Music for baby in womb

The human brain is both wired with innate music abilities and shaped by music experience, starting in utero and continuing across the lifespan ¹⁾. A growing body of literature from music therapy, music cognition, musicology, neurosciences, and affective and behavioral sciences target fetal and neonatal life, shedding light on the emergence and early development of sound and music perception. However, the great variability present in the literature in terms, for example, of type of music exposure, means of music administration, or age at exposure, has not yet allowed a clear understanding of how music experience impacts and shapes the human infant brain in the context of early neuroplasticity ²⁾.

The wide effects of music on brain function, encompassing auditory perception, language processing, attention and memory, emotion and mood, and motor skills, have suggested the use of music as a therapeutic tool in neuropsychiatric patients, including young infants at neurodevelopmental risk. Several systematic reviews and meta-analyses have examined the therapeutic role of music in preterm infants at neurodevelopmental risk, with inconclusive results, mainly due to the variation in study quality and methodology ³⁾. In most cases, the effects of the intervention were assessed in relation to cardiorespiratory parameters, growth and feeding outcomes, length of stay, effects on behavioral state, or pain. Much less is known on the effect of music intervention on direct measures of brain function and structure or on short- and long-term neurodevelopmental outcomes ⁴⁾.

The effects of a music interventions—both live or recorded, administrated by parents or trained specialists—on very preterm infants with severe health complications or with very immature brains are currently unknown. Most of the studies in the previously reported systematic reviews and meta-analyses evaluating the effects of music interventions are limited to stable preterm infants. Moreover, music experience for preterm and full-term infants has to be accurately planned with a trained developmental specialist. Similar to all of the early interventions delivered in the neonatal intensive care units (NICU), the music administration should consider infant needs and behavioral state. There is no evidence demonstrating that a specific music (i.e., Mozart Sonata) is beneficial per se for every infant and without an individualized and intentional professional intervention ⁵⁾.

Every music intervention should respect the sound level guidelines for NICUs. The guideline was published by the American Academy of Pediatrics recommending for the combination of continuous background sound and operational sound to not exceed an hourly equivalent continuous sound level of 45 decibels ⁶⁾.

The types of music that have been tested and most frequently reported in systematic reviews include a limited pitch and dynamic range, an absence of sudden change (increase or decrease) in intensity, a slow tempo, and frequent repetitions.

Live music, directed to an individual infant ⁷⁾, either administered by singing parents or supported by professionals, is primarily suggested as an early music intervention in the frame of environmental enrichment and infant emotional development ⁸⁾. A recorded music administration should follow the principles of increasing in structure complexity and individualization to infant’s reactions. With the increase of age, following a careful individual observation, the administered music can present further degrees of acoustical complexity, such as multiple instrumentation, a moderate degree of variation or length ⁹⁾.

Early in gestation—at around 16 weeks, the fetus’s auditory system is formed ¹⁰⁾. Between the 26th and 30th weeks, the fetus is able to detect and react to sound stimuli ¹¹⁾. This period in the womb is considered to be a critical period for neurodevelopment ¹²⁾. Development of neural networks in the perinatal period is highly dependent on the intrinsic and extrinsic multisensory activity driving maturation of neuronal circuits ¹³⁾. In particular, music during prenatal and early postnatal period in rats has been shown to modulate brain development in improving learning capacities ¹⁴⁾. Music induces activity in limbic (e.g., amygdala and hippocampus) and paralimbic structures (e.g., orbitofrontal cortex, parahippocampal gyrus, and temporal poles), regions implicated in emotion generation and regulation and might therefore influence the maturation of socioemotional development ¹⁵⁾.

Vandormael et al. ¹⁶⁾ discuss how the “fine-tuning process takes place in the uterus where both internal (e.g., respiration, heart rhythm, and digestion) and external sounds (e.g., voices and music) can be perceived”. They also cite significant recent research in numerous neonatal intensive care units (NICU) conditions showing evidence that too much chaotic noise or not enough sounds, largely people’s voices, may have detrimental, or deprived conditions which can show up in delayed language capacity in toddlerhood ¹⁷⁾. In a recent review, results of 512 preterm infants among 15 recent clinical trials using live and recorded maternal voice interventions showed fewer cardiorespiratory episodes and significant improvement of physiologic and behavioral conditions ¹⁸⁾.

Few studies investigated through neurophysiological techniques the effects of fetal exposure to music. In one study, fetal exposure to a simple recorded lullaby presented 5 times per week starting from the 29th week of pregnancy until birth was compared to controls. The exposure group had significantly stronger amplitude event-related potential (ERP) responses at birth and 4 months that also correlated with the amount of prenatal exposure ¹⁹⁾. This indicates that prenatal music exposure has an effect on the neural responsiveness to sounds several months later, supporting a sustained effect of fetal memory through early infancy.

In preterm-born infants, amplitude-integrated EEG (aEEG, a restricted channel, compressed display EEG) has been utilized to investigate the effect of recording music on sleep-wake cycles, reporting positive effects of music exposure on quiet sleep in hospitalized premature infants ²⁰⁾. More recently, amplitude-integrated EEG was used to study the effect of Brahms’ Lullaby on the sleep-wake cycle of low-risk preterm infants between 33 and 37 weeks of gestation, reporting fewer interruptions of quiet sleep and increased postconceptional age sleep patterns as the result of music exposure ²¹⁾. The results, however, were called to be read with caution due to the potential conceptual flaws in the interpretation of the findings presented by the authors ²²⁾.

A recent study of 35, <32 weeks gestational age neonates revealed that those who listened to 8 minutes of pre-composed music five times per week, based on nursing assessment of developmental need (assessed on a neonatal behavioral assessment scale), timed to be offered at the moment and distinctly related to need of sleep, wakefulness-interactive, or at a time of alertness, such as prior to feeding, led to functional brain architectures (shown through fMRI) that were more similar to those of full-term newborns ²³⁾. This provided their evidence for a “beneficial effect of music on the preterm brain.” This example of identifying the timing of a music intervention is quite indicative of sensitivity to best practice needs and might provide a unique platform for the inclusion of the infant’s state and readiness for music, suggestive of a dynamic aspect of signal reading and its importance when providing intervention for the music applied.

However, the music intervention, and its meter and instruments “composed of a soothing background, bells, harp, and punji (charming snake flute) five times per week from a gestational age of 33 weeks until the MRI” may not provide aspects related to the most efficacious provisions of the music itself. Unfortunately, readers are not provided with the music applied-and when one seeks to gather the evidence and arrives at the website ²⁴⁾, the original music provided for this referenced study is not easily found.

In a recent study, of 272 infants born prematurely, and serving as their own controls within a randomized 2-week intervention period in 11 hospitals, when exposed to entrained music therapy conditions, either in parental or music therapist singing conditions, vital signs improved ²⁵⁾. Implementing song of kin; parent-selected familiar melodies, or improvised to create in-the-moment, meaningful lyrics, within a simple melodic construct, or using womb sounds simulated through the use of a quietly entrained Remo ocean disc, sleep patterns were enhanced, and heart rate patterns were more even (regulated) and soothed (promoting sleep) ²⁶⁾.

Examining the mother’s voice, and recordings of her heartbeat sounds have shown auditory cortex improvement ²⁷⁾, at 1 month in 40 infants born extremely prematurely (between 25- and 32-week gestation). Newborns were randomized to receive auditory enrichment in the form of audio recordings of maternal sounds (including their mother’s voice and heartbeat) or routine exposure to hospital environmental noise. They were shown to elicit strengthened auditory plasticity at 1 month compared to their controls. This study again used recorded sounds that were static, and not meeting the meter or condition of the premature infant’s signals in the here and now. However, the organized sounds (music) and familiarity rendered better outcomes when compared with noxious hospital noise ²⁸⁾.

Entrainment means synchronization of the beats of music with natural body function or processes. A recent study of five infants with congenital heart disease explored entrainment on the physiologic measurements of withdrawal through live singing and guitar accompaniment. This single case withdrawal pilot study examined the effects of music therapy “entrainment” on heart rate, respiratory rate, blood pressure and oxygen saturation rate, of five infants suffering from congenital heart disease, in the cardiac intensive care unit. Receiving music therapy “entrainment sessions” before and after heart surgery, and consistently, 3–5 times a week for up to 3 weeks, their physiological measures were recorded every 15 s after the music therapy intervention began, until 20 min after the intervention was complete. Although the outcomes showed improvements when “entrainment” was used from baseline to follow up, the songs implemented, when not informed by parents did not necessarily consider range, melodic content, nor musical elements. The entrainment was matched with the guitar accompaniment (many strings) rather than the singing (single-toned phrase). A metronome was instituted, which produces a static rhythm, likely not providing sensitivity to the actual shifts of heart rhythms that one would advantageously follow to match the infants’ rhythmic heart rate changes moment by moment ²⁹⁾. Even so, the study had an 80% success rate, whereby four of the five infants experienced decreases in average heart rate and respiratory rate and improvements in the derivative of the heart rate signal as well.

Neonatal intensive care units (NICU) around the world increasingly use music interventions. Recent systematic review of randomized controlled trials (RCTs) that 20 included studies encompassed 1128 participants receiving recorded or live music interventions in the NICU between 24 and 40 weeks gestational age. Twenty-six different outcomes were reported which were classified into three categories: physiological parameters; growth and feeding; behavioral state, relaxation outcomes and pain ³⁰⁾. Live music interventions were shown to improve sleep in three out of the four studies and heart rate in two out of the four studies. Recorded music improved heart rate in two out of six studies. Better feeding and sucking outcomes were reported in one study using live music and in two studies using recorded music ³¹⁾. Although music interventions show promising results in some studies, the variation in quality of the studies, age groups, outcome measures and timing of the interventions across the studies makes it difficult to draw strong conclusions on the effects of music in premature infants ³²⁾.

Music and Executive Functioning

Studies addressing very early exposure to music in (extremely) preterm born infants and a possible outcome-transfer to long-term effects on cognitive functions such as executive function or learning are rare. Therefore, it is crucial to understand music itself and how it affects, touches and possibly influences brain and cognitive development, in a broader context. Being able to trace musical stimuli through the brain and linking this activity to a possible cognitive effect provides a means toward understanding neural development across the life span. Research on the development of the human brain has indicated that the brain reaches its full level of maturity at an age of around 30 years ³³⁾.

Within these crucial years of development, the frontal lobe is one of the last to reach its full maturity ³⁴⁾. With the prefrontal cortex being the primary seat of executive functions, correlated with a possible influence of music (a combination of listening, playing and improvising), this area has the potential to influence the developing neural structures through the very complexity of the music itself and the conditions within which it is provided.

Processing music engages long fiber tracts in the brain and overlaps with regions responsible for executive functions, and we expect a stimulation of executive function when perceiving and performing music ³⁵⁾. Understanding the influence of music on executive function can, in turn, provide insight into pathologies later in life, which manifest in a form of executive dysfunction. Music therapeutically informed interventions hold the potential, to stimulate the brain, supporting processes of neural plasticity, and can offer an enhanced start into life for (extremely) prematurely born infants, who have entered this world with so often physical and cognitive disadvantages stemming from birth trauma and/or deprivation.

Music and Brain Function

Early exposure to music can have strong influences on cognitive reserve and development later in childhood ³⁶⁾. As there is limited research on the development of executive functions in preterm born children (regarding their age for neuropsychological testing) arguments from the literature which indicate improvements in executive functioning in relation to music training and exposure ³⁷⁾. This approach affords the tracing back of steps potentially contributing to neural development as informed by neural plasticity, utilizing large published data sets; a method that borrows from historical and anthropological research.

Frontal brain regions mainly process anticipation and expectation and the execution of musical thought during the event of listening and execution. Furthermore, they relate to music improvisation, which also relates to the amygdala and the hippocampus. Of note is the dorsolateral prefrontal cortex (dlPFC), which plays a crucial role in improvisation as well as in learning and memory, connecting deeper brain regions with frontal regions via the thalamocortical-thalamic loop. When it comes to music learning and its likely associated executive functioning, it is crucial to examine the difference between music listening and music playing. Both listening and especially playing music, activate a wide array of brain areas. These neural activity networks, however, should be linked in kind to cognitive processes. Understanding the differences between mere exposure to music and playing music, within a collaborative signal-reading environment, can have a significantly different outcome, especially as studies propose causality between music and far transfer domains ³⁸⁾.

Linking back to prematurely born infants, to have a deeper understanding of the impact of musical learning and its capacity to affect learning in neurologic development, it may be useful to distinguish four modalities of music participation: (1) passive listening; (2) active listening; (3) music-making; and (4) improvisation. All four, even though consecutively building upon each other, translate uniquely and distinctly to a possible effect on cognition and should, therefore, be considered as influential when analyzing the effects of music on brain function, emotion and behavior.

In premature infancy, the listening conditions might translate well within a quiet or active alert state context, and the musical vocalizing might translate to a contingent singing ³⁹⁾ or infant-directed singing ⁴⁰⁾ exploration. In such contexts, the in-the-moment improvisatory experience might be indicative of a developing repartee and one whereby the music therapist is singing back the premature infant’s vocalization, strategically on the exact pitch of the infant’s tone. Eventually, the premature infant might absorb the vibration percept and create a new tone or an interval of two tones outside of the tone of the formerly set condition. This may unfold without prompt and occur seemingly suddenly, such as a crying sound with accented phrasing, or a comforting sound wherein the rhythmic meter of the plosive mouthing sounds indicates exploration ⁴¹⁾.

Keto diet during pregnancy

Keto diet also known as ketogenic diet, is a high fat, low carbohydrate, adequate protein diet, which has been gaining support as a lifestyle diet for weight maintenance ¹⁾ and body-building purposes in healthy adults ²⁾. The “classic” ketogenic diet is a special high-fat, low-carbohydrate diet that helps to control seizures in some people with epilepsy. The ketogenic diet has been used for many years to treat children whose seizures are not responding to several different seizure medicines; however it is not usually used as a first-option treatment. There are now different forms of the keto diet and some less restrictive forms have been taken up by adults with epilepsy. The typical “classic” ketogenic diet, called the “long-chain triglyceride diet,” provides 3 to 4 grams of fat for every 1 gram of carbohydrate and protein. Keto diet is prescribed by a physician and carefully monitored by a dietitian.

The keto diet is a safe treatment for epilepsy in children. There are some possible side effects with long-term use, though, including:

• Constipation
• Kidney stones
• Dehydration
• High cholesterol levels in the blood
• Slowed growth
• Weak bones
• Bone fractures

A person starting the ketogenic diet may feel sluggish for a few days after the diet is started. This can worsen if a child is sick at the same time as the diet is started. Make sure to encourage carbohydrate-free fluids during illnesses.

The increasing use of the keto diet or ketogenic diet particularly by women of child-bearing age, raises a question about its suitability during pregnancy. A keto diet during pregnancy results in alterations in embryonic organ growth. Such alterations may be associated with organ dysfunction and potentially behavioral changes in postnatal life ³⁾. Prenatal and early postnatal exposure to a ketogenic diet also results in significant alterations to neonatal brain structure, and results in retarded physiological growth. These alterations could be accompanied by functional and behavioral changes in later postnatal life. Futhermore, keto diet while pregnant deleteriously affects maternal fertility and increases susceptibility to fatal ketoacidosis during lactation ⁴⁾.

Studies on adult humans and rodents have shown that sparse carbohydrate and glucose availability initiates a process of ketogenesis that produces ketones, which all organs – including the brain – can use for energy ⁵⁾. During pregnancy, since the embryo’s capability to carry out ketogenesis is very limited, it relies on ketone supply from maternal circulation. Ketone supply is modulated by the carriers Monocarboxylate Transporters ⁶⁾. Studies using non-ketogenic gestational diets report that Monocarboxylate Transporter expression in the placenta decreases at the end of gestation ⁷⁾, implying restricted ketone availability to the fetus. This observation seems contrary to other studies that reported an increase in ketone utilization enzymes within the brain during the second half of gestation ⁸⁾. This increase in ketone utilization enzymes was speculated to facilitate lipid and myelin (white-matter) synthesis ⁹⁾, implying greater availability would be favorable for the developing brain. A similar conclusion could be drawn from studies linking ketones and cerebral protein synthesis ¹⁰⁾. Yet, while ketones may be important metabolic substrates, an excessive supply to fetal brain can also damage nucleotide bio-synthesis, impairing nucleic acid production and brain growth ¹¹⁾.

Not only can the keto diet lead to developmental delays in your baby but it can also cause nutritional deficiencies if done incorrectly, which can lead to serious problems for both pregnant women and their babies. Many people who follow the keto diet strictly don’t eat foods like fruits, nuts, beans, and many vegetables—sources of essential micronutrients necessary for the healthy development of your baby.

What is keto diet like?

The typical “classical” ketogenic diet, called the “long-chain triglyceride diet,” provides 3 to 4 grams of fat for every 1 gram of carbohydrate and protein. That is about 90% of calories from fat. Usually when the classic ketogenic diet is prescribed, the total calories are matched to the number of calories the person needs. For example, if a child is eating a 1500 calorie regular diet, it would be changed to a 1500 calorie ketogenic diet. For very young children only, the diet may be prescribed based on weight, for example 75 to 100 calories for each kilogram (2.2 pounds) of body weight. If it sounds complicated, it is! That’s why people need a dietician’s help when using this diet.

A ketogenic diet “ratio” is the ratio of fat to carbohydrate and protein grams combined.

• A 4:1 ratio is more strict than a 3:1 ratio and is typically used for most children.
• A 3:1 ratio is typically used for infants, adolescents, and children who require higher amounts of protein or carbohydrate for some other reason.

The kinds of foods that provide fat for the ketogenic diet are butter, heavy whipping cream, mayonnaise, and oils (e.g., canola or olive). Because the amount of carbohydrate and protein in the diet have to be restricted, it is very important to prepare meals carefully. No other sources of carbohydrates can be eaten.

The ketogenic diet is supervised by:

• a dietician who monitors the child’s nutrition and can teach parents and the child what can and cannot be eaten
• a neurologist who monitors medications and overall benefits.

Typically the keto diet is started in the hospital. The child traditionally begins by fasting (except for water) under close medical supervision for 18-24 hours. The diet is then started, either by slowly increasing the calories or the ratio. Most centers today do NOT start with a fasting period. The primary reason for admission in most centers is to monitor for any increase in seizures on the diet, ensure all medications are carbohydrate-free, and educate the families.

Is the keto diet safe while you’re pregnant?

No, pregnant women shouldn’t go keto diet.

Now that you know the keto diet might be off the table, what diet should you follow?

Healthy eating during pregnancy key points

1. Healthy eating during pregnancy includes getting enough nutrients for you and your baby as well as knowing how much to eat.
2. Eat food from different groups like grains, proteins, vegetables, fruits and dairy. Some foods from these groups are good sources for nutrients like folic acid, iron, calcium and Vitamin D, which are helpful for you and your baby.
3. If you’re pregnant, thinking about getting pregnant or breastfeeding, eat 8 to 12 ounces each week of fish that are low in mercury.
4. Talk to your health care provider about nutrients, eating a healthy amount of food and when you have any concerns about your diet

Healthy eating during pregnancy includes knowing how much to eat and what foods are healthy. It’s also finding a balance between getting enough nutrients for your baby’s growth and keeping a healthy weight for you and your baby’s health. Talk to your provider about how you can get the nutrients you need in your diet.

What nutrients do I need during pregnancy to keep my baby and me healthy?

During pregnancy, you can get a lot of nutrients from different sources or food groups such as grains, proteins, vegetables, fruits, and dairy. Other sources of nutrients are fats and vitamins and minerals.

Proteins help your body with muscle and tissue growth and also with your baby’s growth. Protein can be found in foods like:

• Beef, pork, fish and poultry
• Eggs
• Milk, cheese and other dairy foods
• Beans and peas
• Nuts and Seeds
• Soy products like tempeh and tofu

Carbohydrates are found in food like grains and they’re your body’s fuel to help you do your activities. . There are different types of carbohydrates. Foods can have a combination of all three types of carbohydrates.

Simple carbohydrates are broken down fast, spiking your blood sugar quickly. It’s best to limit foods high in simple carbohydrates like:

• Table sugar
• Certain breakfast cereals
• Sugary desserts

Complex carbohydrates give longer lasting energy and can be found in:

• Whole grain products, like bread, rice and pasta
• Beans
• Starchy vegetables like potatoes and corn

Fiber is also a type of complex carbohydrate and can be found in plant foods. Fiber can help with digestion. The following foods are good sources of fiber:

• Vegetables such as cabbage, spinach, kale
• Fruits like, berries, oranges, apples and peaches with the skin
• Legumes such as chickpeas, black beans, lentils

Certain amounts of fat are also important for your body. During pregnancy, the fats you eat are a source of energy and help with your baby’s organs and the placenta. However, be careful not to eat too much saturated fat (such as butter, heavy cream and meats with high content of fat) and trans fat (often found in margarine, microwave popcorn, cookies and pastries made with vegetable shortening) because those can cause problems for your health.

Other nutrients that you need during pregnancy to keep yourself and your baby healthy include:

• Folate or Folic acid. These can help prevent birth defects of the brain and spine in your baby, called neural tube defects. This can be found in enriched and fortified products (like bread, rice, cereals), leafy green vegetables, citrus fruits and beans and peas. Enriched and fortified means the nutrient was added to a food product.
• Calcium. This strengthens bone and teeth for your baby and also helps your body stay healthy during pregnancy. Good sources of calcium are dairy products, broccoli and kale. Fortified cereals or juices may also be a good source.
• Vitamin D. This is also helpful for building your baby’s bones and teeth. Good sources include fatty fish like salmon or fortified milk or orange juice.
• Iron. This helps your body create more blood to help make sure your baby gets enough oxygen. Good sources of iron are meat products and beans. Your body can absorb iron more easily if you also get enough Vitamin C. Vitamin C can be found in orange juice, citrus fruits and strawberries.
• Docosahexaenoic acid (DHA). This is a kind of fat call an omega-3 fatty acid. This is important for brain and eye development of your baby.
• Iodine. This is a mineral that helps with your baby’s brain and nerve growth.

How much should you eat each day during pregnancy?

Most pregnant women need only about 300 extra calories per day during the last 6 months of pregnancy. A glass of skim milk two small crackers and a tablespoon of peanut butter have approximately 300 calories. The exact amount depends on your weight before pregnancy. If you’re underweight before pregnancy, you may need more calories. If you’re overweight before, you may need less. Talk to your doctor about what’s right for you.

Use this sample menu to plan healthy meals.

Knowing how big each of these serving sizes is can be tricky. Here are some everyday items that can help:

• 1 cup is about the size of a baseball.
• 1/3 cup is about as much as you can fit in your hand (a rounded or full handful).
• ½ cup is about the size of a tennis ball.
• ¼ cup is about the size of a golf ball.
• 1 tablespoon is about the size of ½ a ping pong ball.
• 1 ounce of meat (chicken, pork, beef, fish, etc.) is about the size of two thumbs.
• 3 ounces of meat is about the size of a deck of cards or the palm of your hand.
• A small fruit (orange or apple) is about the size of a tennis ball.

Go to ChooseMyPlate.gov website (https://www.choosemyplate.gov) to learn more about how to make healthy food choices during pregnancy. ChooseMyPlate shows the amounts and foods that you may want to eat at every trimester during your pregnancy. They break down food into five groups:

1. Grains. These include bread, pasta, oatmeal, cereal and tortillas.
2. Fruits. These can be fresh, frozen, canned or dried
3. Vegetables. These can be raw, cooked, frozen, canned, dried or 100% vegetable juice.
4. Dairy. These include milk and products made from milk like cheese, yogurt and ice cream. While pregnant, make sure you eat pasteurized dairy foods (this means it has gone through a heating process that makes it safer to eat) and try to choose fat-free or low-fat types.
5. Protein Foods. These include meat, poultry, seafood, beans, peas, eggs, tofu, nuts and seeds.

Follow these ChooseMyPlate guidelines:

• Make 1/2 of your plate fruits and vegetables.
• Drink skim milk or 1% milk.
• Make 1/4 of your plate grains. When you eat grains, try to use whole grains ½ of the time.
• Make 1/4 of your plate protein. Use different sources of protein such as low mercury fish 2 or 3 times a week. See more information about fish in the section below. Choose lean meats and poultry.
• Aim at eating less “empty” calories. This means the food has a lot of calories but not a lot of nutrients such as candy, chips, or sugary drinks.

Other ways to eat healthy and make sure you’re getting enough nutrients are:

• Eat snacks that have good amounts of nutrients such as fruit, cereal and yogurt. Choose snacks that are low in fat and sugar.
• You may find it easier to eat six smaller meals throughout the day. This can also be helpful later in pregnancy to avoid indigestion.
• Drink six to eight glasses of water each day.
• Take your prenatal vitamin every day. This is a multivitamin made just for pregnant women and can help you make sure you get enough folic acid and iron.
• Make sure your whole meal fits on one plate. Don’t make huge portions.

Is it okay to eat fish when you’re pregnant?

Yes, as long as you eat the right kinds! Most fish are low in fat and high in protein and other nutrients your body needs like omega-3 fatty acids. Omega-3 fatty acids are important for brain development.

Some fish have mercury, a metal that can harm your baby. When you’re pregnant, it’s OK to eat fish as long as it’s low in mercury. And be careful to limit the amount. If you’re pregnant, thinking about getting pregnant or breastfeeding, eat 8 to 12 ounces each week of fish that are low in mercury like:

• Shrimp
• Salmon
• Sardines
• Catfish
• Canned light tuna
• Albacore (white) tuna — Don’t have more than 6 ounces of this tuna in 1 week.

Figure 1. Pregnancy and fish diet

How can I eat healthy if I am a vegetarian?

If you’re a vegetarian and pregnant, it’s possible to get the nutrients you need. Talk to your provider about how to get the nutrients you and your baby need during pregnancy. Some helpful tips are:

• Make sure you get enough protein from sources like soy milk, tofu and beans. If you’re on a diet that allows for animal products, you can also eat eggs, milk and cheese.
• Eat lots of foods that have good amounts of iron such as vegetables and legumes like spinach, white beans, kidney beans and chickpeas.
• For calcium if you cannot have dairy foods, eat dark leafy greens, calcium-enriched tofu and other products enriched with calcium such as soy milk, rice milk or orange juice.
• Some cereals and milk may also be fortified with vitamin B12.

What if I have other concerns about my diet?

Some women may be lactose intolerant, they can’t fully digest lactose in dairy products. Others are unable to eat things like gluten (found in wheat, barley and rye) due to Celiac disease. Your doctor can help you plan your diet or advise you take certain supplements. Other helpful tips for healthy eating are:

• For lactose intolerant women, calcium can be found in other foods like seeds, nuts and soy. There are also lactose-free milks, cheeses and other dairy products.
• For women with Celiac disease, many gluten-free options can be found in grocery stores and include a variety of fruits, vegetables, meats potatoes, poultry and beans.

Baby poops after every feeding

It’s normal for babies will poop after every feed and some every three days. How often your baby poops and what it looks like will depend on what you are feeding your baby. Pooping after every feed is actually a good sign that your baby is getting plenty of milk. As your baby’s stomach fills up, the milk stimulates her digestive tract, giving her the urge to do a poop.

In the early weeks, your baby may poop during or after every feed. But after a few weeks, you may find that she does fewer poops as her stomach grows and her bowel movements settle into a routine. On the other hand, she may continue to poop after every feed. All babies are different.

Breastfed babies are more likely to do a poop straight after each feed than formula-fed babies. This is because formula can be harder to digest, so it takes longer to pass through your baby’s system. Even so, there’s no need to worry if your formula-fed baby does poop after every feed, especially in the early weeks.

Once your baby starts solids at six months, you may find that the frequency of her poops changes. Fiber-rich foods, such as raisins or baked beans, may pass straight through your baby without being digested, and end up in her nappy whole. This will change as she gets older and is able to digest fiber more efficiently.

As long as your baby’s poops are soft and easy to pass, there’s no cause for concern if she’s pooping after every feed. However, frequent pooping can sometimes be a sign of diarrhea. Your baby may have diarrhea if:

• Her poop is very runny.
• She is pooping more often than usual, or passing larger amounts.
• The poop is explosive and spurts out of her bottom, or runs down her leg.

Diarrhea should clear up without treatment within about a week. If it doesn’t, or if your baby has any other signs of illness, visit your doctor.

In the meantime, offer your baby her usual food and milk, and keep a close eye on her for signs of dehydration. You can also see your pharmacist for an oral rehydration solution, which helps to replace water and salts lost through diarrhea. If you suspect that your baby may be becoming dehydrated, visit your doctor as soon as possible.

How often do newborns poop?

You may be surprised at the number of diapers your newborn goes through every day.

Many newborns have at least 1 or 2 bowel movements (poops) a day. By the end of the first week, your baby may have as many as 5 to 10 a day. Your baby may pass a poop after each feeding. The number of poops may go down as your baby eats more and matures during that first month.

By 6 weeks of age, your baby may not have a bowel movement every day. This usually isn’t a problem as long as your baby seems comfortable and is healthy and growing, and as long as the poops aren’t hard.

What will the poops look like?

Your newborn baby’s bowel movements (poops) can change a lot in the days, weeks, and months after birth. The poops can come in many different colors and textures—all of which may be perfectly normal for your child.

• The first poop your baby passes is thick, greenish black, and sticky. It’s called meconium.
• The poops usually change from this thick, greenish black to green in the first few days. They’ll change to yellow or yellowish brown by the end of the first week.
• The poops of breastfed babies tend to be more yellow than those of formula-fed babies. They may also be seedy-looking.
• It’s normal for your baby’s poop to be runny or pasty, especially if he or she is breastfed.

How do poops change as your baby grows?

As your baby grows and begins eating solid foods, you may notice changes in your baby’s poop.

• When you formula-feed or breastfeed, the poop can range from soft to loose or even runny.
• When you start to give your baby solid foods, the poops will become firmer and may have a stronger odor.
• If food is not strained, you may see pieces of food in the poop.

What is normal poop color?

Many parents worry about poop color. But most color changes are caused by food coloring or additives to food and not a serious problem. When you notice a color change, think about what your baby has been eating.

• Brown, tan, yellow, and green are all normal colors for a baby’s poop. Green poops could be caused by green vegetables or green gelatin.
• Black or red poop can mean bleeding in the intestine, but it can also be caused by beets, tomato juice or soup, or red gelatin.
• A white poop could mean a liver problem. It could also be caused by medicines or a diet of milk only.

What should you watch for?

Your newborn’s soiled diapers can give you clues about your baby’s health.

Because a baby’s poop does change a lot, it can be hard to know if your baby may have a problem. In general:

• A hard or dry poop could mean that your baby is not getting enough liquids or that your baby is losing liquids because of a fever or other illness.
• An increase in the number of bowel movements or a lot of liquid in poops could be a sign of diarrhea.
• Explosive diarrhea may be a sign of infection with a virus or bacteria. Diarrhea is usually caused by a virus, and medicines don’t help. Diarrhea may cause a loss of fluid (dehydration).

What is normal pooping patterns for baby?

What’s considered normal for a baby and for months to come ranges anywhere from one poop every several days to several poops every day. Some are like the sprinters of the pooping world—fast and furious—while others are more like distance runners—slow and steady.

For the first couple of days after she’s born, your baby will pass meconium. Meconium is greeny-black in color, and has a sticky, tar-like texture. It is made up of mucus, amniotic fluid, and everything your baby has swallowed while she was in your uterus (womb). Your colostrum, or first milk, acts as a laxative, helping to push meconium out of your baby’s system.

Pooing after every feed is especially common if you’re breastfeeding your baby. It’s a sign that your baby is getting plenty of milk. As your baby’s stomach fills up, the milk stimulates her digestive tract, giving her the urge to do a poo.

Once your milk comes in, after about three days, your baby’s poos should:

• Get lighter in color, changing from a greenish-brown to bright or mustard yellow.
• Become looser in texture. The poos may seem grainy at times, curdled at others.

In the early weeks, your baby may poo pduring or after every feed. But after a few weeks, you may find that she does fewer poops as her bowel movements settle into a routine. If you continue to exclusively breastfeed your baby, it is common for her to do only one poop a week. On the other hand, she may continue to poop after every feed. All babies are different.

If you formula feed your baby, she may poop less often than breastfed babies. This is because formula milk isn’t as easily digested as breastmilk. Even so, there’s no need to worry if she does poop after every feed, especially in the early weeks. Her poo will also have a different color and smell than a breastfed baby.

• In general, breastfed babies poop more than formula-fed ones, and younger babies poop more than older ones. Newborn babies and young infants also tend to have several tiny poops in succession, so as a point of practicality we recommend waiting a few minutes until your newborn is convincingly finished rather than jumping into diaper-changing action after the first signs of activity.

Starting your baby on solids may affect the frequency of her poos. Fiber-rich foods, such as corn or baked beans, may pass straight through your baby and end up in her nappy. This will change as she gets older and is able to digest fiber more efficiently.

From your pediatrician’s perspective, the actual number of poops is likely to be less important than the fact that everything is generally moving along.

To help you distinguish between the healthy but fast and furious pooper and those newborns pooping beyond the limits of acceptability, experts in the field of newborn care suggest the following rule of thumb:

• Any time a newborn’s poop becomes progressively more watery or outpaces feeding frequency, it’s time to seek medical advice.

As long as your baby’s poops are soft and easy to pass, there’s no cause for concern. However, your baby may have diarrhea if:

• her poop is very runny
• she is pooping more often, or passing larger amounts than normal
• the poop has an offensive smell
• the poop is explosive or spurts out of her bottom

If your baby has diarrhea, the cause could be:

• an infection, such as gastroenteritis
• too much fruit or juice
• a reaction to medication
• a sensitivity or allergy to a food

Diarrhea should clear up without treatment within 24 hours. If it doesn’t, and especially if your baby is vomiting and has a fever, speak to your doctor, as your baby could become dehydrated.

Toddler throwing things

Throwing things is a new and enjoyable skill for many children between 18 months and 3 years of age. It takes fine-motor skills to open the fingers and let go of an object, and considerable hand-eye coordination to actually throw it. Your toddler discovers that whatever she throws falls down – never up. She can’t say “gravity,” but she can certainly observe its effects. If she throws a ball, it bounces. If she tosses a plum, it goes splat. Of course, for you it’s maddening when spaghetti winds up all over your just-mopped kitchen floor or a clean pacifier lands on a dirty sidewalk, but to your toddler, it’s all great fun.

Unless your toddler’s throwing a rock through a window or really threatening to hurt someone, don’t give him a time-out or punish him. It’s futile to try to stop your child from throwing at this age. Concentrate instead on limiting what he throws and where he throws it with these tips.

Show her what she can throw. Your toddler will learn what not to throw more quickly if there are lots of things that she is allowed – and even encouraged – to throw. Balls are an obvious choice (stocking up on foam balls will minimize accidents indoors). But actual throwing games (like tossing beanbags in a basket or skipping stones on a pond) are even more fun for a 2-year-old, especially if you play with her.

The message you want to convey is that throwing things is fine if she throws the right things in the right place at the right time. When she throws something inappropriate, like a shoe, calmly take it away from her and say, ‘Shoes aren’t for throwing, but balls are.’ Then give her a ball to play with.

But parents can help kids learn self-control and teach them how to respond without just acting on impulse.

Teaching self-control is one of the most important things that parents can do for their kids because these skills are some of the most important for success later in life.

When kids are out of control

As difficult as it may be, resist the urge to yell when you’re disciplining your kids. Instead, be firm and matter of fact. During a child’s meltdown, stay calm and explain that yelling, throwing a tantrum, and slamming doors are unacceptable behaviors that have consequences — and say what those consequences are.

Your actions will show that tantrums won’t get kids the upper hand. For example, if your child gets upset in the grocery store after you’ve explained why you won’t buy candy, don’t give in — thus demonstrating that the tantrum was both unacceptable and ineffective.

Also, consider speaking to your child’s teachers about classroom settings and appropriate behavior expectations. Ask if problem-solving is taught or demonstrated in school.

And model good self-control yourself. If you’re in an irritating situation in front of your kids, tell them why you’re frustrated and then discuss potential solutions to the problem. For example, if you’ve misplaced your keys, instead of getting upset, tell your kids the keys are missing and then search for them together. If they don’t turn up, take the next constructive step (like retracing your steps when you last had the keys in-hand). Show that good emotional control and problem solving are the ways to deal with a difficult situation.

If you continue to have difficulties, ask your doctor if family counseling sessions might help.

How to teach kids learn self-control

By learning self-control, kids can make appropriate decisions and respond to stressful situations in ways that can yield positive outcomes.

For example, if you say that you’re not serving ice cream until after dinner, your child may cry, plead, or even scream in the hopes that you will give in. But with self-control, your child can understand that a temper tantrum means you’ll take away the ice cream for good and that it’s wiser to wait patiently.

Discipline is helping your child learn how to behave – as well as how not to behave. It works best when you have a warm and loving relationship with your child.

Discipline doesn’t mean punishment. In fact, discipline and discipline strategies are positive. They’re built on talking and listening, and they guide children towards:

• knowing what behavior is appropriate, whether it’s at home, a friend’s house, child care, preschool or school
• managing their own behavior and developing important skills like the ability to get along well with others
• learning to understand, manage and express their feelings.

The ways that you use discipline will change depending on what’s happening for your child at different stages of development.

Here are a few suggestions on how to help kids learn to control their behavior:

Babies

Babies do things to test their developing skills. They also enjoy making things happen. For example, your baby probably likes getting a reaction when he pulls your hair.

But babies don’t understand consequences. They also don’t know the difference between right and wrong.

This means that negative consequences, or punishment, don’t work for babies.

Instead, babies need warm, loving care so they feel secure. So when your baby pulls your hair, you might say ‘no’ and show him how to touch your hair gently. You’ll probably need to do this over and over again because your baby might not remember from one time to the next.

Toddlers

Toddlers often struggle with big feelings like frustration and anger. Their social and emotional skills are only just starting to develop, and they might be testing out their growing independence. Toddlers often respond with temper tantrums. Try to prevent outbursts by distracting your little one with toys or other activities.

You can help your child behave well by tuning in to his feelings, changing the environment, distracting him and planning ahead for challenging situations.

For kids reaching the 2-year-old mark, try a brief timeout in a designated area — like a kitchen chair or bottom stair — to show the consequences for outbursts and teach that it’s better to take some time alone instead of throwing a tantrum.

The key is to keep the time-out brief (a good rule of thumb is 60 seconds for every year of age) so your child doesn’t forget why she was made to stop what she was doing.

If she persists in throwing things in a hurtful manner, even though you’ve tried to deter her calmly and consistently, you may have no choice but to keep a close eye on the toys she plays with and shadow her while she plays with them.

Fasten his toys to his seat. When he’s in his stroller or car seat, try attaching a few playthings within easy reach (tie the toys with short pieces of string and trim the ends so they can’t get wrapped around his neck). He’ll quickly discover that in addition to throwing the objects, he can fish them back again. Double the fun for him, half the work for you.

Clean up together. Don’t ask your toddler to pick up everything he throws. That’s an overwhelming task for a child this age. Instead, try getting down on your hands and knees together and enlisting his help by saying, “Let’s see how fast we can pick up the blocks together,” or, “Can you help me find all the yellow M&M pieces?”

Set a good example. You don’t have to avoid casually tossing a pillow on the sofa to set a good example for your toddler. In fact, you can use the items you normally toss around your home to show her what’s good to throw and what’s not. The next time she throws something she shouldn’t, take a tour of your house together and toss socks in the hamper, tissues in the wastebasket, and toys in the toy chest instead.

Sit with him at mealtimes. This is a messy eating stage, but you can often avoid the worst of it by sitting with your toddler while he eats. That way you’re right there to gently but firmly tell him no when he makes a move to toss his lunch and to hold his plate down with your hand if need be. Parents should always sit with their children at mealtimes to engage them in conversation and help develop their language skills. It’s also the best way to make sure your toddler chews his food before swallowing so he doesn’t choke.

Use toddler-proof dishes. Never use your fine china or even breakable stoneware to feed your toddler. Instead, try getting her a special toddler dish with suction cups that fasten to the table or highchair tray so she can’t pick up the dish. Keep in mind, though, that while these work well enough that a casual grab won’t send her dish scuttling across the floor, they won’t stop a child who’s amazed to find her dish “stuck” and is determined to pry it off.

To minimize spills, give beverages in a cup with a snap-on lid. You can also try handing your child the cup when she’s ready for a drink, but keeping it out of reach between sips.

Stick to small portions. You’ll waste less and your toddler will have less ammunition if you serve him tiny portions of finger foods and hold off on dishing up more until he’s eaten what’s there. Don’t push him to eat more than he wants to unless your pediatrician says he’s having trouble thriving.

Most kids don’t start throwing their food until they’ve finished eating and grown bored. So, no matter how much he’s eaten, take your toddler’s food-flinging as a sign that he’s finished his meal. To avoid teaching him that flinging food is the right way to end a meal, calmly remind him, “Food isn’t for throwing,” before removing him from the table or highchair.

You might want to say something like, “Food is for eating, not for playing. You must not be hungry, so let’s put your lunch away.” To let him know you mean business, don’t feed him again until the next meal. You shouldn’t have to rearrange your family’s meal schedule, but it may help to feed your toddler only when he’s hungry.

If a bit of food does escape his hands, either by accident or on purpose, try to keep some perspective about it. After all, a dropped slice of bread or a pinch of grated cheese on the floor may be annoying, but we all drop things sometimes

Behavior management

Behavior management is about guiding your child’s behavior so that she learns the appropriate way to behave. Behavior management strategies work best when you’re putting time and effort into building a positive atmosphere at home and strengthening your family relationships with affection and communication.

Good family relationships help your child feel secure and loved. This is what children need to grow and learn.

A positive and constructive approach is often the best way to guide your child’s behavior. This means giving your child attention when he behaves well, rather than just punishing him when he does something you don’t like.

But it’s normal for children to behave in challenging ways at different stages and in particular situations. So trying to understand your child’s behavior is an important step in managing it. This way you can choose a reliable behavior management option that’s well matched to the causes of your child’s behavior.

And if you use behavior management strategies at the same time as you nurture strong family relationships, you’re well on your way to helping your child learn about appropriate behavior.

The first step to child behavior management

If you can understand why your child is behaving in a particular way, you can work out how best to respond. So before you choose behavior management strategies, it’s a good idea to check a few things.

• First, if your child’s behavior changes suddenly, check whether your child is healthy and getting enough sleep. Sometimes challenging behavior is the first sign that children aren’t well. If you’re not sure, take your child to your doctor for a check-up.
• Next think about your child’s development. It’s good to keep in mind that different kinds of challenging behavior are normal at different stages of development. For example, tantrums are very common in toddlers and preschoolers, because at this age children have big feelings and not enough words to express them.
• Third, consider whether there have been any changes in your family life that might affect your child’s behavior. For example, challenging behavior is normal after the birth of a new baby, when children start school or after a death in the family.

Understanding the developmental reasons and emotions behind your child’s behavior doesn’t mean you can ignore challenging behavior, but it does help you work out how to respond. Also, knowing what’s typical at different stages and in different circumstances helps you know whether you need extra help with your child’s behavior.

Choosing behavior management tools that are right for you

No single behavior management strategy will fix everything. Some strategies might work better than others for your family and situation. You’ll probably have to use a few strategies in combination. If you’re managing challenging behavior in children with autism spectrum disorder, you might need extra support.

Tried and tested behavior management strategies

• When you’re choosing behavior management strategies to guide your child’s behavior, you want options that will work.
• All the behavior management options on this website are based on reliable research evidence. And they’ve been tried and tested many times in many practical family situations.
• You might still have to try a few different options to work out what best suits your child’s age and stage and your family circumstances.

Four steps towards discipline and better child behavior

Clear expectations for your child’s behavior are the foundation of discipline for your child. Here’s how to get started.

1. Decide on family rules

A good place to start is with 4-5 family rules. For example, your family rules might be things like:

• We speak nicely to each other.
• We look after other people.
• Everyone helps out around the house.
• We look after our own belongings.

Children as young as three can help you make the rules and talk about why your family needs them.

2. Be a role model for the behavior you expect

Children learn by watching what you do. Showing your child the behavior you like by doing it yourself will help your child learn. For example, if you want your child to sit down to eat, sitting down together to eat family meals can help children learn this behavior.

3. Praise your child for good behavior

Praise is when you tell your child what you like about her or her behavior. When your child gets praise for behaving well, she’s likely to want to keep behaving well.

Descriptive praise is when you tell your child exactly what it is that you like. It’s best for encouraging good behavior. For example, ‘John, I really like how you used please and thank you just then. Great manners!’

4. Set clear limits and consequences

Decide on a consequence for breaking a family rule. For example, if your eight-year-old hasn’t done his household chores, the consequence might be the loss of pocket money for the week.

When you use consequences in the same way and for the same behavior every time, your child knows what to expect.

Ages 3 to 5

You can continue to use timeouts, but rather than setting a specific time limit, end timeouts when your child calms down. This helps kids improve their sense of self-control. And it’s just as important to praise your child for not losing control in frustrating or difficult situations by saying things like, “I like how you stayed calm” or “Good job keeping your cool.”

Ages 6 to 9

As kids enter school, they’re better able to understand the idea of consequences and that they can choose good or bad behavior. It may help your child to imagine a stop sign that must be obeyed and think about a situation before responding. Encourage your child to walk away from a frustrating situation for a few minutes to cool off instead of having an outburst. Praise kids when they do walk away and cool off — they’ll be more likely to use those skills in the future.

Ages 10 to 12

Older kids usually better understand their feelings. Encourage them to think about what’s causing them to lose control and then analyze it. Explain that sometimes situations that are upsetting at first don’t end up being so awful. Urge kids to take time to think before responding to a situation. Help them to understand that it’s not the situation that’s upset them — it’s what they think about the situation that makes them angry. Compliment them as they use their self-control skills.

Ages 13 to 17

By now kids should be able to control most of their actions. But remind teens to think about long-term consequences. Urge them to pause to evaluate upsetting situations before responding and talk through problems rather than losing control, slamming doors, or yelling. If necessary, discipline your teen by taking away certain privileges to reinforce the message that self-control is an important skill. Allow him or her to earn the privileges back by demonstrating self-control.

Finger feeding baby

Finger-feeding is a technique that allows you to feed your baby if your baby is not attaching to your breast for feeds (latching-on) and without giving your baby an artificial nipple. Finger feeding is also a method that helps train the baby to take the breast. Your baby is not attaching to your breast for feeds (latching-on) can be a common challenge for both mother and baby in the early days but, with the right support, you will both be breastfeeding soon. During the time that your baby is not attaching to your breast it is important to make sure they receive your expressed breast milk. In the very early days this can be given using an oral syringe, as the first milk (called colostrum) is thick and sticky. However, as your milk supply increases it becomes thinner/more liquid, and it becomes unsafe to feed your baby in this way as there is a greater risk of choking.

Some babies can find it difficult to attach to the breast if they are fed with artificial teats/bottles or given dummies while they are learning to breastfeed. This can be because of two things:

1. They get a faster and more continuous milk flow from the bottle.
2. They have to use a different mouth, jaw and tongue action with a dummy/artificial teat compared to suckling at the breast.

Finger-feeding is a short-term solution to bridge the gap while your baby learns to attach to your breast, meaning you can choose not to introduce an artificial teat and bottle. There are several benefits that have been seen and recorded of finger-feeding over bottle-feeding if you are intending to breastfeed:

• Finger-feeding attempts to mimic the experience of breastfeeding more closely than feeding with a bottle.
• Your baby has to suck for a few seconds before they receive the milk, just like breastfeeding.
• Your baby must keep their tongue forward over their bottom gum, have a wide mouth (this is why using your largest finger is best) and have their jaw forward – all things they need to do when breastfeeding.
• It allows your baby to control the flow of milk and means that your baby has to actively feed rather than just swallow – just as if breastfeeding.
• It encourages your baby to co-ordinate their tongue movements and associate this with reward (milk).

Finger feeding may be used if:

1. Your baby refuses your breast for whatever reason or if your baby is too sleepy at the breast to breastfeed well. It is also a very good way to wake up a sleepy baby during the first few days of life and there are concerns about intake.
2. Your baby does not seem to be able to latch on to the breast properly, and thus does not get milk well. However, if your baby is latching on, even not well, then it is better to use a lactation aid at the breast to give extra milk.
3. The baby is separated from the mother, for whatever reason. However, in such a situation, a cup is probably a better method of feeding the baby. Since finger feeding should be used primarily to help a baby take the breast when he/she is reluctant or temporarily unable, the best technique is not finger feeding if the mother is not present to breastfeed him/her.
4. Breastfeeding is stopped temporarily there are very few legitimate reasons to stop breastfeeding.
5. Your nipples are so sore that you cannot put your baby to the breast. Finger feeding for several days may allow your nipples to heal without causing more problems by getting the baby used to an artificial nipple. Cup feeding is also more appropriate in this situation and takes less time. Taking a baby off the breast should be a last resort only but too often is done as a first resort. Proper positioning and a good latch help sore nipples far more than finger feeding. And a good “all purpose nipple ointment” will help as well. The so called “nipple holiday” is not advisable and if suggested within the first few days of life may be a terrible mistake. Taking the baby off the breast does not always result in painless feedings once you start again and sometimes the baby will refuse to latch on.

Finger feeding is much more similar to breastfeeding than is bottle feeding. In order to finger feed, the baby must keep his tongue down and forward over the gums, his mouth wide (the larger the finger used, the better so using a baby finger to do finger feeding is not a good idea), and his jaw forward. Furthermore, the motion of the tongue and jaw is similar to what the baby does while feeding at the breast. Finger feeding is best used to prepare the baby who is refusing to latch on to take the breast. It needs to be done only for a minute or two, at the most, just before trying the baby on the breast if the baby is refusing to latch on. See video clip Finger feed to latch. If the mother is not present to feed the baby or if the baby still doesn’t latch on after the finger feeding is attempted, then feeding the baby with a cup is better than finger feeding which can be slow.

Figure 1. Finger-feeding using a syringe (fasten the syringe to your clothing)

Figure 2. Finger-feeding using a bottle (the bottle should be on a flat surface so the fluid in the bottle is level with the baby’s head.)

Figure 3. How to finger-feed your baby (your finger is inserted just past the first knuckle, soft side up, just as far as where the hard palate meets the soft palate)

How to finger-feed your baby

Finger-feeding is essentially a glorified straw. You will be using a tube called a nasogastric tube (NG tube) taped to your finger and will let your baby suck from it while the other end is in the milk.

To finger feed newborn baby you’ll need these:

• Nasogastric tube (NG tube) size 5French, 93 cm or 36 inches long
• Soft tape
• Scissors
• Teat
• Bottle or a syringe without a needle with the plunger removed
• Your expressed breastmilk, donor breast milk (or artificial milk if neither of these are available).

Instructions:

1. Wash your hands and make sure your nails are not too long. Parents can use their bare finger or thumb, or you can cover your hand with a hospital glove. Health-care professions will wear a glove if they finger feed your baby. Make sure the nail on the finger or thumb that you will use is cut short so that you do not hurt your baby’s mouth.
2. Cut a larger hole in the top of the teat, using scissors. Then attach the teat to the bottle of milk.
   1. If you are using a bottle, pour the feeding supplement into the bottle. Put the wide end of the feeding tube into the feeding supplement. Put the small end of the feeding tube through the enlarged nipple hole, leaving the large end of the tube touching the bottom of the bottle. Place the bottle on a flat surface close to you so the fluid is at the same level as your baby’s head.
   2. If you are using a syringe, attach the wide end of the feeding tube to the tip of the syringe. Pour the feeding supplement into the syringe. Place the elastic band around the top of the syringe. Then put a safety pin through the end of the elastic. Pin the syringe to your clothing so the bottom of the syringe is at the same level with your baby’s head.
3. Cut off the flap/stopper of the nasogastric tube, but leave the black end in place.
4. Post the black end through the hole you have made in the teat and into the milk.
5. Place the other end of the nasogastric tube so that it is level with the tip of your biggest finger (pad-side facing upwards).
6. Secure the tube to your finger using the soft tape; stick this a few centimeters away from your finger-tip.
7. Cuddle your baby close with your baby on your lap. It is best to position yourself and the baby comfortably. Your baby should be facing you. The baby’s head should be supported with one hand behind his shoulders and neck; the baby should be on your lap, half seated. Your baby should be sitting almost upright, but at a little bit of an angle. However, any position which is comfortable for you and the baby and which allows you to keep your finger flat in the baby’s mouth will do.
8. Gently encourage your baby to root and open their mouth. This can be done by stroking their cheek or top lip. Once your baby opens their mouth, gently insert your finger or thumb soft side up (pad-side facing upwards). Place the thin end of the feeding tube on your finger so that the end of the feeding tube is at the end of your finger. Tape the feeding tube in place behind the second joint of your finger or the first joint of your thumb.
9. Move your finger back and forth slightly along the baby’s tongue if you need to encourage your baby to suck.
10. Allow your baby to suck your finger and the milk will gradually be pulled up the tube (like a straw).
11. Let your fingertip move to the back of the baby’s mouth with each suck. Your finger should just touch the ridge at the top of the mouth where the hard part of the mouth becomes soft. Your finger will be in your baby’s mouth up to between the first and second knuckle.
12. Make sure your baby is getting enough feeding supplement. The feeding supplement should flow when the baby sucks and stop when the baby stops sucking. Your baby is getting enough feeding supplement if you can hear them swallowing with each suck.

The nasogastric tube is not likely to become blocked. If your baby gags, just move your finger back so that it is not so far into their mouth.

If you are having trouble getting the baby to latch on to or to suckle at the breast, remember that a ravenous baby can make the going very difficult. Take the edge off his hunger by using the finger feeding technique for a minute or so. Once the baby has settled a little, and sucks well on your finger (usually only a minute or so), try offering the breast again. If you still encounter difficulty, do not be discouraged. Go back to finger feeding and try again later in the feed or next feeding. This technique usually works. Sometimes several days, or on occasion a week or more, of finger feeding are necessary, however.

After you leave hospital, if you need any help with finger-feeding, breastfeeding or have any other questions, please speak to your community midwife and/or the Infant Feeding Team. If you are discharged home finger-feeding, a follow-up will also be arranged for you to see how you are getting on with breastfeeding.

Finger-feeding troubleshooting

If your baby is not getting enough feeding supplement, try the following things:

• Check for bends or kinks in the feeding tube.
• Check the position of the feeding tube in your baby’s mouth.
• Raise the bottle or syringe higher above the level of your baby’s head.

If your baby is getting the feeding supplement too fast, lower the bottle or syringe so it is below the level of your baby’s head.

How much and how long to finger feed?

It is important that you understand why you are finger feeding your baby. If you cannot breastfeed your baby a few times a day, or even for a whole day, your baby can still get enough milk to satisfy their hunger if they are finger fed properly.

Finger feeding should not take longer than any other method of feeding. Thirty to 40 minutes is usually long enough.

Ask your baby’s nurse or dietitian how much feeding supplement your baby should be getting at each feeding and how often they should be fed. This information will give you an idea of how much breast milk or formula to prepare and how often your baby might want to eat.

Breast milk empties from the stomach very easily and faster than formula. For this reason, babies may eat more often when they are having breast milk than when they are having formula.
Giving a supplement by finger feeding when breastfeeding

If you are using finger feeding to give a feeding supplement to your baby who is already feeding at the breast, you should ask the dietitian about the following things:

• How much feeding supplement to give your baby.
• How often you should feed your baby.
• How to make the feeding supplement.
• How to wean your baby off the feeding supplement.

Ask your doctor how long the finger feedings should continue

Your doctor or health-care worker who has special training in how to breastfeed babies will tell you how long you should continue to finger feed your baby. See your family doctor three days after your baby leaves the hospital. After that, take your baby to the doctor for a regular check-up every week.

When you visit the doctor, they will weigh your baby and ask you about how you feed your baby. The doctor will tell you how well your baby is gaining weight and if you still need to give your baby a feeding supplement.

These are important signs that your baby is feeding well:

• Your baby is gaining weight.
• Your baby has at least six to eight soaking wet diapers every 24 hours.
• Your baby has two or more bowel movements (poos) every 24 hours in the first month of life.
• After a month, your baby may not have as many bowel movements but should still have six to eight soaking wet diapers every 24 hours.

Once your baby is gaining weight and latching on well to the breast, you may not need to give your baby extra feeding supplement any longer.

If you have any concerns about your baby at any time, talk to your doctor.

If you have concerns about the supplement you are feeding your baby, call your health-care worker.

How to clean finger feeding supplies

Cleaning your finger feeding supplies is easy. You can use your finger feeding supplies at home as long as you clean the supplies thoroughly right after you feed your baby. Follow these steps to clean the supplies:

• Wash your finger-feeding supplies with warm soapy water.
• Rinse the supplies well with warm clean water. Make sure there is no dry feeding supplement left in the feeding supplies.
• Keep the feeding supplies wrapped in a clean towel or in a sealed plastic bag after you wash them.

The feeding tube can generally be used for seven days or until it becomes hard.

Note: You should not boil the feeding supplies because boiling will make the plastic hard too quickly.

Uroflowmetry

Uroflowmetry is a simple, diagnostic screening procedure used to measures the flow rate of urine over time (urine speed and urine volume). Uroflowmetry tracks how fast urine flows, how much flows out, and how long it takes. It’s a diagnostic test to assess how well your urinary tract functions. Your doctor may suggest uroflowmetry if you have trouble urinating, or have a slow stream. Uroflowmetry test is noninvasive (the skin is not pierced), and may be used to assess bladder and sphincter function. Uroflowmetry measurements are performed in a health care provider’s office; no anesthesia is needed.

By measuring the average and top rates of urine flow, this test can show an obstruction in your urinary tract such as an enlarged prostate. When combined with the cystometrogram, uroflowmetry can help find problems like a weak bladder.

For uroflowmetry test, you should arrive at the doctor’s office with a fairly full bladder. If possible, do not urinate for a few hours before the test.

You will be asked to urinate privately into a special toilet that has a container for collecting the urine and a scale or a funnel connected to the electronic uroflowmeter. The equipment creates a graph that shows changes in urine flow rate from second to second so your doctor can see when the flow rate is the highest and how many seconds it takes to get there. This records information about your urine flow on a flow chart. The flow rate is calculated as milliliters (ml) of urine passed per second. Both average and top flow rates are measured.

Results of this test will be abnormal if the bladder muscles are weak or urine flow is blocked. Another approach to measuring flow rate is to record the time it takes to urinate into a special container that accurately measures the volume of urine.

Common urine flow patterns:

• Flow rate (Q): Volume of fluid expelled via the urethra per unit time (mL/s).
• Voided volume (V_void): Total volume expelled via the urethra (mL).
• Average flow rate (Q_ave): Voided volume divided by the flow time.
• Maximum flow rate (Q_max): Maximum measured value of the flow rate after correction for artefacts.
• Voiding time: Total duration of micturition (second).
• Flow time: Time over which measurable flow actually occurs.
• Time to maximum flow: Elapsed time from onset of flow to maximum flow.

The fastest flow rate, also known as maximum flow rate (Q_max), is used to understand if a block or obstruction is severe.

Your doctor will know your test results right away. Average results are based on your age and sex.

• Typically, urine flow rate from 10 ml to 21 ml per second. Women range closer to 15 ml to 18 ml per second.
• A slow or low flow rate may mean there is an obstruction at the bladder neck or in the urethra, an enlarged prostate, or a weak bladder.
• A fast or high flow rate may mean there are weak muscles around the urethra, or urinary incontinence problems.

You may be asked to take other tests to fully learn what’s going on for treatment. Your urologist will create a treatment plan based on test results and your health history.

Facts about urine:

• Adults pass about a quart and a half of urine each day, depending on the fluids and foods consumed.
• The volume of urine formed at night is about half that formed in the daytime.
• Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi.
• The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall.

Figure 1. Uroflowmetry

How does the urinary system work?

The body takes nutrients from food and converts them to energy. After the body has taken the food components that it needs, waste products are left behind in the bowel and in the blood.

The urinary system helps the body to eliminate liquid waste called urea and keeps the chemicals, such as potassium and sodium, and water in balance. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys, where it is removed along with water and other wastes in the form of urine.

Urinary system parts and their functions:

• Two kidneys. This pair of purplish-brown organs is located below the ribs toward the middle of the back. Their function is to remove liquid waste from the blood in the form of urine, keep a stable balance of salts and other substances in the blood, and produce erythropoietin, a hormone that aids the formation of red blood cells. The kidneys also help to regulate blood pressure. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
• Two ureters. These narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.
• Bladder. This triangle-shaped, hollow organ is located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder’s walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.
• Two sphincter muscles. These circular muscles help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder
• Nerves in the bladder. The nerves alert a person when it is time to urinate, or empty the bladder
• Urethra. This tube allows urine to pass outside the body

Figure 2. Urinary system and anatomy

Reasons for the uroflowmetry test

Uroflowmetry is a quick, simple diagnostic screening test that provides valuable feedback about the health of the lower urinary tract. It is commonly performed to determine if there is obstruction to normal urine outflow. Medical conditions that can alter the normal flow of urine include, but are not limited to, the following:

• Benign prostatic hypertrophy. A benign enlargement of the prostate gland that usually occurs in men over age 50. Enlargement of the prostate interferes with normal passage of urine from the bladder. If left untreated, the enlarged prostate can obstruct the bladder completely.
• Cancer of the prostate, or bladder tumor.
• Urinary incontinence. Involuntary release of urine from the bladder.
• Urinary blockage. Obstruction of the urinary tract can occur for many reasons along any part of the urinary tract from kidneys to urethra. Urinary obstruction can lead to a backflow of urine causing infection, scarring, or kidney failure if untreated.
• Neurogenic bladder dysfunction. Improper function of the bladder due to an alteration in the nervous system, such as a spinal cord lesion or injury.
• Frequent urinary tract infections.

Uroflowmetry may be performed in conjunction with other diagnostic procedures, such as cystometry, cystography, retrograde cystography, and cystoscopy.

There may be other reasons for your doctor to recommend uroflowmetry.

Urine flow rate test

Uroflowmetry is performed by having a person urinate into a special funnel that is connected to a measuring instrument. The measuring instrument calculates the amount of urine, rate of flow in seconds, and length of time until completion of the void. This information is converted into a graph and interpreted by a doctor. The information helps evaluate function of the lower urinary tract or help determine if there is an obstruction of normal urine outflow.

During normal urination, the initial urine stream starts slowly, but almost immediately speeds up until the bladder is nearly empty. The urine flow then slows again until the bladder is empty. In persons with a urinary tract obstruction, this pattern of flow is altered, and increases and decreases more gradually. The uroflowmeter graphs this information, taking into account the person’s gender and age. Depending on the results of the procedure, other tests may be recommended by your doctor.

Other related procedures that may be used to diagnose urinary outflow obstruction or lower urinary tract dysfunction include cystometry, cystography, retrograde cystography, and cystoscopy.

Before the urology flow rate test

• Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• Generally, no prior preparation, such as fasting or sedation, is required.
• You may be instructed to drink about four glasses of water several hours before the test is performed to ensure that your bladder is full. In addition, you should not empty your bladder before arriving for the procedure.
• If you are pregnant or suspect that you are pregnant, you should notify your doctor.
• Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
• Based on your medical condition, your doctor may request other specific preparation.

During the urology flow rate test

Uroflowmetry may be performed on an outpatient basis or as part of your stay in the hospital. Procedures may vary depending on your condition and your doctor’s practices.

Generally, uroflowmetry follows this process:

1. You will be taken into the procedure area and instructed how to use the uroflowmetry device.
2. When you are ready to urinate, you will press the flowmeter start button and count for five seconds before beginning urination.
3. You will begin to urinate into the funnel device that is attached to the regular commode. The flowmeter will record information as you are urinating.
4. You should not push or strain as you urinate. You should remain as still as possible.
5. When you have finished urinating, you will count for five seconds and press the flowmeter button again.
6. You should not put any toilet paper into the funnel device.
7. The procedure will be concluded at this point. Depending on your specific medical condition, you may be asked to perform the test on several consecutive days.

After the urology flow rate test

Generally, there is no special type of care following uroflowmetry. However, your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Uroflowmetry normal flow

There is great variation in uroflowmetry parameters even in the non‐symptomatic population ¹⁾, although flow curves are generally repeatable for the same patient. In particular, there are no definitive ‘normal’ ranges for maximum flow rate (Q_max), although it decreases with age and voided volume (but not in a directly proportional manner). Males aged <40 years usually have a Q_max of >25 mL/s, and females usually have a Q_max of 5–10 mL/s more than males at a given bladder volume. Beware the ‘normal flow’ that in fact represents the effect of a compensatory increase in the voiding pressure generated by the detrusor in patients with bladder outlet obstruction ²⁾.

Decreased urine flow

This is the most common abnormal flow trace seen in practice and is represented by a dampened curve with decreased Qmax and prolonged flow time. A significantly decreased Qmax (generally accepted as <15 mL/s) cannot be used to distinguish between BOO in men, outflow obstruction in women, and impaired detrusor contractility 6; in appropriate cases, formal multichannel urodynamic studies with concomitant measurements of flow and detrusor pressures are important to delineate between these conditions.

Despite the limitations, Qmax remains the single best non‐invasive urodynamic test to detect possible lower urinary tract obstruction. The test is also useful in some clinical situations to guide further evaluation to predict outcome after surgery and for preoperative counseling:

• Males with a Qmax above the threshold value of 15 mL/s (or 12 mL/s) ³⁾ may have a poorer outcome after prostate surgery for presumed bladder outlet obstruction ⁴⁾ and these men should be considered for formal urodynamics to arrive at a definite diagnosis and decrease treatment failures.
• Females undergoing mid‐urethral sling surgery with a Qmax of <15 mL/s at preoperative uroflowmetry are more likely to fail a trial of void after sling surgery ⁵⁾.

Plateau urine flow

A long flow time, associated with a poor flow is typical of a stricture in the lower urinary tract. Another commonly encountered scenario is the patient with post‐radical prostatectomy incontinence. One should suspect an anastomotic stricture if this flow curve pattern is seen in the office during initial postoperative assessment. The patient should be considered for a cystoscopy with a view to treat the stricture as the next step in management, rather than referral for a formal urodynamic study as difficult catheterisation is commonly encountered.

Intermittent urine flow

This may be seen in patients who void with some abdominal straining due to bladder outlet obstruction or a poorly contractile detrusor, and is often superimposed on a decreased or plateauing curve pattern.

‘Saw‐tooth’ urine flow

Often pathogneumonic of detrusor‐sphincter‐dyssynergia, this curve should prompt urgent pressure‐flow studies to investigate high intravesical pressures that might damage the upper tracts.

‘Super‐voider’

This is seen after surgery for bladder outlet obstruction (e.g. TURP or urethroplasty), in patients with decreased urethral resistance (e.g. intrinsic urethral sphincter deficiency), or occasionally in those with detrusor overactivity. It may be considered ‘normal’ if there are no symptoms or signs to suggest underlying pathology, and is sometimes seen in young healthy female patients who may have a Qmax exceeding 40 mL/s.

‘Kicking the bucket’, and other artefacts

Urologists must be wary of artefacts and always compare the automated printout reading with the curve and clinical context. Smooth muscle physiology suggests that there should not be any abrupt spikes on a trace. A patient who accidentally kicks the flowmeter can appear to have a ‘normal’ Qmax. Other artefacts created by abdominal straining, squeezing the prepuce, or even variations in the direction of the urinary stream (within the funnel of the uroflowmeter) are common and urologists must recognise these.

Uroflowmetry procedure risks

Because uroflowmetry is a noninvasive procedure, it is safe for most persons. The test is usually done in privacy to ensure that the person voids in a natural setting.

There may be risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Certain factors or conditions may interfere with the accuracy of uroflowmetry. These factors include, but are not limited to, the following:

• Straining with urination
• Body movement during urination
• Certain medications that affect bladder and sphincter muscle tone

Anemia of prematurity

Anemia of prematurity means that a baby born early (prematurely) does not have enough red blood cells. Red blood cells carry oxygen to the body. Preterm infants with birth weight <1.0 kg (commonly designated as extremely low birth weight or ELBW, infants) have completed ≤29 weeks of gestation, and nearly all will need red blood cell (RBC) transfusions during the first weeks of life. Every week in the United States, approximately 10,000 infants are born prematurely (ie, <37 weeks of gestation), with 600 (6%) of these preterm infants being extremely low birth weight ¹⁾. Approximately 90% of extremely low birth weight neonates will receive at least one red blood cell transfusion ²⁾.

All babies have some anemia (decrease in hemoglobin concentration) when they are born. In healthy term infants, the nadir hemoglobin value rarely falls below 10 g/dL at an age of 10 to 12 weeks ³⁾. This is normal and is called “physiological anemia of infancy”. For the term infant, a physiologic and usually asymptomatic anemia is observed 8-12 weeks after birth. But in premature babies, the number of red blood cells may decrease faster and go lower than in full-term babies. This may happen because:

• A premature baby may not make enough red blood cells.
• A premature baby may need tests that require blood samples. It may be hard for the baby to produce enough red blood cells to make up for the blood that’s taken out and used in the tests.
• A baby’s red blood cells don’t live as long as an older child’s red blood cells.

Anemia of prematurity is an exaggerated, pathologic response of the preterm infant to this transition. Anemia of prematurity is a normocytic, normochromic, hyporegenerative anemia characterized by a low serum erythropoietin (EPO) level, often despite a remarkably reduced hemoglobin concentration ⁴⁾. Nutritional deficiencies of iron, vitamin E, vitamin B-12, and folate may exaggerate the degree of anemia, as may blood loss and/or a reduced red cell life span.

The anemia of prematurity is caused by untimely birth occurring before placental iron transport and fetal erythropoiesis are complete, by phlebotomy blood losses taken for laboratory testing, by low plasma levels of erythropoietin due to both diminished production and accelerated catabolism, by rapid body growth and need for commensurate increase in red cell volume/mass, and by disorders causing red blood cell losses due to bleeding and/or hemolysis ⁵⁾.

The risk of anemia of prematurity is inversely related to gestational maturity and birthweight ⁶⁾. As many as half of infants of less than 32 weeks gestation develop anemia of prematurity. Anemia of prematurity is not typically a significant issue for infants born beyond 32 weeks’ gestation.

Race and sex have no influence on the incidence of anemia of prematurity.

Testosterone is believed to be at least partially responsible for a slightly higher hemoglobin level in male infants at birth, but this effect is of no significance with regard to risk of anemia of prematurity. The nadir of the hemoglobin level is typically observed 4-10 weeks after birth in the tiniest infants, with hemoglobin levels of 8-10 g/dL if birthweight was 1200-1400 grams, or 6-9 g/dL at birth weights of less than 1200 grams and to approximately 7 g/dL in infants with birth weights <1 kg ⁷⁾.

Anemia of prematurity is usually not serious. Anemia of prematurity spontaneously resolves in many premature infants within 3-6 months of birth ⁸⁾. In others, however, medical intervention is required, because the low oxygen levels in a premature infant can make other problems worse, such as heart and lung problems. Most infants with birth weight <1.0 kg are given multiple red blood cell (RBC) transfusions within the first few weeks of life ⁹⁾.

Red blood cell transfusions are the mainstay of therapy for anemia of prematurity with recombinant human erythropoietin (EPO) largely unused because it fails to substantially diminish red blood cell transfusion needs despite exerting substantial erythropoietic effects on neonatal marrow.

Anemia of prematurity causes

The three basic mechanisms for the development of anemia of prematurity include:

1. Inadequate red blood cell production,
2. Shortened red blood cell life span,
3. Blood loss.

Taken together, the premature infant is at risk for the development of anemia of prematurity because of limited red blood cell synthesis during rapid growth, a diminished red blood cell life span, and an increased loss of red blood cells.

Inadequate red blood cell production

The first mechanism of anemia is inadequate red blood cell production for the growing premature infant. The location of erythropoietin (EPO) and red blood cell production changes during gestation. Erythropoietin (EPO) synthesis initially occurs in the fetal liver but gradually shifts toward the kidney as gestation advances. By the end of gestation, however, the liver remains the major source of erythropoietin (EPO).

Fetal erythrocytes are produced in the yolk sac during the first few weeks of embryogenesis. The fetal liver becomes more important as gestation advances and, by the end of the first trimester, has become the primary site of erythropoiesis. Bone marrow then begins to take on a more active role in producing erythrocytes. By about 32 weeks’ gestation, the burden of erythrocyte production in the fetus is shared evenly by liver and bone marrow. By 40 weeks’ gestation, the marrow is the sole erythroid organ. Premature delivery does not accelerate the ontogeny of these processes.

Although erythropoietin (EPO) is not the only erythropoietic growth factor in the fetus, it is the most important. Erythropoietin (EPO) is synthesized in response to anemia and consequent relative tissue hypoxia. The degree of anemia and hypoxia required to stimulate erythropoietin (EPO) production is far greater for the fetal liver than for the fetal kidney. Erythropoietin (EPO) production may not be stimulated until a hemoglobin concentration of 6-7 g/dL is reached. As a result, new red blood cell production in the extremely premature infant, whose liver remains the major site of erythropoietin (EPO) production, is blunted despite what may be marked anemia. In addition, erythropoietin (EPO), whether endogenously produced or exogenously administered, has a larger volume of distribution and is more rapidly eliminated by neonates, resulting in a curtailed time for bone marrow stimulation.

Erythroid progenitors in premature infants are quite responsive to erythropoietin (EPO), but the response may be blunted if iron or other substrate or co-factor stores are insufficient. Another potential problem is that while the infant may respond appropriately to increased erythropoietin (EPO) concentrations with increased reticulocyte counts, rapid growth may prevent the appropriate increase in hemoglobin concentration.

Shortened red blood cell life span or hemolysis

Also important in the development of anemia of prematurity is that the average life span of a neonatal red blood cell is only one half to two thirds that of an adult red blood cell. Cells of the most immature infants may survive only 35-50 days. The shortened red blood cell life span of the neonate is a result of multiple factors, including diminished levels of intracellular adenosine triphosphate (ATP), carnitine, and enzyme activity; increased susceptibility to lipid peroxidation; and increased susceptibility of the cell membrane to fragmentation.

Blood loss

Finally, blood loss may contribute to the development of anemia of prematurity. If the neonate is held above the placenta for a time after delivery, fetal-placental transfer of blood may occur. Conversely, delayed cord clamping may lessen the degree of anemia of prematurity ¹⁰⁾, although a study by Elimian et al ¹¹⁾ did not find this to be true. More commonly, because of the need to closely monitor the tiny infant, frequent samples of blood are removed for various tests. These losses are often 5-10% of the total blood volume.

Anemia of prematurity differential diagnoses

Conditions to consider in the differential diagnosis of anemia of prematurity are those which diminish red cell production, increase red cell destruction, or cause blood loss.

• Acute Anemia
• Birth Trauma
• Chronic Anemia
• Head Trauma
• Hemolytic Disease of the Newborn
• Parvovirus B19 Infection
• Intraventricular Hemorrhage in the Preterm Infant

Conditions that diminish red blood cell synthesis are as follows:

• Bone marrow infiltration
• Bone marrow depression (eg, pancytopenia, drugs)
• Diamond-Blackfan anemia
• Substrate deficiencies (eg, iron, vitamin E, folic acid)
• Congenital fetal infections (eg, cytomegalovirus, parvovirus, syphilis)

Conditions that cause hemolysis are as follows:

• Congenital fetal infections (eg, cytomegalovirus, parvovirus, syphilis)
• Acute systemic infections (leading to disseminated intravascular coagulation)
• Abnormal red blood cells (spherocytosis, elliptocytosis)
• Nonspherocytic hemolytic anemias (eg, G6PD deficiency, kinase and isomerase deficiencies)
• Hemolytic disease of the newborn (Rh, ABO, other major blood-group incompatibilities between mother and fetus)

Conditions that reduce blood volume are as follows:

• Twin-to-twin transfusion syndrome (donor twin)
• Iatrogenic (eg, excessive blood sampling)
• Hemorrhage (eg, gastrointestinal, central nervous system, subcutaneous tissues)

Anemia of prematurity symptoms

Many clinical findings have been attributed to anemia of prematurity, but they are neither specific nor diagnostic. These symptoms may include the following:

• Poor weight gain despite adequate caloric intake
• Cardiorespiratory symptoms such as tachycardia, tachypnea, and flow murmurs
• Decreased activity, lethargy, and difficulty with oral feeding
• Pallor
• Increase in apneic and bradycardic episodes, and worsened periodic breathing
• Metabolic acidemia – Increased lactic acid secondary to increased cellular anaerobic metabolism in relatively hypoxic tissues

Anemia of prematurity diagnosis

The following are useful laboratory studies:

• Complete blood count (CBC) – White blood cell (WBC) and platelet values are normal in anemia of prematurity. Low hemoglobin values, below 10 g/dL, are found. They may descend to a nadir of 6-7 g/dL. Lowest levels are generally observed in the smallest infants. Red blood cell indices are normal (eg, normochromic, normocytic) for age.
• Reticulocyte count – The reticulocyte count is low when the degree of anemia is considered, as a result of the low levels of erythropoietin (EPO). Conversely, an elevated reticulocyte count is not consistent with the diagnosis of anemia of prematurity.
• Peripheral blood smear – Red blood cell morphology should be normal. Red blood cell precursors may appear to be more prominent.
• Maternal and infant blood typing; direct antibody test (Coombs) – The direct Coombs test result may be coincidentally positive. Despite this, it is important to ensure an immune-mediated hemolytic process related to maternal-fetal blood group incompatibility (hemolytic disease of the newborn) is not present.
• Serum bilirubin – An elevated serum bilirubin level should suggest other possible explanations for the anemia. These would include hemolytic entities, such as G-6-PD deficiency or other kinase/isomerase/enzyme deficiencies, or more common causes such as infection or hemolytic disease of the newborn.
• Lactic acid – Elevated lactic acid levels have been suggested by some to be useful as an aid to determine the need for transfusion.

Anemia of prematurity treatment

Medical treatment options are blood transfusion(s), recombinant erythropoietin (EPO) treatment, and observation.

Observation may be the best course of action for infants who are asymptomatic, not acutely ill, and are receiving adequate nutrition. Adequate amounts of vitamin E, vitamin B-12, folate, and iron are important to blunt the expected decline in hemoglobin levels in the premature infant. Periodic measurements of the hematocrit level in infants with anemia of prematurity are necessary after hospital discharge. Once a steady increase in the hematocrit level has been established, only routine checks are required.

Packed red blood cell transfusions

Packed red blood cell transfusions are the mainstay of therapy for anemia of prematurity. The frequency of blood transfusion varies with gestational age, degree of illness, and, interestingly, the hospital evaluated. Unfortunately, there is considerable disagreement about the indication, timing, and efficacy of packed red blood cell transfusion.

Guidelines for transfusing red blood cells to preterm neonates are controversial, and practices vary greatly ¹²⁾. This lack of a universal approach stems from limited knowledge of the cellular and molecular biology of erythropoiesis during the perinatal period, an incomplete understanding of infant physiological/adaptive responses to anemia, and contrary/controversial transfusion practice guidelines as based on results of randomized clinical trials and expert opinions. Generally, red blood cell transfusions are given to maintain a level of blood hemoglobin or hematocrit believed to be optimal for each neonate’s clinical condition. Guidelines for red blood cell transfusions, judged to be reasonable by most neonatologists to treat the anaemia of prematurity, are listed by Table 1. These guidelines are very general, and it is important that terms such as “severe” and “symptomatic” be defined to fit local transfusion practices/policies. Importantly, guidelines are not mandates for red blood cell transfusions that must be followed; they simply suggest situations when an red blood cell transfusion would be judged to be reasonable/acceptable.

The decision to give a transfusion should not be made lightly, because significant infectious, hematologic, immunologic, and metabolic complications are possible. Late-onset necrotizing enterocolitis has been reported in stable-growing premature infants electively transfused for anemia of prematurity ¹³⁾. Transfusions also transiently decrease erythropoiesis and EPO levels. There is also agreement that the number of transfusions, as well as the number of donor exposures, should be reduced as much as possible.

Clinical trials designed to determine the efficacy of blood transfusions in relieving symptoms ascribed to anemia of prematurity have produced conflicting results ¹⁴⁾. Improved growth has been an inconsistent finding. While some studies have demonstrated a decrease in apneic episodes after blood transfusion, others have found similar results with simple crystalloid volume expansion.

Subjective improvement in activity, decreased lethargy, and improved feeding have been described in some studies. Blood transfusions have been documented to decrease lactic acid levels in otherwise healthy preterm infants who are anemic. Blood transfusions have reduced tachycardia in anemic infants who are transfused.

Some medical professionals have suggested using lactate levels as an aid in determining the need for transfusion.

Table 1. Allogeneic red blood cell transfusions for the anemia of prematurity

Transfuse to maintain the blood hematocrit per each clinical situation:

• > 40% (35 to 45% ^*) for severe cardiopulmonary disease
• > 30% for moderate cardiopulmonary disease
• > 30% for major surgery
• >25% (20 to 25% ^*) for symptomatic anemia
• > 20% for asymptomatic anemia

*Reflects practices that vary among neonatologists. Thus, any value within range is acceptable for local practices.

Reducing the number of transfusions

Studies from individual centers have documented a marked decrease in the administration of packed red blood cell transfusions in the past decades, even before the use of EPO became more frequent. This decrease in transfusions is almost certainly multifactorial in origin. Adoption of standardized transfusion protocols that take various factors into account, including hemoglobin levels, degree of cardiorespiratory disease, and traditional signs and symptoms of pathologic anemia, are acknowledged as an important factor in this reduction. A restricted transfusion protocol may decrease the number of transfusions while also decreasing the hematocrit at discharge ¹⁵⁾.

A 2011 study ¹⁶⁾ evaluated 41 preterm infants with birth weights of 500-1300 g who were enrolled in a clinical trial that compared high and low hematocrit thresholds for transfusion. A rise in systemic oxygen transport and a decrease in lactic acid after transfusion was noted in both groups; however, oxygen consumption did not change significantly in either group. In the low hematocrit group only, cardiac output and fractional oxygen extraction fell after transfusion, which shows that these infants had increased their cardiac output to maintain adequate tissue oxygen delivery in response to anemia. The results demonstrate that infants with low hematocrit thresholds may benefit from transfusion, while transfusion in those with high hematocrit thresholds may provide no acute physiological benefit ¹⁷⁾.

The Premature Infant in Need of Transfusion study ¹⁸⁾ showed that transfusing infants to maintain higher hemoglobin level (8.5-13.5 g/dL) conferred no benefit in terms of mortality, severe morbidity, or apnea intervention compared with infants transfused to maintain a low hemoglobin levels (7.5-11.5 g/dL).

These findings differ from the Iowa study, which found less parenchymal brain hemorrhage, periventricular leukomalacia, and apnea in infants whose transfusion criteria was not restricted and whose hemoglobin level was higher. Clearly, no universally accepted guidelines for transfusion in infants with anemia of prematurity are available at this time, and clinicians must determine their individual standardized transfusion practices.

Anemia of prematurity guidelines

No universally accepted guidelines for transfusion in infants with anemia of prematurity are available at this time, and clinicians must determine their individual standardized transfusion practices.

As an example, note the Children’s Hospital of Wisconsin Transfusion Committee guidelines for consideration:

• An infant with a hemoglobin (Hb) level of less than 8 g/dL may be transfused at the discretion of the attending physician
• A stable infant with a hemoglobin level of 8-10 g/dL without clinical symptoms or other exceptions listed below may be transfused
• An infant with a hemoglobin level of 11-13 g/dL without a supplemental oxygen or continuous positive airway pressure (CPAP) requirement, apnea/bradycardia, significant tachycardia or tachypnea, or other exceptions listed below should not be transfused
• An infant with a hemoglobin level of more than 13 g/dL without an oxygen requirement of more than 40% by hood, CPAP, or ventilator; hypotension that requires pressor medication; major surgery; or other exceptions listed below should not be transfused
• An infant with a hemoglobin level of more than 15 g/dL without cyanotic heart disease, extracorporeal membrane oxygenation (ECMO) therapy, regional oxygen saturations less than 50%, or hypotension that requires pressor medications should not be transfused
• An infant with a history of massive blood loss may be transfused at the discretion of the attending physician

It is of obvious importance to discuss with the family their child’s need for transfusion and to obtain consent before the transfusion. It is also important to discuss with parents the normal course of anemia, the criteria for and risks associated with transfusions, and the advantages and disadvantages of erythropoietin (EPO) administration. Also necessary is consideration of the family’s religious beliefs regarding transfusions.

Reducing the number of donor exposures

Reducing the number of donor exposures is also important. Preservatives and additive systems allow blood to be stored safely for as long as 35-42 days. This can be accomplished by using packed red blood cells stored in preservatives (eg, citrate-phosphate-dextrose-adenine [CPDA-1]) and additive systems (eg, Adsol). Infants may be assigned a specific unit of blood, which may suffice for treatment during their entire hospitalization and thus limit exposure to the single donor of that unit. Concerns that stored blood might increase serum potassium levels are unfounded if the transfused volume is low.

Complications

Potential complications of transfusion include the following:

• Infection (eg, hepatitis, cytomegalovirus [CMV], human immunodeficiency virus [HIV], syphilis)
• Fluid overload and electrolyte imbalances
• Exposure to plasticizers
• Hemolysis
• Posttransfusion graft versus host disease

An important tool in reducing at least one of these transfusion risks is to use all available screening techniques for infection. The risk of cytomegalovirus (CMV) transmission can be dramatically reduced by use of CMV-safe blood. This can be accomplished by using CMV serology–negative cells, along with blood processed through leukocyte-reduction filters or inverted spin technique. These methods also reduce other WBC-associated infectious agents (eg, Epstein-Barr virus, retroviruses, Yersinia enterocolitica) by yielding a leukocyte-poor suspension of packed red blood cells. The American Red Cross now provides exclusively leukocyte-reduced blood to hospitals in the United States.

Recombinant Erythropoietin treatment

Multiple investigations have established that premature infants respond to exogenously administered recombinant human EPO and supplemental iron with a brisk reticulocytosis. Subcutaneous administration of EPO may be preferred, as intravenous administration has increased urinary losses. Although EPO cannot prevent early transfusions, modest decreases in the frequency of late packed red blood cell transfusions have been documented. Additional iron supplementation is necessary during exogenous EPO treatment.

Trials have evaluated the impact of EPO treatment in populations of the most immature neonates. These studies likewise have demonstrated that infants with very low birth weight (VLBW) are capable of responding to EPO with a reticulocytosis.

Studies and a Cochrane Neonatal Systemic review suggest an association between exogenous EPO administration and retinopathy of prematurity ¹⁹⁾.

Yasmeen et al ²⁰⁾ studied 60 preterm low birth weight infants and concluded that short-term recombinant human erythropoietin with iron and folic acid was effective in preventing anemia of prematurity.

EPO with iron does not adversely affect growth or developmental outcomes, but the impact on the number of transfusions a premature infant receives ranges from nonexistent to small.

At this time, no agreement regarding the safety, timing, dosing, route, or duration of therapy has been established. In short, the cost-benefit ratio for EPO has yet to be clearly established, and this medication is not universally accepted as a standard therapy for an infant with anemia of prematurity.

Anemia of prematurity prognosis

Spontaneous recovery of mild anemia of prematurity may occur 3-6 months after birth. In more severe, symptomatic cases, medical intervention may be required.

Baby not smiling

Smiles are the first building blocks of warm, loving and responsive relationships. Smiles and frowns are the first way your baby relates to you. Smiles are very important early positive experiences. Smiles teach your baby a lot about himself and his world, when he’s too young to understand words. When you and your child smile at each other, it releases chemicals in your bodies that make you both feel happy and safe. On the other hand, if a baby is feeling insecure or stressed, there’s an increase in the stress hormones in her body. It’s worth remembering that a simple smile is one building block for your relationship with your child. Your face is where your child looks for reassuring, comforting responses and attention. Each smile your baby sees sends a great message that she’s loved and cherished. The more grins you share with baby, the more you’ll be rewarded with smiles.

Many babies start to smile at around 7 weeks. If your baby’s first smile is taking a little longer, it’s perfectly normal. Not all babies are natural smilers. Your baby may show his pleasure in other ways, such as by making cooing sounds or vigorous movements.

You may find that your baby isn’t quite ready to smile yet because he’s still too busy adjusting to the world around him. He may show this by looking away when you talk to him face-to-face.

This is a useful strategy for a baby, as it lets him control how much stimulation he gets. It doesn’t mean he’s not interested in you or upset with you, just that he’s overwhelmed by all his new experiences.

If your baby was premature or ill at birth, he’ll probably be quite easily overwhelmed by stimulation. Watch his body language to gauge just how much attention he can cope with at any one time. You may find that he needs more time before he can do the same things as other babies his age.

It’s a good idea to measure your premature baby’s development against the age he would be if he had been born on his due date, instead of his actual date of birth. This will give you a better idea of what he’s able to do, and when.

Your baby is wired to relate to you. Smiling is a part of this, whether it occurs at seven weeks or at a later age.

If you want to encourage your baby to smile, it’s best to wait until he is comfortable and ready to play. When your baby is quiet and alert, he’s probably ready to talk and play. It is also when he is most likely to smile. Look for times when your baby is calm and relaxed, yet still paying close attention to the world around him.

Make sure your baby can see you clearly. Hold your face about 30cm from his, then talk to him and smile. Give your baby some time to see if he wants to respond.

To avoid overstimulating your baby, give him a chance to rest between short bursts of play. Some babies need long breaks before they are ready for more play time, while other babies recover more quickly.

Watch your baby’s behavior and wait for signs that he is ready to interact with you again. When your baby looks at you intently and examines your face, he’s ready. This is the time when he is most likely to start to smile!

Some babies like to look at you for a long time before they smile. Keep talking to him softly, whilst smiling yourself, if you think he’s about to grin.

If your baby often turns away when you talk to him, don’t press him to respond. Just smile at him without talking the next time he looks at you. Try not to worry if it takes a while before your baby is comfortable smiling back. It’s a big and confusing world for him!

The more you watch and learn about your baby, the more likely it is that you’ll be able to work out his individual pace. Try slowing down your reactions to match his. You may find you both get into the same rhythm. And then you’ll both be smiling!

Your baby is also influenced by what you are feeling yourself. He may be more inclined to smile at times when you’re happy and relaxed.

If, like many parents, you find yourself frequently feeling low, and struggling with being a parent, there is no reason to feel guilty. Many women struggle after their baby’s birth and support is available. Try not to worry about your baby’s development. With the right help, it’s never too late to “tune in” to your baby.

Many mums worry if their babies don’t seem to be developing exactly according to schedule. However all babies develop at their own pace, and they all have different personalities. This includes learning to smile. If your baby is taking his time, there’s almost certainly nothing wrong.

Your baby may not feel very smiley if:

• he’s still working on coordinating his movements
• he generally tends to fuss or cry a lot
• he’s having tummy aches

If you have any concerns, talk to your baby’s doctor.

My baby is not smiling

Smiling begins at different times for different babies. On average most parents say they see their baby’s first smile between 6 and 8 weeks, though some are convinced their baby smiles from 4 weeks and others that there is no hint of a grin until 12 weeks. But if your baby doesn’t smile often, that doesn’t mean anything is wrong with him. Just like adults, babies have different temperaments.

Babies almost always smile by accident the first time they do it, while exercising their facial muscles or passing wind. But the reaction they get from you — enormous smiles, whoops of joy, big eyes, lots of talk — is so exciting that they try a smile again pretty soon. Once your baby sees that something works, she will use it again and again.

Until about 7 months, babies smile at just about anyone and anything, although by 4 to 6 months they save their biggest smiles for the people they love the best, but around this time, new faces may cause crying also. From about 7 months, babies begin to realize that some of the people they see and some of the places they go are not familiar, and they smile more warily or not at all at strangers, or in strange places — sometimes hiding their faces in their parent’s shoulder, as though if they don’t look at the unfamiliar person, that person won’t be there. That’s completely normal and a sign that baby is beginning to separate the world into the people she knows and strangers.

This discriminate smiling is an important step in your baby’s sense of how she fits into the world. Her ecstatic smile when she sees you rapidly comes to mean that she expects good things when you are around, and her lack of a smile to others means she doesn’t feel so safe with them.

In the highly unlikely event that your baby does not smile at all by the time she is 3 months old, talk to your baby’s doctor.

If baby doesn’t smile yet and you are concerned when do babies smile, remember that it’s far more important to observe your baby’s level of engagement with the world. Regardless of your baby’s smile status, by 3 months old, your baby should be “communicating” with you, other caregivers and even strangers via eye contact and vocal expressions (for example, making protesting noises when baby’s pulled away from the bottle or breast). If your baby’s not doing any of that by 3 months, bring up your concerns with your pediatrician. Often, a parent’s concern is that if their baby doesn’t smile, that means he or she is autistic. But autism isn’t something that is diagnosed in infancy. (Autism spectrum disorder is generally not diagnosed until 18 months to 2 years old. Some autistic babies smile; some don’t. But not smiling or engaging is something you want to get it checked out. Because occasionally, a young baby that doesn’t smile because they may have a vision problem that needs addressing.

When do babies smile?

Between 1 month to 3 months of age, babies begin smiling regularly at mom and dad, but may need some time to warm up to less familiar people, like grandparents. Many babies start to smile at around seven weeks. Baby’s first smile is a key milestone in infant development. That said, every baby develops at her own pace, and it’s not unusual for baby to take until the three-month mark to smile on purpose. If your baby’s first smile is taking a little longer, it’s perfectly normal. However, according to research, baby has been smiling long before arriving on the scene, with reflex smiles actually happen in utero, between 25 and 27 weeks gestational age. But this type of baby smile is not in response to an emotional trigger—it’s just a biological way for baby to start practicing different skills. Along with smiling, sucking, blinking and even crying, baby can be captured via ultrasound long before birth.

After a baby is born, it’s not uncommon for some parents to see a reflex smile from day one. Contrary to the name, reflex smiles aren’t in response to anything. They occur randomly and can even occur during sleep. In fact, sleep is the most common time to see your smiling baby.

Baby smile is important for your baby’s development because it signals that her vision and nervous system have not only matured enough to be able to zero in on your face and eyes, but that she recognizes a smile is a way of communicating with the world around her.

How can you spot the difference between a reflex smile and a baby social smile during the first few weeks?

See if you can drag your eyes away from her adorable upturned mouth for a moment and look into her eyes. When baby is giving a social smile, she’s also engaging in eye contact. A baby social smile also happens when baby is awake, and will likely look less lopsided and more symmetrical than a reflex smile. It’s also longer; she wants to connect and will hold it until she gets feedback in the form of a smile or eye contact from you.

Why do babies smile when they sleep?

Similar to how we sometimes make expressions or talk in our sleep, babies make lots of funny faces while sleeping, including smiling. These smiles are spontaneous and often occur when baby is drowsy or during REM stages of sleep. Being gassy while sleeping can also trigger this smile reflex.

Regardless of whether baby is asleep or awake, reflex smiles tend to only last a few seconds and can look like a grimace. In fact, the smile you see will probably be super short, probably lopsided and often happen when baby isn’t looking at anything in particular. Not all babies exhibit reflex smiles, though, and because they’re so blink-and-you’ll-miss-them, they can be hard to spot for even the most attentive caregivers. So now that you know about reflex smiles, you’re probably anxious to find out when do babies start smiling for real (aka a baby social smile)?

How to make your baby smile

Just like adults, some babies are more serious than others and may be more selective with their smiles. Again, this says nothing about whether or not they love you, it’s just a sign how they’re naturally wired. If you’re wondering how to make your baby smile on purpose, certain games and activities can help. For starters, giving baby your widest grin whenever possible. Babies are very good mimics. If they see you smile a lot, chances are they’ll try to emulate the expression. Then try some or all of these other smile-inducing tactics:

• Get close and be dramatic. Newborns are nearsighted (their full visual capacity doesn’t happen until about 3 months), so make sure baby has plenty of opportunities to be up close and face-to-face with you, about a foot away is ideal. Talk or sing to baby and exaggerate your expressions: Let your eyes get wide, your smile get broad and really show baby what a happy face looks like.
• Play games. Games like peekaboo are also great to engage baby. The element of surprise at being confronted with your familiar face can excite baby enough to elicit a baby smile. In fact, babies often respond to surprise with a smile, so engage baby with toys that make different noises or squeaks, stuffed animals with various textures or read a book and change your voice for the different characters.
• Get physical. If you’re wondering how to make your baby smile, engage with her physically. Tickle her belly or give her raspberry kisses as you change her diaper. Sit on an exercise ball and gently bounce up and down or lie on your back on the floor and lift her up into the air, bringing her down to kiss her. The more you engage with baby, the more she’ll want to engage with you. As baby learns that a smile elicits an even bigger grin from you, baby will up the ante by adding laughter, coos and other cues that she’s your number one fan.

How to detect ovulation

Ovulation occurs each month when an egg is released from one of your ovaries. Occasionally, more than one egg is released, usually within 24 hours of the first egg. Ovulation usually happens at around the same time each month.

Ovulation occurs though a sequence of hormonal responses. Located deep within your brain, the pituitary gland releases the follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which travel through your blood stream to your ovaries. These hormones signal the development and release a single egg cell from one of your ovaries. The sweeping motion of the fimbriae draws the egg cell through a very small space in the open body cavity into the uterine tube or fallopian, tube. The egg may be fertilized here if there is sperm in the fallopian tube. At the same time, the lining of your womb begins to thicken for the egg to be implanted in it after it has been fertilized and the mucus in your cervix becomes thinner, so that sperm can swim through it more easily. An unfertilized egg may live for up to 12 hours. If your egg is not fertilized, it passes out of your body during the your monthly period, along with the lining of your womb. The egg is so small that it cannot be seen.

Ovulation depends on the activity of various glands and their hormones, including:

• Hypothalamus – located within the brain. The hypothalamus uses hormones to communicate with the pituitary
• Pituitary gland – known as the ‘master gland’ of the hormone (endocrine) system. It is located within the brain, at the base of the skull, and is connected to the hypothalamus by a thin stalk. The pituitary uses chemicals to prompt the ovaries to produce their hormones
• Ovaries – the two almond-shaped glands located within a woman’s pelvis that contain the ova. The ovaries make the two female sex hormones estrogen and progesterone.

Common causes of ovulatory problems include:

• Hypothalamus – conditions that can alter the functioning of the hypothalamus include polycystic ovary syndrome (PCOS), overexercising, poor nutrition and chronic stress
• Pituitary gland – conditions that can prevent the pituitary gland from producing enough hormones include benign pituitary tumors or direct injury to the pituitary itself
• Ovaries – conditions that can prevent the ovaries from releasing ova include early menopause (also known as ovarian failure), or damage to or removal of the ovaries.

If you want to find out when you ovulate, there are a number of things you can use:

1. The length of your menstrual cycle – A menstrual cycle is counted from the first day of one period to the first day of the next period. Some women have shorter and some have longer cycles and timing of ovulation depends on the length of the cycle. A normal menstrual cycle is between 28 to 32 days. The day a woman starts her period is considered to be cycle day 1. Ovulation often occurs around day 14 of your cycle (ovulation usually occurs around 10 to 16 days before your period starts), so you may be able to work out when you’re likely to ovulate if you have a regular menstrual cycle. If on average you have a period every 28 days you ovulate around day 14 and your best chance of conceiving is between days 11 and 14. But if you have a shorter interval between periods, say 24 days, ovulation happens around day 10 and your ‘fertile window’ is between days 7 and 10 (see Figure 6 below). If on the other hand you have 35 days between periods, you should focus your baby making efforts between days 18 and 21.
   • One way to calculate your estimated time of ovulation is as follows:
     • Work out the length of your average menstrual cycle. Day one is the first day of the menstrual period and the last day is the day before your next period begins. Let’s say your menstrual cycle is 28 days long.
     • Subtract 17 days. In our example, 28 days minus 17 days equals day 11.
     • Use the ovulation predictor kit on day 11. Continue testing daily until the test comes back positive. A positive result means you are going to ovulate within the next 24 to 36 hours.
     • Having sex around the time of ovulation means that the sperm and ovum have a good chance of meeting in the fallopian tube.
2. Changes in your cervical mucus (mucus method) – During ovulation, your cervical mucus is stretchy, clear, and slick. You may notice wetter, clearer and more slippery mucus around the time of ovulation. It looks and feels like an uncooked egg white.
3. Changes in your body temperature (symptothermal method) – there’s a small rise in your body temperature after ovulation takes place, which you may be able to detect with a thermometer. You can take your body temperature in your mouth, vagina, or rectum. A regular basal body temperature is between 97°F and 98°F (36.1° C to 36.7° C). At the time of ovulation, your basal body temperature will rise between 0.5 and 1 degree. You should take your basal body temperature in the morning before you have moved or get out of bed. Ideally, it should be the same time of day. You should use the thermometer the same way each day to get accurate results.
4. Ovulation predictor kits – hormone levels increase around the time of ovulation and this can be detected using ovulation predictor kits also known as luteinizing hormone urine test (LH urine test) that measure the level of luteinizing hormone (LH) in your urine

Using a combination of these methods is likely to be most accurate. In all 4 methods, you must use a calendar or chart to track the data and changes. This predicts when you ovulate, so you can partake in (or abstain from sex). You may notice other symptoms you can track. These include bloating, backache, tender breasts, or pain in your ovaries.

Some women may experience other symptoms when they’re ovulating, including breast tenderness, bloating and mild one-sided pain in their lower abdomen, but these are not a reliable way of predicting ovulation.

Ovulation pain also called mittelschmerz (German for “middle pain” or “pain in the middle of the month”) happens about 14 days before your period, when your ovary releases an egg as part of your menstrual cycle.

Figure 1. Female reproductive organs

Menstrual cycle

Ovulation is part of the menstrual cycle. This cycle is caused by the complex and interrelated activity of various hormones. The cycle includes:

• Menstruation – the shedding of the uterine lining (also known as menstrual bleeding or having your period)
• Follicular phase – the hypothalamus triggers the pituitary gland to release follicle stimulating hormone (FSH), which prompts the ovaries to produce up to 20 follicles. Each follicle contains an immature ovum. Usually, only one follicle survives to maturity. Assuming the menstrual cycle is around 28 days long, a single ovum matures at about day 10. This event also prompts the thickening of the uterine lining (endometrium) in preparation for a fertilised ovum
• Ovulation – the maturing follicle prompts the release of higher amounts of oestrogen. The hypothalamus responds by secreting a chemical known as gonadotrophin-releasing hormone (GnRH), which makes the pituitary produce luteinizing hormone (LH) and follicle stimulating hormone (FSH). High levels of LH trigger ovulation within about two days. The mature follicle releases the ovum into the peritoneal cavity; it is then drawn into the open end of the fallopian tube. Small hair-like structures within the fallopian tube wave or ‘massage’ the ovum towards the uterus. Unless the ovum encounters a sperm within 24 hours, it will die
• Luteal phase – the follicle becomes the corpus luteum, a structure that makes the hormone progesterone. Unless a fertilised ovum implants into the uterine lining, the corpus luteum dies. Without its contribution of progesterone, the uterus can’t maintain the thickened uterine lining, and menstruation occurs.

Figure 2. Menstrual cycle

Figure 3. Pituitary gland hormones under the influence of the hypothalamus controlling the ovaries production of egg cell, ovulation and development of the female secondary sex characteristics

Abbreviations: GnRH = Gonadotropin-Releasing Hormone; FSH = Follicle-Stimulating Hormone; LH= Luteinizing Hormone

Figure 4. Ovarian Follicle Maturation

Figure 5. Ovarian activity during the Menstrual cycle

Footnote: Major events in the female menstrual cycle. (a) Plasma hormonal concentrations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) affect follicle maturation in the ovaries. (b) Plasma hormonal concentrations of estrogen and progesterone influence changes in the uterine lining.

Abbreviations: FSH = Follicle-Stimulating Hormone; LH= Luteinizing Hormone

How does ovulation relate to my periods?

Ovulation is the release of an egg from one of your ovaries. The same hormones that cause the uterus lining to build up also cause an egg to leave one of the ovaries. The egg travels through a thin tube called a fallopian tube to the uterus.

If the egg is fertilized by a sperm cell, it attaches to the wall of the uterus, where over time it develops into a baby. If the egg is not fertilized, the uterus lining breaks down and bleeds, causing a period.

When am I are most fertile?

The five days before ovulation, together with the day you ovulate, are the days when you are most likely to conceive. Sperm can live up to five days inside your body, so if you have sex up to five days before your egg is released, you can get pregnant. After ovulation, though, your egg can only live for 12 to 24 hours. After this time is up, your time for getting pregnant has gone for now till the following month.

Your chances of getting pregnant are at their highest in the three days leading up to and including ovulation.

Do periods happen regularly when my menstruation starts?

For the first few years after a girl starts her period, it may not come regularly. This is normal at first. By about 2–3 years after her first period, a girl’s periods should be coming around once every 4–5 weeks.

Can a girl get pregnant as soon as her period starts?

Yes, a girl can get pregnant as soon as her period starts. A girl can even get pregnant right before her very first period. This is because a girl’s hormones might already be active. The hormones may have led to ovulation and the building of the uterine wall. If a girl has sex, she can get pregnant, even though she has never had a period.

How to detect fertile days

Knowing when ovulation happens is critical when you want to get pregnant because the window of opportunity to conceive is fairly small every month. As shown in the graph below (Figure 6), conception is only possible from about five days before ovulation through to the day of ovulation. These six days are the “fertile window” in a woman’s cycle and reflect the lifespan of sperm (five days) and the lifespan of the egg (24 hours). But the likelihood of conceiving is dramatically increased if sex occurs in the three days leading up to and including ovulation. If a woman has sex six or more days before she ovulates, the chance she will get pregnant is virtually zero. Then, the probability of pregnancy rises steadily and is 27-33% in the three days leading up to and including ovulation. From that point, the probability of pregnancy declines rapidly. Twelve to 24 hours after ovulation, a woman is no longer able to get pregnant during that cycle.

If all this seems too complicated, an alternative is to have sex every two to three days. That way all bases are covered without getting too technical about when the chance of conceiving is greatest.

Figure 6. Fertile window

Signs and symptoms of ovulation

The female body shows several signs of ovulation. You may experience some or all of these signs, including:

• regular menstrual cycles – menstrual periods that arrive every 24–35 days are more likely to be ovulatory than periods that occur more or less often
• mucus changes – about two weeks before menstruation, if you are ovulating you may notice slick and slippery cervical mucus
• abdominal pain – some women experience pain during ovulation. The pain may be general or localised to one side of the abdomen
• premenstrual symptoms – ovulation may accompany premenstrual symptoms such as breast enlargement and tenderness, abdominal bloating and moodiness
• temperature rise – women who use a natural family planning method of contraception will notice a small rise in their basal temperature after ovulation has occurred. The temperature rise is about half a degree Fahrenheit (Celsius). This temperature rise does not predict ovulation – it suggests that ovulation has already taken place.

How to detect ovulation at home

There are many different kinds of ovulation predictor kits on the market. Most work by measuring the level of luteinizing hormone (LH) in your urine (LH urine test). Luteinizing hormone (LH) levels rise about 24 to 36 hours before ovulation takes place.

An ovulation home test also known as luteinizing hormone urine test (LH urine test) is used by some women to detect ovulation. The LH urine test involves normal urination. There is no pain or discomfort. Ovulation home test helps you to determine the time in your menstrual cycle when getting pregnant is most likely. This at-home ovulation test is often used by women to help predict when an egg release is likely. This is when pregnancy is most likely to occur. These kits can be bought at most drug stores.

The ovulation test detects a rise in luteinizing hormone (LH) in the urine. A rise in this hormone signals the ovary to release the egg. A positive result indicates an “LH surge.” This is a sign that ovulation may soon occur. Talk to your doctor if you are unable to detect an “LH surge” or do not become pregnant after using the kit for several months. You may need to see an infertility specialist.

Luteinizing hormone (LH) urine tests are not the same as the home fertility monitors. Fertility monitors are digital handheld devices. They predict ovulation based on electrolyte levels in your saliva, luteinizing hormone (LH) levels in your urine or your basal body temperature. These devices can store ovulation information for several menstrual cycles.

How the ovulation test is performed

Ovulation prediction test kits most often come with five to seven sticks. You may need to test for several days to detect a surge in luteinizing hormone (LH).

The specific time of month that you start testing depends on the length of your menstrual cycle. For example, if your normal cycle is 28 days, you’ll need to begin testing on day 11. That is, the 11th day after you started your period. If you have a different cycle interval than 28 days, talk to your doctor about the timing of the test. In general, you should begin testing 3 to 5 days prior to the expected date of ovulation.

You will need to urinate on the test stick, or place the stick into urine that has been collected into a sterile container. The test stick will turn a certain color or display a positive sign if a surge is detected.

A positive result means you should ovulate in the next 24 to 36 hours, but this may not be the case for all women. The booklet that is included in the kit will tell you how to read the results.

You may miss your surge if you miss a day of testing. You may also not be able to detect a surge if you have an irregular menstrual cycle.

How to prepare for the ovulation test

DO NOT drink large amounts of fluids before using the test.

Drugs that can decrease luteinizing hormone (LH) levels include estrogens, progesterone, and testosterone. Estrogens and progesterone may be found in birth control pills and hormone replacement therapy.

The drug clomiphene citrate (Clomid) can increase luteinizing hormone (LH) levels. This drug is used to help trigger ovulation.

Why the ovulation test is performed?

The ovulation test is most often done to determine when a woman will ovulate to assist in difficulty in getting pregnant. For women with a 28-day menstrual cycle, this release normally occurs between days 11 and 14.

If you have an irregular menstrual cycle, the kit can help you tell when you are ovulating.

The ovulation home test may also be used to help you adjust doses of certain medicines such as infertility drugs.

Medical tests for ovulation

Medical tests can check whether or not ovulation took place. These tests can include:

• blood test – to check for the presence of progesterone. A level greater than 20 nmol/L indicates that ovulation took place. This test must be taken about three to 10 days before the first day of the next expected period
• pregnancy ultrasound – the presence of a fetus is the only absolute proof that ovulation took place. Medical tests such as ovulation predictor kits and blood tests can only ascertain that ovulation probably – not definitely – occurred.

How to increase your chances of ovulation

Ways to increase your chances of ovulation include:

• Women who are seriously obese or underweight may have problems with ovulation. Try to keep your weight around the average for your height and build.
• Excessive exercise can prevent ovulation. Ease back on your physical activity levels – this may require expert help if your desire to exercise is actually a form of bulimia.
• Repeated crash dieting, fasting, skipping meals and other disordered eating habits can hamper your body’s ability to regularly ovulate. Make sure to eat properly and regularly. Once again, you may need expert help if these habits are associated with an eating disorder such as anorexia or bulimia nervosa.
• Chronic emotional stress can play havoc with your menstrual cycle. Try to reduce the amount of stress in your life, and learn ways to better cope with stress. For example, relaxation training may be helpful.

Some women who aren’t ovulating regularly can be helped by reproductive technologies including tablets and injections to trigger higher production of ovulatory hormones. The dosage needs to be carefully monitored, because ovulation induction can trigger the maturation of a number of ova, which could lead to a multiple pregnancy.

The best time to get pregnant

You’re most likely to get pregnant if you have sex within a day or so of ovulation (releasing an egg from the ovary). This is usually about 14 days after the first day of your last period, if your cycle is around 28 days long. An egg lives for about 12-24 hours after being released. For pregnancy to happen, the egg must be fertilized by a sperm within this time. Sperm can live for up to 7 days inside a woman’s body. So if you’ve had sex in the days before ovulation, the sperm will have had time to travel up the fallopian tubes to “wait” for the egg to be released. When the egg and sperm meet, it’s called fertilization. The fertilized egg also called an embryo moves through your fallopian tubes and attaches to the wall of your uterus where it grows and develops into a baby. When the embryo attaches to the uterus, it’s called implantation.

It’s difficult to know exactly when ovulation happens, unless you are practising natural family planning, or fertility awareness.

If you want to get pregnant, having sex every 2 to 3 days throughout the month will give you the best chance.

You don’t need to time having sex only around ovulation.

To get pregnant:

1. A woman’s body must release an egg from one of her ovaries (ovulation).
2. A man’s sperm must join with the egg along the way (fertilize).
3. The fertilized egg must go through a fallopian tube toward the uterus (womb).
4. The fertilized egg must attach to the inside of the uterus (implantation).
5. Infertility may result from a problem with any or several of these steps.
6. If you want to get pregnant, having sex every 2 to 3 days throughout the month will give you the best chance. You don’t need to time having sex only around ovulation.

Getting pregnant (conception) happens when a man’s sperm fertilizes a woman’s egg. For some women this happens quickly, but for others it can take longer.

You can get pregnant if you have unprotected sex any time from 5 days before and the day of ovulation. The more often you have sex during this time, the more likely you are to get pregnant. Your egg is fertile (can become an embryo) for 12 to 24 hours after ovulation. Your partner’s sperm can live inside you for up to 72 hours after you have sex.

However, it’s difficult to know exactly when your ovulation happen, unless you are practising natural family planning, or fertility awareness.

Out of every 100 couples trying for a baby, 80 to 90 will get pregnant within 1 year. The rest will take longer, or may need help to conceive.

To understand getting pregnant (conception) and pregnancy, it helps to know about the male and female sexual organs, and to understand how a woman’s monthly menstrual cycle and periods work.

The menstrual cycle is counted from the first day of a woman’s period (day 1). Some time after her period she will ovulate, and then around 12-16 days after this she’ll have her next period.

The average menstrual cycle lasts 28 days. But normal cycles can vary from 21 to 35 days. The amount of time before ovulation occurs is different in every woman and even can be different from month to month in the same woman, varying from 13 to 20 days long. Learning about this part of the cycle is important because it is when ovulation and pregnancy can occur. After ovulation, every woman (unless she has a health problem that affects her periods or becomes pregnant) will have a period within 14 to 16 days.

Being aware of your menstrual cycle and the changes in your body that happen during this time can help you know when you are most likely to get pregnant. See how the menstrual cycle works by watching the video below. Each month your ovaries release an egg about 14 days before the first day of your period. This is called ovulation. When you and your partner have unprotected sex around the time of ovulation, his sperm swim to meet your egg. Unprotected sex means you don’t use any kind of birth control to help prevent pregnancy.

Trouble getting pregnant

Trouble getting pregnant, difficulty conceiving is also known as infertility, which is usually defined as not being able to get pregnant after 12 months of unprotected sexual intercourse. A broader view of infertility includes not being able to carry a pregnancy to term. Finding out that you or your partner are unable to fall pregnant can be upsetting and difficult to deal with.

Because fertility in women is known to decline steadily with age, some health providers evaluate and treat women aged 35 years or older after just 6 months of unprotected sex. Women with infertility should consider making an appointment with a reproductive endocrinologist—a doctor who specializes in managing infertility. Reproductive endocrinologists may also be able to help women with recurrent pregnancy loss, defined as having two or more spontaneous miscarriages.

Pregnancy is the result of a process that has many steps.

To get pregnant:

1. A woman’s body must release an egg from one of her ovaries (ovulation).
2. A man’s sperm must join with the egg along the way (fertilize).
3. The fertilized egg must go through a fallopian tube toward the uterus (womb).
4. The fertilized egg must attach to the inside of the uterus (implantation).

Infertility may result from a problem with any or several of these steps.

Impaired fecundity (the ability to produce new offspring or fertility) is a condition related to infertility and refers to women who have difficulty getting pregnant or carrying a pregnancy to term.

• About 6% of married women aged 15 to 44 years in the United States are unable to get pregnant after one year of trying (infertility). Also, about 12% of women aged 15 to 44 years in the United States have difficulty getting pregnant or carrying a pregnancy to term, regardless of marital status (impaired fecundity).
• Infertility is not always a woman’s problem. Both men and women can contribute to infertility. Many couples struggle with infertility and seek help to become pregnant, but it is often thought of as only a woman’s condition. However, in about 35% of couples with infertility, a male factor is identified along with a female factor. In about 8% of couples with infertility, a male factor is the only identifiable cause.
• Almost 9% of men aged 25 to 44 years in the United States reported that they or their partner saw a doctor for advice, testing, or treatment for infertility during their lifetime.

For couples trying for a baby, it is normal to have feelings of uncertainty, disappointment and anxiety. It may affect a couple the same way or in different ways.

It is good to talk through any problems, and have both of you talk about how you feel.

If there are difficulties between you, talk to your doctor as a couple. Your doctor may refer you both to a counsellor if necessary.

There are many causes of infertility. For about 4 couples in 10 it will relate to a sperm problem. In another 4 couples in 10 there will be a female reproductive cause. Sometimes there is a combination of factors.

Treatment for infertility is available and can bring hope to people wanting to have a baby, but it also has financial, physical and emotional costs. And success is not guaranteed.

Kids sprained ankle

A sprained ankle means one or more ligaments on the outer side of your ankle were stretched or torn. Ankle sprains are one of the most common injuries in children. Ankles are made up of three bones with ligaments (tough, stretchy tissue that hold the bones together). The ligaments help stop the ankle joint from moving around too much.

Ankle sprains usually happen when there is a sudden movement or twist – often when the foot rolls over – and the ligaments are overstretched. This causes tears and bleeding (which show as bruising and swelling) around the ankle joint. These movements are more likely to happen when a person is running, jumping or quickly changing direction e.g. in sports such as basketball, netball or football. Risk factors for both include poor conditioning, fatigue, poor warm up, slippery surfaces and poorly fitting footwear.

Pain, swelling, bruising, tenderness, difficulty moving the ankle or difficulty walking are common symptoms of an ankle sprain. However,  symptoms of a severe sprain are similar to those of a broken bone and require prompt medical evaluation.

A sprained ankle can vary greatly in severity from a minor “rolled ankle” to a complete ligament rupture with or without bone tendon or muscle injury. They are graded as 1, 2 or 3 depending on the severity. If a sprained ankle is not treated properly, you could have long-term problems. Typically sprained ankle is rolled either inward (inversion sprain) or outward (eversion sprain). Inversion sprains cause pain along the outer side of the ankle and are the most common type. Pain along the inner side of the ankle may represent a more serious injury to the tendons or to the ligaments that support the arch and should always be evaluated by a doctor.

Ankle sprains happen when you overstretch or torn a ligament. Ankle sprains occur most commonly by a sudden twisting or rolling action of your ankle often on unstable irregular surfaces. The ligaments affected is determined by the direction the foot rolls. The most common ankle sprain is the ligament on the side which occurs when the foot is turned in.

Certain factors can put a person at greater risk of spraining their ankle including poor footwear, not warming up before exercising, tired muscles and playing sport, previous injury, reduced strength, poor biomechanics or poor balance receptors. You’re most likely to sprain your ankle when you have your toes on the ground and heel up (plantar flexion). This position puts your ankle’s ligaments under tension, making them vulnerable. A sudden force like landing on an uneven surface may turn your ankle inward (inversion). When this happens, one, two or three of your ligaments may be hurt.

A sprained ankle can be difficult to differentiate from a fracture (broken bone) without an x-ray. If you are unable to bear weight after this type of injury, or if there is significant swelling or deformity, you should seek medical treatment from a doctor. This may be your primary care physician, an emergency department, or an orthopaedist, depending on the severity of your injury.

Ankle sprains are very common injuries. There’s a good chance that while playing or stepping on an uneven surface you sprained your ankle–some 25,000 people do it every day.​​​

Sometimes, it is an awkward moment when you lose your balance, but the pain quickly fades away and you go on your way. But the sprain could be more severe; your ankle might swell and it might hurt too much to stand on it. If it’s a severe sprain, you might have felt a “pop” when the injury happened.

Treatment for a sprained ankle depends on the severity of the injury. Although self-care measures and over-the-counter pain medications may be all you need, a medical evaluation might be necessary to reveal how badly you’ve sprained your ankle and to determine the appropriate treatment.

Minor ankle strains/sprains require rest, ice, compression, elevation (RICE) and over-the-counter pain relievers for treatment. An ankle brace may be helpful to support the ankle while it heals.

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability after months of rehabilitation and nonsurgical treatment.

Ankle Joint ligaments

The ankle (talocrural) joint includes two articulations—a medial joint between the tibia and talus and a lateral joint between the fibula and talus, both enclosed in one joint capsule. The malleoli of the tibia and fibula overhang the talus on each side like a cap and prevent most side-to-side motion. The ankle therefore has a more restricted range of motion than the wrist.

Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilize the joint.

The ligaments of the ankle include (1) anterior and posterior tibiofibular ligaments, which bind the tibia to the fibula; (2) a multipart medial (deltoid) ligament, which binds the tibia to the foot on the medial side; and (3) a multipart lateral (collateral) ligament, which binds the fibula to the foot on the lateral side.

Most sprained ankles occur in the lateral ligaments on the outside of the ankle. Sprains can range from tiny tears in the fibers that make up the ligament to complete tears through the tissue.

The ankle joint is responsible for plantarflexion and dorsiflexion of the ankle. The subtalar joint lies underneath the true ankle joint and is the articulation between the talus and calcaneus. It assists the talo-crural joint in inversion and eversion. Most ankle sprains occur from an inversion mechanism of injury (rolled in).

The calcaneal (Achilles) tendon extends from the calf muscles to the calcaneus. It plantarflexes the foot and limits dorsiflexion. Plantar flexion is limited by extensor tendons on the anterior side of the ankle and by the anterior part of the joint capsule.

The most commonly injured ligaments of the ankle are the lateral ligaments which sit on the outside of the ankle. These include the anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligament. The ligament on the inside of the ankle is called the deltoid ligament which is much stronger and hence more difficult to injure.

Sprains (torn ligaments and tendons) are common at the ankle, especially when the foot is suddenly inverted or everted to excess. They are painful and usually accompanied by immediate swelling. They are best treated by immobilizing the joint and reducing swelling with an ice pack, but in extreme cases may require a cast or surgery.

High ankle sprains refer to injury to the inferior tibiofibular ligaments and syndesmosis which bind the tibia (shin bone) and fibula (calf bone) together above the ankle. A high ankle sprain is a much more debilitating injury, requiring a longer recovery time.

Figure 1. Ankle joint ligaments

Grades of Ankle Sprains

After the examination, your doctor will determine the grade of your sprain to help develop a treatment plan. Sprains are graded based on how much damage has occurred to the ligaments.

Some sprained ankles are minor injuries that heal with little treatment. Others can be more serious, though. The three grades of ankle sprains, based on how much damage is done to the ligaments, are (see Figure 2 below):

Figure 2. Sprained ankle grades

Grade 1 Sprain (Mild)

• This is a mild sprain where ligaments stretch slightly.
• Slight stretching and microscopic tearing of the ligament fibers
• Someone with a grade 1 sprain will feel some soreness and may notice a bit of swelling around the ankle

Grade 2 Sprain (Moderate)

• This is a moderate sprain where ligaments tear partly, making the ankle joint feel loose.
• Partial tearing of the ligament
• Moderate tenderness and swelling around the ankle
• If the doctor moves the ankle in certain ways, there is an abnormal looseness of the ankle joint
• The ankle will feel painful, and may stay swollen for a while. Putting weight on the foot can be difficult.

Grade 3 Sprain (Severe)

• This is the most severe kind of sprain, where an ankle ligament tears completely.
• Complete tear of the ligament
• Significant tenderness and swelling around the ankle
• If the doctor pulls or pushes on the ankle joint in certain movements, substantial instability occurs
• The ankle joint will be very painful, with quite a bit of swelling. The person’s ankle will feel loose and unsteady and early on the person probably won’t be able to put any weight on the ankle.
• If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. Over time, this instability can result in damage to the bones and cartilage of the ankle joint.

Tell your doctor what you were doing when you sprained your ankle. He or she will examine it and may want an x-ray to make sure no bones are broken. Most ankle sprains do not require surgery, and minor sprains are best treated with a functional rehabilitation program.

If you repeatedly sprain the same ankle or feel pain for more than 4 to 6 weeks, you may have what’s called a chronic sprain. This type of lasting sprain can flare up and be made worse by activities that involve rolling or twisting the feet, like running, dancing, or playing sports.

What is Chronic Ankle Sprains?

Once you have sprained your ankle, you may continue to sprain it if the ligaments do not have time to completely heal. It can be hard for patients to tell if a sprain has healed because even an ankle with a chronic tear can be highly functional because overlying tendons help with stability and motion.

If pain continues for more than 4 to 6 weeks, you may have a chronic ankle sprain. Activities that tend to make an already sprained ankle worse include stepping on uneven surfaces and participating in sports that require cutting actions or rolling and twisting of the foot.

Abnormal proprioception—a common complication of ankle sprains—can also lead to repeat sprains. There may be imbalance and muscle weakness that causes a reinjury. If you sprain your ankle over and over again, a chronic situation may persist with instability, a sense of the ankle giving way, and chronic pain. This can also happen if you return to work, sports, or other activities before your ankle heals and is rehabilitated.

How long does a sprained ankle take to heal?

After 2 weeks, most ankle sprains and strains will feel better. Avoid strenuous exercise such as running for up to 8 weeks, as there’s a risk of further damage.

Severe ankle sprains (grade 2 and 3) and strains can take months to get back to normal.

Most importantly, successful outcomes are dependent upon patient commitment to rehabilitation exercises. Incomplete rehabilitation is the most common cause of chronic ankle instability after a sprain. If a patient stops doing the strengthening exercises, the injured ligament(s) will weaken and put the patient at risk for continued ankle sprains.

I sprained my ankle last spring while I was running. The ankle doesn’t really hurt anymore, but it keeps ‘giving out’. What should I do?

Ankle sprains are the most common foot and ankle injury in sports. Typically, sprains occur when the foot inverts with an awkward step while running or jumping. As the foot rotates inward, the ligaments on the outside, or lateral aspect of the ankle, are stretched, causing swelling and pain. Most frequently, sprains will recover completely with rest, ice, compression, elevation and early mobilization.

In less than 10% of cases, while ankle swelling and pain improves, the ankle continues to “give out” or feel unstable. Classically, this occurs when walking on uneven ground or when stepping off of a curb. Repeated episodes of “giving out” is a condition called chronic ankle instability. Most frequently, this is a result of incomplete recovery from an acute ankle sprain that leaves the ankle with weakness and impaired postural control.

The initial treatment for chronic ankle instability is a program of structured rehabilitation with the help of a physical therapist. Exercises are aimed specifically at strengthening the peroneal tendons which run on the outside aspect of the ankle. The regimen should also include use of a balance board or similar device to work on proprioception – awareness of the position of the foot and ankle in space. Improved proprioception helps the ankle react more quickly to stresses, preventing future sprains.

After 6-8 weeks of intensive therapy, if the ankle continues to feel unstable, one might be a candidate for surgery to reconstruct the injured ankle ligaments. At this point, an MRI is helpful to identify any underlying injury such as cartilage damage at the ankle or peroneal tendon tears. Complete recovery from surgery takes at least 3 months, but patients will typically be able to return to full activity without limitation, and, most importantly, without the sensation of their ankle “giving out”.

Sprained ankle causes

A sprain occurs when your ankle is forced to move out of its normal position, which can cause one or more of the ankle’s ligaments to stretch, partially tear or tear completely.

The most common type of sprained ankle is called an inversion sprain, or lateral ligament sprain. With this type of sprain, the ankle turns so the sole of the foot is facing inwards, stretching and possibly damaging the ligaments on the outer part of the ankle.

You don’t have to be playing hard to injure an ankle: sprains can happen just from taking an awkward step or tripping on the stairs.

Causes of a sprained ankle might include:

• A fall that causes your ankle to twist
• Landing awkwardly on your foot after jumping or pivoting
• Walking or exercising on an uneven surface
• Another person stepping or landing on your foot during a sports activity, while you are running, causing your foot to twist or roll to the side
• Participating in sports that require cutting actions or rolling and twisting of the foot—such as trail running, basketball, tennis, football, and soccer.

Risk factors for sprained ankle

Factors that increase your risk of a sprained ankle include:

• Sports participation. Ankle sprains are a common sports injury, particularly in sports that require jumping, cutting action, or rolling or twisting of the foot such as basketball, tennis, football, soccer and trail running.
• Uneven surfaces. Walking or running on uneven surfaces or poor field conditions may increase the risk of an ankle sprain.
• Prior ankle injury. Once you’ve sprained your ankle or had another type of ankle injury, you’re more likely to sprain it again.
• Poor physical condition. Poor strength or flexibility in the ankles may increase the risk of a sprain when participating in sports.
• Improper shoes. Shoes that don’t fit properly or aren’t appropriate for an activity, as well as high-heeled shoes in general, make ankles more vulnerable to injury.

Sprained ankle prevention

The following tips can help you prevent a sprained ankle or a recurring sprain:

• Warm up before you exercise or play sports.
• Be careful when walking, running or working on an uneven surface.
• Use an ankle support brace or tape on a weak or previously injured ankle.
• Wear shoes that fit well and are made for your activity.
• Minimize wearing high-heeled shoes.
• Don’t play sports or participate in activities for which you are not conditioned.
• Maintain good muscle strength and flexibility.
• Slow down or stop activities when you feel pain or fatigue.
• Practice stability training, including balance exercises.

Signs and symptoms of ankle sprains

Signs and symptoms of a sprained ankle vary depending on the severity of the injury. If your child has sprained their ankle, they may have:

• Swelling, which develops in minutes or over several hours – this is caused by soft tissue damage
• Pain around the outside part of the ankle joint
• Bruising, which shows up within two to three days
• Ankle pain, especially when you bear weight on the affected foot
• Tenderness when you touch the ankle (injured ligaments will be quite tender to touch in that initial phase)
• Restricted range of motion
• Instability in the ankle
• If there is severe tearing of the ligaments, your child might also hear or feel a “pop” when the sprain occurs.
• In the cases of a severe ankle sprain, your child may have difficulty walking and may require the use of crutches to mobilize.

Symptoms of a severe sprain are similar to those of a broken bone and require prompt medical evaluation.

Sprained ankle complications

Failing to treat a sprained ankle properly, engaging in activities too soon after spraining your ankle or spraining your ankle repeatedly might lead to the following complications:

• Chronic ankle pain
• Chronic ankle joint instability
• Arthritis in the ankle joint

Kids sprained ankle diagnosis

During a physical, your doctor will examine your ankle, foot and lower leg. The doctor will touch the skin around the injury to check for points of tenderness and move your foot to check the range of motion and to understand what positions cause discomfort or pain.

Depending on how many ligaments are injured, your sprain will be classified as Grade 1, 2 or 3. In a mild sprain (grade 1), the ankle ligament simply is overstretched. More severe ankle sprains can involve partial tearing of the ankle ligament (grade 2), or complete tearing (grade 3).

If the injury is severe, your doctor may recommend one or more of the following imaging scans to rule out a broken bone or to evaluate in more detail the extent of ligament damage:

• X-ray. During an X-ray, a small amount of radiation passes through your body to produce images of the bones of the ankle. This test is good for ruling out bone fractures.
• Stress x-rays. In addition to plain X-rays, your doctor may also order stress X-rays. These scans are taken while the ankle is being pushed in different directions. Stress X-rays help to show whether the ankle is moving abnormally because of injured ligaments.
• Magnetic resonance imaging (MRI). MRIs use radio waves and a strong magnetic field to produce detailed cross-sectional or 3-D images of soft internal structures of the ankle, including ligaments. Your doctor may order an MRI if he or she suspects a very severe injury to the ligaments, damage to the cartilage or bone of the joint surface, a small bone chip, or another problem. The MRI may not be ordered until after the period of swelling and bruising resolves.
• CT scan. CT scans can reveal more detail about the bones of the joint. CT scans take X-rays from many different angles and combine them to make cross-sectional or 3-D images.
• Ultrasound. An ultrasound uses radio waves to produce real-time images. These images may help your doctor judge the condition of a ligament or tendon when the foot is in different positions.

How to treat a sprained ankle yourself

See your doctor if your child has pain and swelling in his ankle and you suspect a sprain. Self-care measures may be all you need, but talk to your doctor to discuss whether your child should have his ankle evaluated. If signs and symptoms are severe, your child may have significant damage to a ligament or a broken bone in his ankle or lower leg.

Care at home

If your child has sprained their ankle, you can care for them at home using first aid principles (the Rest, Ice, Compression, Elevation (RICE) strategy) and ankle exercises. For a Grade 1 sprained ankle, follow the R.I.C.E. guidelines to help bring down swelling and support the injury. Treatment should start immediately and continue for the next two to three days.

• Rest: rest the ankle by not walking on it and avoid activities that cause a lot of pain. If your child is having difficulty walking, crutches should be used. You can hire crutches from your local pharmacy.
• Ice: apply ice to the injured area for 10–15 minutes. Never place the ice directly on the skin because it can burn the skin – wrap the ice or ice pack in a tea towel or a pillow case. Ice the injury every two to four hours for two to three days, when your child is awake. You can make an ice pack using a plastic bag with some ice and water in it. This moulds better to the ankle joint area than ice alone. Don’t ice more than 20 minutes every 2 to 3 hours at a time to avoid frost bite.
• Compression: wrap a firm bandage that is not too tight and does not stop circulation or cause extra pain. The bandage should cover from just above the ankle right down to the foot. Do not cover the toes.
• Elevation: raise the ankle whenever possible to help reduce the swelling. For example, raise your child’s injured leg and rest it on some pillows while they are watching TV, reading or resting.

Some children will need medicine to help with the pain. In most cases, acetaminophen (paracetamol) is enough. Anti-inflammatory medications may help, but these are not suitable for every child. Ask your doctor for further advice. Always read and follow the instructions on the package for the appropriate dose of medication for your child. See our fact sheet Pain relief for children.

Figure 3. How to wrap a sprained ankle

In the first two to three days after your child’s injury, avoid:

• heat (e.g. heat packs or hot baths) – this increases blood flow and makes the swelling worse
• re-injury – protect the ankle joint from re-injury by keeping weight off it and moving carefully
• massage – this promotes blood flow and makes the swelling worse.

Swelling usually goes down with a few days.

• Take nonsteroidal anti-inflammatory drugs (NSAIDs). Ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs) can help relieve pain and reduce swelling in the ankle.
• Crutches. In most cases, swelling and pain will last from 2 to 3 days. Walking may be difficult during this time and your doctor may recommend that you use crutches as needed.
• Avoid activities that put pressure on your ankle. Don’t play sports that require running, cutting, or stopping quickly until your doc says it’s OK. Don’t hike, jog, or exercise on uneven surfaces until the ankle is properly healed.
• Do stretching and strengthening exercises. After the pain and swelling have improved, ask your doctor about an exercise program to improve your ankle’s strength and flexibility. Depending on the severity of the sprain, the doctor may recommend physical therapy to help the healing process.
• Immobilization. During the early phase of healing, it is important to support your ankle and protect it from sudden movements. For a Grade 2 sprain, a removable plastic device such as a cast-boot or air stirrup-type brace can provide support. Grade 3 sprains may require a short leg cast or cast-brace for 2 to 3 weeks.

For a Grade 2 sprained ankle, follow the R.I.C.E. guidelines and allow more time for healing. A doctor may immobilize or splint your sprained ankle.

A Grade 3 sprained ankle puts you at risk for permanent ankle instability. Rarely, surgery may be needed to repair the damage, especially in competitive athletes. For severe ankle sprains, your doctor may also consider treating you with a short leg cast for two to three weeks or a walking boot. People who sprain their ankle repeatedly may also need surgical repair to tighten their ligaments.

Doctors usually try immobilization and other treatments before recommending surgery. But if your doctor decides surgery is the best option, he or she may start with arthroscopy. This involves inserting a small camera device into the joint through a tiny cut. It allows the doctor to look inside the joint to see what’s going on — like if part of the ligament is caught in the joint or there are bone fragments in the joint — and treat it if necessary.

In very rare cases, doctors will recommend surgery to reconstruct a torn ligament. It’s unlikely that most teens will need this type of surgery for a sprained ankle, though. Your body will probably heal on its own as long as you don’t overdo it too quickly.

Not overdoing things is key when it comes to sprained ankle. So follow your doctor’s advice and don’t push yourself or feel pressure to get back into sports or other activities too soon. Sprains usually heal well, but they need time to get fully better.

Rehabilitating your sprained ankle

Every ligament injury needs rehabilitation. Otherwise, your sprained ankle might not heal completely and you might re-injure it. All ankle sprains, from mild to severe, require three phases of recovery:

• Phase 1 includes resting, protecting and reducing swelling of your injured ankle.
• Phase 2 includes restoring your ankle’s flexibility, range of motion and strength.
• Phase 3 includes maintenance exercises and the gradual return to activities that do not require turning or twisting the ankle. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities)—such as tennis, basketball, or football.

This three-phase treatment program may take just 2 weeks to complete for minor sprains, or up to 6 to 12 weeks for more severe injuries.

Once you can stand on your ankle again, your doctor will prescribe exercise routines to strengthen your muscles and ligaments and increase your flexibility, balance and coordination. Later, you may walk, jog and run figure eights with your ankle taped or in a supportive ankle brace.

It’s important to complete the rehabilitation program because it makes it less likely that you’ll hurt the same ankle again. If you don’t complete rehabilitation, you could suffer chronic pain, instability and arthritis in your ankle. If your ankle still hurts, it could mean that the sprained ligament has not healed right, or that some other injury also happened.

To prevent future sprained ankles, pay attention to your body’s warning signs to slow down when you feel pain or fatigue, and stay in shape with good muscle balance, flexibility and strength in your soft tissues.

Sprained ankle exercises

Rehabilitation exercises are used to prevent stiffness, increase ankle strength, and prevent chronic ankle problems.

• Early motion. To prevent stiffness, your doctor or physical therapist will provide you with exercises that involve range-of-motion or controlled movements of your ankle without resistance.
• Strengthening exercises. Once you can bear weight without increased pain or swelling, exercises to strengthen the muscles and tendons in the front and back of your leg and foot will be added to your treatment plan. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Exercises with resistance are added as tolerated.
• Proprioception (balance) training. Poor balance often leads to repeat sprains and ankle instability. A good example of a balance exercise is standing on the affected foot with the opposite foot raised and eyes closed. Balance boards are often used in this stage of rehabilitation.
• Endurance and agility exercises. Once you are pain-free, other exercises may be added, such as agility drills. Running in progressively smaller figures-of-8 is excellent for agility and calf and ankle strength. The goal is to increase strength and range of motion as balance improves over time.

How to Stretch Your Ankle After A Sprain

You should perform the following stretches in stages once the initial pain and swelling have receded, usually within five to seven days. First is restoration of ankle range of motion, which should begin when you can tolerate weight bearing.

Once ankle range of motion has been almost or completely restored, you must strengthen your ankle. Along with strengthening, you should work toward a feeling of stability and comfort in your ankle, which orthopaedic foot and ankle specialists call proprioception.

Consider these home exercises when recuperating from an ankle sprain. Perform them twice per day.

• While seated, bring your ankle and foot all the way up as much as you can.
  • Do this slowly, while feeling a stretch in your calf.
  • Hold this for a count of 10.
  • Repeat 10 times.
• From the seated starting position, bring your ankle down and in.
  • Hold this inverted position for a count of 10.
  • Repeat 10 times.
• Again from the starting position, bring your ankle up and out.
  • Hold this everted position for a count of 10.
  • Repeat 10 times.
• From the starting position, point your toes down and hold this position for a count of 10.
  • Repeat 10 times.

This stretch should be done only when the pain in your ankle has significantly subsided.

• While standing on the edge of a stair, drop your ankles down and hold this stretched position for a count of 10.
  • Repeat 10 times.
• Stand 12 inches from a wall with your toes pointing toward the wall.
  • Squat down and hold this position for a count of 10.
  • Repeat 10 times.

How to Strengthen Your Ankle After a Sprain

Following an ankle sprain, strengthening exercises should be performed once you can bear weight comfortably and your range of motion is near full. There are several types of strengthening exercises. The easiest to begin with are isometric exercises that you do by pushing against a fixed object with your ankle.

Once this has been mastered, you can progress to isotonic exercises, which involve using your ankle’s range of motion against some form of resistance. The photos below show isotonic exercises performed with a resistance band, which you can get from your local therapist or a sporting goods store.

Figure 4. Sprained ankle exercises

Range of Motion

• Ankle Alphabet: Spell out each letter of the alphabet with your foot, keeping your leg still while moving at the ankle. Use the biggest movements your ankle allows to go through the whole thing, A-Z.
• Calf Stretches: As soon as you can, start stretching your calves by putting the injured leg behind you, keeping your leg straight, and leaning pushing on a wall. If you can’t tolerate standing on your injured foot, straighten your leg by propping it up on a chair, or while sitting on your bed, then use a towel to pull the ball of your foot towards you. Hold for 30 seconds and repeat 3 times.

Strengthening

• Resisted 4-Way Ankle Holds: As pain allows, use a resistance band or towel to work against while you pull your ankle as far as you can in all 4 directions: up, down, inverted (top of foot towards the outside) and everted (sole of the foot towards the outside). Hold for 10 seconds, 5 times in each direction.
• Heel Raises: Once you can bear weight on your foot, stand on the ground and slowly raise your heels off as far as you can, hold for 5 seconds then slowly lower back down. Do 3 sets of 10 reps. You can progress this by standing half-way on a stair with both heels hanging off. Allow your heels to drop below the stair as you come down, holding that position for 5 seconds before rising back up (this can be a great way to stretch your calves too). Once you’re feeling really strong, switch to just using one foot at a time, rinse and repeat.

Balance

• Single Leg Stands: Stand on one foot (once you can tolerate it) while working up to balancing for 30 seconds. If needed, stand next to a chair or wall for support. Make it even tougher by closing your eyes, then progress to standing on a pillow to destabilize you. Stand with your affected leg on a pillow. Hold this position for a count of 10. Repeat 10 times.
• Advanced Balance Training: Once you’ve mastered single leg stands, you can really get your balance on by standing on one leg (yes, again) and putting both arms straight up above your head. Now slowly bend forward at the waist (keeping your back straight) as far as you can while keeping your balance. Not so easy, right? Try bending backwards as far as you can (hands still above your head), then to the left and to the right. Finally you can slowly twist to the left and right all while keeping balanced and tight in your core.

These same exercises that you’ve used to rehab your ankle can serve to strengthen it for future protection against another sprain. Progressing to longer periods of balancing and more reps on your resisted exercises will keep you strong and in tune with your ankle for years to come.

Once you have regained the motion and strength in your ankle, you are ready for sporting activities such as gentle jogging and biking. After you feel your ankle strength is approximately 80% of your other side, then you can begin cutting or twisting sports.

Using a brace or getting your ankle wrapped during risky activities will also help prevent future ankle sprains by adding increased support to your injured ligaments, even once they’ve healed. Whether the brace is soft or hard, find something comfortable and supportive that you’re willing to use each time you lace up your sport shoes.

Surgery

In rare cases, surgery is performed when the injury doesn’t heal or the ankle remains unstable after a long period of physical therapy and rehabilitative exercise.

Surgery may be performed to:

• Repair a ligament that won’t heal
• Reconstruct a ligament with tissue from a nearby ligament or tendon

Surgical options may include:

• Arthroscopy. During arthroscopy, your doctor uses a small camera, called an arthroscope, to look inside your ankle joint. Miniature instruments are used to remove any loose fragments of bone or cartilage, or parts of the ligament that may be caught in the joint.
  Reconstruction. Your doctor may be able to repair the torn ligament with stitches or sutures. In some cases, he or she will reconstruct the damaged ligament by replacing it with a tissue graft obtained from other ligaments and/or tendons found in the foot and around the ankle.

• Immobilization. There is typically a period of immobilization following surgery for an ankle sprain. Your doctor may apply a cast or protective boot to protect the repaired or reconstructed ligament. Be sure to follow your doctor’s instructions about how long to wear the protective device; if you remove it too soon, a simple misstep can re-tear the fixed ligament.

Rehabilitation

Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.