination.

Are vaccinations toxic?

The short answer is no. Millions of children are vaccinated daily in the world, so if they were toxic, you’d know about it. The main concerns have been about

• Thimerosal – this is an anti-fungal substance used as a preservative. It contains ethyl mercury which is not toxic (unlike methyl mercury which you get in some quantity in sushi, and is potentially toxic).  It does not cause autism.
• Aluminium – this binds vaccine molecules together to improve the immune response. In the first six months, a baby will get 4 mg aluminium from vaccines as compared to 10 mg from breast milk  or 40 mg from milk formula.

Do vaccinations cause autism?

No. Vaccines, and particularly the MMR vaccine, do not cause autism.

I can say this because large whole population studies in places like Denmark and Japan have shown no link between MMR and autism.

I can say this because the so-called evidence that MMR caused autism was false, and the doctor concerned has been struck off the medical register in the UK for publishing fake research (for which he was paid a lot of money).

As a result of the scare that this false research caused, unvaccinated children died of measles.

Are many vaccinations at the same time dangerous?

No. The body deals with large numbers of antigens (molecules from germs that make us produce protective antibodies and immunity) every day, even more when we have an illness like a cold, so no, there is generally no problem having more than one vaccine at a time. Some vaccines like the new measles vaccine (Measbio) are only registered for use on their own. The clinic sister will guide you.

So are there any dangers of vaccinations?

All vaccines can cause minor side effects like fever and irritability, usually easy to manage with paracetamol and over within a day.

More severe reactions like fever fits are very rare, not dangerous (see my blog on fever), and would need to be checked out by your doctor.

Severe allergic reactions (anaphylaxis) are extremely rare – approximately 1 case in 1.5 million vaccinations. They generally start within 15 minutes of the vaccination with itchy rash, swelling and shortness of breath and require urgent medical attention.

There are 2 very useful links from Western Australia which give more details of the side effects of different vaccines:-

http://healthywa.wa.gov.au/Articles/N_R/Possible-side-effects-of-vaccination

http://healthywa.wa.gov.au/Articles/U_Z/Vaccination-safety

Are vaccinations compulsory in South Africa?

Not at present, though some private schools may refuse entry to unvaccinated children.

Many countries have vaccination conditions for travel, and a vaccination record would certainly be a condition for immigration or a work visa.

The following link discusses the current position in Europe

Germany looks at fining parents not vaccinating children

Final Thoughts…

I understand that there is a lot of negative information out there which is difficult for  parents to digest, so I’ve tried to provide some balance to help decision making. A few parting thoughts…

In my years as a doctor I have seen many changes. 35 years ago I witnessed the devastation of measles in the Eastern Cape which left many children dead. I have not seen a true case of measles in my last 25 years as a paediatrician.

Meningitis caused by Haemophilus and Pneumococcus was common when I started in private practice, and I have not seen a case since the introduction of the Hib and PCV vaccines 18 and 8 years ago.

And I have so far never seen a severe vaccine reaction.

Vaccines have changed the way the world looks, and have perhaps become a victim of their own success. So people have the privilege of wondering whether or not to vaccinate their children…Surely if I keep my unvaccinated child safe and away from places they may pick diseases up, they’ll be OK?

Maybe. But only if everyone else continues to vaccinate their children, exposing them to the small risks of vaccination so that my unvaccinated child can stay safe.

And only if my child stays under my roof for the rest of his/her life, and doesn’t travel in Africa, or go on exchange to Vietnam, or do relief work in Pakistan, or stay in a boarding house or university residence, because that I can’t control.

They’re only under your care for a while. Make sure they are protected against vaccine preventable diseases for the rest of their lives.

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Their main worries seem to be

• that a high fever can in itself be harmful to a child
• that a high fever is an indicator of a serious illness

So I’ll try to cover both of these, and answer some commonly asked questions along the way.

Is a high fever harmful to a child?

No. In fact there’s a growing school of thought that we may be far too active with our treating of fevers, because a fever is part of the body’s way of fighting infection.

What about fever fits (pyrexial convulsions)?

Although they are frightening to witness, a brief fever fit (less than 10 minutes) is not harmful to the child. Lie the child on his/her side with the head slightly down, bring the temperature down with a suppository and sponging with water in front of a fan, and keep an eye on the time. Bring the child in to the nearest ER if the fit continues for more than 3-4 minutes so the fit can be stopped with medication. If the child settles after a brief fit it would be reasonable to have him/her checked in any case to find the cause of the fever.

What is a dangerous temperature?

No such thing really. On the one hand a child can have a fever fit with a temperature of 38 (and even this is not dangerous), on the other hand a common cold and sore throat can start with a fever of 39 or 40. So you treat the fever if the child looks uncomfortable, and whether the fever is 38 or 40,  the treatment is the same.

When is a fever an emergency?

1. Young babies – if a baby is less than 3 months old and suddenly has a high fever, he/she should be seen in ER for an examination and tests.
2. The very sick child – if a child of any age has a fever with other signs of a serious illness (like persistent vomiting, very drowsy/won’t wake up, shortness of breath/laboured breathing, severe headache, neck stiffness, severe rash) then an emergency visit is essential.

On the other hand if a child has no worrying signs apart from the fever, and looks better when you treat the fever with medication, it would be fine to see a doctor the next day if there is still a high temperature. Remember that even if a child has a treatable cause of fever like an ear infection or tonsillitis, an antibiotic will still take 12 to 18 hours to start working, and in this time one is still left with the job of treating the fever, so an ER visit at midnight is not essential.

Is it better to take the child to the doctor while the temperature is high?

Absolutely not. Treating a fever will never hide signs of an important illness, so don’t delay giving fever medicines. It’s reassuring if the child looks better when the temperature is down.

How should I treat a fever?

A mild fever (less than 38) in a well looking child doesn’t need treatment. For a higher temperature or if the child is very miserable, treat with paracetamol syrup (Panado or Calpol) 0.5ml per kg every 6 hours. If the child refuses or vomits the syrup, paracetamol suppositories (Empaped) can be used (125mg under a year, 250mg over a year). For very high temperatures (39-40) a lukewarm bath or sponging in front of a fan will help, and anti-inflammatory medicines like mefenamic acid (Ponstan/Ponstel), ibuprofen (Brufen/Nurofen) or diclofenac (Voltaren/Panamor suppositories in children older than 2 years) can be used together with paracetamol, also 6 hourly. Most medications will take 45-60 minutes to work.

How about my gut feel?

No-one knows a child like a mother does, and it’s been shown in studies that a mother’s instinctive feeling that there is something seriously wrong with her child will often prove to be true. So if your child has a fever and you feel something important is going on but can’t put your finger on it, rather have the child checked by a doctor.

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What causes jaundice in the newborn?

• Physiological jaundice is the most common cause (discussed above)
• Blood group mismatch, either Rhesus or ABO, between mother and baby can result in breakdown of the baby’s red blood cells (haemolysis) which causes jaundice, usually in the first 2 days of life.
• Prematurity – a premature baby is more likely to develop jaundice than a term baby because of an immature liver.
• Breastfeeding jaundice happens when the baby loses a lot of weight because of feeding problems and becomes dehydrated which makes physiological jaundice worse. The solution is breastfeeding support.
• Breastmilk jaundice –  about 2% of breastfed babies have mild jaundice from certain hormones and enzymes in breastmilk, which can last for up to 10 weeks and is absolutely harmless to the baby, who is otherwise completely well and gaining weight.

There are many other rare causes of jaundice (thyroid problems, infection or inflammation of the liver, inherited/genetic problems with red blood cells or enzymes) which mostly make the baby ill with poor feeding, weight loss, drowsiness and fever or vomiting.

Is jaundice dangerous?

If the bilirubin level gets very high it can damage the baby’s brain, so to prevent this we do a test if the baby looks very yellow to see what the level is, and treat the baby with phototherapy (lights) in hospital if the level is above a certain number. We then check the level every day until it is low enough to stop the lights. Remember that the level for starting lights is far below the level that is dangerous.

What can I do to prevent jaundice?

Getting the breastfeeding going as soon as possible will stop the baby from becoming dehydrated, which will prevent jaundice from being worse than usual. So a baby who is gaining weight after day 3 is partially protected from severe jaundice.

What should I do if my baby has jaundice?

• Well baby – if the baby is yellow enough to bother you but otherwise well, have the jaundice test done (bilirubin) and phone your doctor to discuss the result. If the level is high enough, the baby will need phototherapy in hospital. If the baby doesn’t need lights, a few minutes of sunlight in the early morning or late afternoon will help.
• Ill baby – if the baby is feeding poorly, losing weight, drowsy, feverish or vomiting he/she should be seen urgently by your doctor.

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Is gastroenteritis dangerous?  

The danger of gastro is dehydration. If you can prevent this by making sure the baby or child drinks enough, the illness will get better on it’s own.

How do I treat gastroenteritis?

• Fluid replacement is the most important thing. If your baby is breastfeeding or formula feeding, try smaller feeds more frequently. If baby vomits milk, use rehydration solution (Rehidrat, Hydrol and many others) from the chemist, since this contains the water, salt and sugar the baby is losing in the stool. Again, small frequent amounts of fluid (use a syringe or medicine measure if you have to) are less likely to be vomited out.
• Probiotic drops help the diarrhoea to settle.
• Zinc suspension (Smart Zinc or Zinplex) also helps the diarrhoea.
• Paracetamol (Panado/Calpol syrup or Empaped suppositories) will help if there’s a fever. Bringing the temperature down may also reduce vomiting.
• Barrier cream (Fissan/Bepanthen and many others) frequently and generously applied will help to prevent nappy rash.

What about antibiotics?

Most gastro is viral and doesn’t need antibiotic treatment.

Anti-diarrhoeals?

Diarrhoea medicines like Imodium can have serious side effects in children under 2 years and should not be used. They may have a place in the treatment of older children.

Anti-nausea medicines?

These medicines, particularly cyclizine (Valoid) and prochlorperazine (Stemetil) also cause severe side effects in young children and shouldn’t be use under 2 years. Ondansetron (Zofer/Zofran) may be used carefully by doctors in hospital or the ER.

Flat Coke or Rooibos tea?

Not ideal, but better than nothing. Add a half teaspoon of salt to 1 litre of flat Coke, and both a half teaspoon of salt and 6 teaspoons of sugar to 1 litre of rooibos tea.

When should I worry?

• vomiting all fluids, even little sips, or refusing all fluid – this child will dehydrate and may need to be admitted on a drip.
• signs of dehydration – sunken eyes and fontanelle (soft spot), dry mouth, no wet nappies, skin stays up when gently pinched. Child needs to be seen by a doctor.
• signs of a severe illness – high fever, drowsiness, irritability, very bloated stomach, severe stomach pain.
• blood in the stool – may need antibiotics
• chronic diarrhoea – if the diarrhoea goes on for more than a week, the child may need tests and other treatment.

If you are not sure whether your child is taking in enough fluid, have the child checked by a doctor.

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When does teething start?

Eruption of the milk teeth takes place between 6 months and 3 years of age, but the signs of teething can start weeks before the teeth emerge.

Can teething make a child very ill?

The short answer is no. Teething has been happening in every child forever, long before there were doctors or chemists, and there’s no evidence that it’s ever caused a serious health problem. On the other hand many childhood illnesses happen during the same time frame, so it’s not surprising that sometimes a serious illness at the same time as a tooth comes through.

What are the signs of teething? 

A teething baby or toddler may be niggly, chews things to relieve itchy gums, drools and may have a low grade temperature (37-38 degrees). The nose may be a bit stuffy and the stool may be a bit looser than usual. There may be a rash around the mouth from the drooling. If the child has a high fever (more than 38), one should look for other infections.

Viral infections of the mouth like herpes or herpangina can cause sores in the mouth, fever and drooling, and are common in this age group.

If the stools are watery, very frequent and foul smelling in a child who is also vomiting, it’s likely to be gastroenteritis.

Does teething cause ear infections?

Although there’s no proof that teething is linked to ear infections, I have to say that my own children got ear infections quite often when they were teething. Perhaps the mild nose congestion is the cause.

What can you do about teething?

Teething is not an illness, so there’s no specific treatment and certainly no cure.

• Something to chew on like a teething ring will help with the discomfort. Avoid traditional teething foods (biscuits, biltong or dry sausage) in young infants because of the risk of choking.
• Paracetamol (Panado/Calpol) is safe and effective for discomfort and low grade temperature.
• A barrier cream (Bepanthen or SBR Repair) will help to prevent the rash around the mouth.

What about teething gels and powders? 

Read the list of ingredients. Many contain things which can be dangerous in babies like alcohol, salicylate (related to aspirin) and local anaesthetics (benzocaine or lidocaine). My advice is to stick with Panado and a teething ring.

The take home message is that you should never blame signs of a serious illness  on teething. If your child has a very high fever, a severe rash, bad diarrhoea and vomiting, a mouth full of sores or is extremely irritable, look for another illness that may need treatment. 

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What must I do to “bring my milk in”?

Just be there. Childbirth triggers the process of milk production, so in fact you’ll make milk even if you don’t breastfeed. Having said that, regular suckling will make it all happen quicker. Latch the baby immediately after birth if possible.

Is it true that you don’t have milk for the first 2 days?

Not really. The colostrum or foremilk that you make in the first 2 days may be low volume but its very potent and provides for the baby’s needs until your milk “comes in”. So the baby takes little bits at a time, and gets by quite happily on 30 – 40 ml per day until day 3 to 4 when the milk arrives. Try to feed every 2-3 hours during this time.

How do I know if baby is getting enough?

If you have a problem free birth and your baby is well, latches nicely on a regular basis and settles between feeds, all is good. Remember the weight will always drop in the first 3 days.

If baby never settles between feeds, or is very drowsy and doesn’t latch for a long time (5 or 6 hours makes most nurses a bit anxious), you’ll get help with breastfeeding, which may sort it out. If there’s still concern we may check the baby’s blood glucose with a heel prick, and if this is low, we will give the baby a cup or syringe feed with expressed breastmilk or formula.

When does the milk “come in”?    

I keep putting this in inverted commas because you do have milk in the first few days, it’s just different. But between 48 and 72 hours after birth your breasts get obviously fuller, the milk volume gets much more, and you can actually hear it going down as baby swallows. Baby will drink for longer,  go for longer between feeds and start to settle in to a routine. The weight will start to go up. At this is the time feeding on the baby’s cues (demand feeding) will allow baby to sleep for longer periods between feeds, hopefully at night!

Should I express milk to be sure how much baby is getting?

Not necessary. Firstly, baby is much better than you are at getting milk out of your breasts, so expressing is not a true reflection. Secondly, neither you nor the baby is a machine, so the milk volume will vary from day to day and feed to feed. Feed on demand and check baby’s weight once a week, and if baby seems content and gains weight well (150-210 grams per week), you have nothing to worry about.

What foods must I avoid while I’m breastfeeding?

There is no one list that applies to everyone. Remember that a mother in India eats completely different food to a mother in Japan or England, and generally the babies are all fine. In the womb the babies gets used to the tastes of the foods that you eat because they flavour the amniotic fluid, and baby swallows this continuously, so if you continue with this healthy, balanced diet during breastfeeding if should be fine. Obviously if you notice that baby becomes fussy and uncomfortable when you raid the chocolate cupboard or eat a tomato, you’d want to make a note of this and avoid that food while you’re breastfeeding. You may in particular try to cut out cow’s milk products if baby develops allergy symptoms (cramps, eczema or a stuffy nose).

What about medications and breastfeeding?

There are 2 important questions: 1. Is the medication bad for the baby? and 2. Is the medication bad for breastfeeding?

• Most medications come through in the breast milk in small amounts, so if you have to take medicines whilst you’re breastfeeding, get advice from your doctor about whether they’re safe for the baby or not.
• Some medications reduce milk supply. Once again, don’t take anything without checking with your doctor.

So the message is try to avoid taking medicines while your breastfeeding, but if you have no choice and have to take something for an important condition, check that it’s safe to continue feeding your baby.

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