Childhood stress

Stress is a function of the demands placed on you and your ability to meet them. These demands often come from outside sources, such as family, jobs, friends, or school. But it also can come from within, often related to what you think we should be doing versus what you’re actually able to do. So stress can affect anyone who feels overwhelmed — even kids. In preschoolers, separation from parents can cause separation anxiety. As kids get older, academic and social pressures (especially from trying to fit in) create stress.

Worry and fear are different forms of anxiety. Fear usually happens in the present. Worry usually happens when a child thinks about past or future situations. For example, a child might be fearful when she sees a dog and also worry about visiting a friend with a pet dog.

After a traumatic event, you or your child might need support, and children suffering post-traumatic stress disorder (PTSD) usually need professional help.

Childhood stress can be present in any setting that requires the child to adapt or change. Stress may be caused by positive changes, such as starting a new activity, but it is most commonly linked with negative changes such as illness or death in the family.

You can help your child by learning to recognize the signs of stress and teaching your child healthy ways to deal with it.

It’s important to distinguish among three kinds of responses to stress: positive, tolerable, and toxic ¹⁾. These three terms refer to the stress response systems’ effects on the body, not to the stressful event or experience itself:

1. Positive stress response is a normal and essential part of healthy development, characterized by brief increases in heart rate and mild elevations in hormone levels. Some situations that might trigger a positive stress response are the first day with a new caregiver or receiving an injected immunization.
2. Tolerable stress response activates the body’s alert systems to a greater degree as a result of more severe, longer-lasting difficulties, such as the loss of a loved one, a natural disaster, or a frightening injury. If the activation is time-limited and buffered by relationships with adults who help the child adapt, the brain and other organs recover from what might otherwise be damaging effects.
3. Toxic stress response is the most dangerous form of stress response, can occur when a child experiences strong, frequent, and/or prolonged adversity (activation of the body’s stress response systems)—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years. The risk factors studied in the Adverse Childhood Experiences Study ²⁾ include examples of multiple stressors (eg, child abuse or neglect, parental substance abuse, and maternal depression) that are capable of inducing a toxic stress response. The essential characteristic of this phenomenon is the postulated disruption of brain circuitry and other organ and metabolic systems during sensitive developmental periods. Such disruption may result in anatomic changes and/or physiologic dysregulations that are the precursors of later impairments in learning and behavior as well as the roots of chronic, stress-related physical and mental illness.

When toxic stress response occurs continually, or is triggered by multiple sources, it can have a cumulative toll on an individual’s physical and mental health—for a lifetime. The more adverse experiences in childhood, the greater the likelihood of developmental delays and later health problems, including heart disease, diabetes, substance abuse, and depression. Research also indicates that supportive, responsive relationships with caring adults as early in life as possible can prevent or reverse the damaging effects of toxic stress response.

Causes of stress in childhood

Stress may be a response to a negative change in a child’s life. In small amounts, stress can be good. But, excessive stress can affect the way a child thinks, acts, and feels.

Children learn how to respond to stress as they grow and develop. Many stressful events that an adult can manage will cause stress in a child. As a result, even small changes can impact a child’s feelings of safety and security.

Pain, injury, illness, and other changes are stressors for children. Stressors may include:

• Worrying about schoolwork or grades
• Juggling responsibilities, such as school and work or sports
• Problems with friends, bullying, or peer group pressures
• Changing schools, moving, or dealing with housing problems or homelessness
• Having negative thoughts about themselves
• Going through body changes, in both boys and girls
• Seeing parents go through a divorce or separation
• Money problems in the family
• Living in an unsafe home or neighborhood

Post traumatic stress in children

Post-traumatic stress is a reaction to a severe traumatic event in which a child was hurt or felt extremely scared or threatened. Events that might trigger these reactions include:

• natural disasters
• personal attacks
• car accidents
• sexual, physical and emotional abuse.

Children who have been affected by a traumatic event usually show some anxiety for a few weeks afterwards. The anxiety then gradually disappears.

Post-traumatic stress disorder (PTSD)

In some cases, children suffer anxiety for many months and years after a traumatic event. This can interfere with their daily lives. This might be post-traumatic stress disorder (PTSD). Children suffering from post-traumatic stress disorder usually need professional help.

Children with PTSD might keep remembering the traumatic event or have bad dreams about it, perhaps even including the trauma in their play. They might suddenly act or feel as if the event is happening again and get very upset. They often try hard to avoid situations that remind them of the trauma and might become emotionally distant. They might be jumpy or irritable and have sleep difficulties.

Specific phobias in children

Specific phobias are fears of particular things or situations. These fears are quite common in children. Some common childhood phobias include the dark, storms, dogs, spiders, costumed characters like clowns, heights, blood and injections.

Say a child is scared of the dark or of dogs, and he happens to be in a darkened room or facing a barking dog. The child might become very anxious and distressed. As with other anxieties, children with specific phobias will try to avoid the situation they’re afraid of. Or they might be extremely distressed if they have to go through it.

Although these anxieties are common, it’s a good idea to seek some professional help if your child’s fear:

• is really interfering with your child’s daily life
• is something you feel your child should have grown out of
• goes on for longer than six months.

Panic attacks in children

Panic attacks are a sudden rush of fear accompanied by physical feelings like a racing heart, breathlessness, tightness in the throat or chest, sweating, light-headedness and/or tingling. During a panic attack, children might believe that they’re dying or that something terrible is happening to them.

These kinds of episodes are quite rare in young children and become more common in teenagers.

Panic disorder

The fear of or anxiety about having panic attacks is known as panic disorder. For children with panic disorder, the fear is of the panic attack itself rather than of the situation. This means that children are afraid of their panic symptoms, rather than of the things that cause anxiety, like people laughing at them, dogs biting them or getting lost.

Panic disorder is very uncommon in young children and younger teenagers. It happens more often in older teenagers and young adults.

If children start avoiding situations because of their panic attacks, this is called panic disorder with agoraphobia. If this happens, it’s worthwhile seeking professional help.

Anxiety and fears in children

Anxiety in children is normal. It’s normal for children to show signs of anxiety, worries and fears sometimes. Childhood anxieties and fears include separation anxiety, fear of the dark and worries about school. In most cases, anxiety in children and fears in childhood come and go and don’t last long.

In fact, different anxieties often develop at different stages. For example:

• Babies and toddlers often fear loud noises, heights, strangers and separation.
• Preschoolers might start to show fear of being on their own and of the dark.
• School-age children might be afraid of supernatural things (like ghosts), social situations, failure, criticism or tests, and physical harm or threat.

Babies and young children don’t tend to worry about things. For children to be worried, they have to imagine the future and bad things that might happen in it. This is why worries become more common in children over eight years of age.

Children also worry about different things as they get older. In early childhood, they might worry about getting sick or hurt. In older childhood and adolescence, the focus becomes less concrete. For example, they might think a lot about war, economic and political fears, family relationships and so on.

If your child shows signs of normal childhood anxiety, you can support him in several ways:

• Acknowledge your child’s fear – don’t dismiss or ignore it.
• Gently encourage your child to do things she’s anxious about, but don’t push her to face situations she doesn’t want to face.
• Wait until your child actually gets anxious before you step in to help.
• Praise your child for doing something he’s anxious about, rather than criticising him for being afraid.
• Avoid labeling your child as ‘shy’ or ‘anxious’.

Types of anxiety in children

Children experience several types of anxiety. A child might have only one type of anxiety, or she might show features of several of them.

Social anxiety in children

Social anxiety is fear and worry in situations where children have to interact with other people, or be the focus of attention. Children with social anxiety might:

• believe that others will think badly of or laugh at them
• be shy or withdrawn
• have difficulty meeting other children or joining in groups
• have only a few friends
• avoid social situations where they might be the focus of attention or stand out from others – for example, talking on the telephone and asking or answering questions in class.

Separation anxiety in children

Separation anxiety is the fear and worry children experience when they can’t be with their parents or carers. Children with separation anxiety might:

• protest, cry or struggle when being separated from their parents or carers
• worry about getting hurt or having an accident (they might worry about their parents or themselves)
• refuse to go to or stay at day care, preschool or school by themselves
• refuse to sleep at other people’s homes without their parents or carers
• feel sick when separated from their parents or carers.

Generalized anxiety in children

Children with generalized anxiety tend to worry about many areas of life – anything from friends at playgroup to world events. Children with generalized anxiety might:

• worry about things like health, schoolwork, school or sporting achievements, money, safety, world events and so on
• feel the need to get everything perfect
• feel scared of asking or answering questions in class
• find it hard to perform in tests
• be afraid of new or unfamiliar situations
• seek constant reassurance
• feel sick when worried.

When to be concerned about anxiety in children

Most children have fears or worries of some kind. But if you’re concerned about your child’s fears, worries or anxiety, it’s a good idea to seek professional help.

You might consider seeing your doctor if:

• your child’s anxiety is stopping him from doing things he wants to do or interfering with his friendships, schoolwork or family life
• your child’s behavior is very different from children the same age – for example, it’s common for most children to have separation fears when going to preschool for the first time, but far less common over the age of eight years
• your child’s reactions seem unusually severe – for example, your child might show extreme distress or be very hard to settle when you leave him.

Severe anxiety can impact on children’s health and happiness. Some anxious children will grow out of their fears, but others will keep having trouble with anxiety unless they get professional help.

Childhood stress effects

Children may not recognize that they are stressed. New or worsening symptoms may lead parents to suspect an increased stress level is present.

Physical symptoms can include:

• Decreased appetite, other changes in eating habits
• Headache
• New or recurrent bedwetting
• Nightmares
• Sleep disturbances
• Upset stomach or vague stomach pain
• Other physical symptoms with no physical illness

Emotional or behavioral symptoms may include:

• Anxiety, worry
• Not able to relax
• New or recurring fears (fear of the dark, fear of being alone, fear of strangers)
• Clinging, unwilling to let you out of sight
• Anger, crying, whining
• Not able to control emotions
• Aggressive or stubborn behavior
• Going back to behaviors present at a younger age
• Doesn’t want to participate in family or school activities

How can parents help with childhood stress

Parents can help children respond to stress in healthy ways. Following are some tips:

• Provide a safe, secure, and dependable home.
• Family routines can be comforting. Having a family dinner or movie night can help relieve or prevent stress.
• Be a role model. The child looks to you as a model for healthy behavior. Do your best to keep your own stress under control and manage it in healthy ways.
• Be careful about which television programs, books, and games that young children watch, read, and play. News broadcasts and violent shows or games can produce fears and anxiety.
• Keep your child informed of anticipated changes such as in jobs or moving.
• Spend calm, relaxed time with your children.
• Learn to listen. Listen to your child without being critical or trying to solve the problem right away. Instead work with your child to help them understand and solve what is upsetting to them.
• Build your child’s feelings of self-worth. Use encouragement and affection. Use rewards, not punishment. Try to involve your child in activities where they can succeed.
• Allow the child opportunities to make choices and have some control in their life. The more your child feels they have control over a situation, the better their response to stress will be.
• Encourage physical activity.
• Recognize signs of unresolved stress in your child.
• Seek help or advice from a health care provider, counselor, or therapist when signs of stress do not decrease or disappear.

Infant flu shot

The flu shot or influenza vaccine is safe for pregnant women and provides effective protection for you and your newborn baby for the first six months of their life.

Seasonal influenza shots protect against the three or four influenza viruses that research indicates will be most common during the season. The flu shot is especially important for people with some medical conditions like kidney disease, diabetes, HIV, heart problems, or asthma to get a flu vaccine. These people are more likely to have serious health problems (like pneumonia) when they get the flu.

Kids and teens who take aspirin regularly also need to be vaccinated. They’re at risk for getting a serious condition called Reye syndrome if they get the flu.

Another reason to get vaccinated is to protect the people around you who might get very ill from flu — like babies, people with serious medical conditions, and the elderly. When you protect yourself with the flu vaccine, you also protect other people who are at risk because there’s less chance you’ll get the flu and pass it on. Sometimes people call this “herd immunity.”

The Centers for Disease Control and Prevention (CDC) recommends that everyone 6 months of age and older get a seasonal flu vaccine each year by the end of October ¹⁾. However, as long as flu viruses are circulating, vaccination should continue throughout flu season, even in January or later.

Special vaccination instructions for children aged 6 months through 8 years of age

• Some children 6 months through 8 years of age require two doses of flu vaccine for adequate protection from flu. Children in this age group getting vaccinated for the first time, and those who have only previously gotten one dose of vaccine, should get two doses of vaccine this season—spaced at least 4 weeks apart. Your child’s health care provider can tell you if your child needs two doses.
• If your child needs the two doses, begin the process early. This will ensure that your child is protected before influenza starts circulating in your community.
• Be sure to get your child a second dose if he or she needs one. It usually takes about two weeks after the second dose for protection to begin.

According to the CDC influenza is more dangerous than the common cold for children. Each year, millions of children get sick with seasonal flu; thousands of children are hospitalized, and some children die from flu. Children commonly need medical care because of flu, especially children younger than 5 years old.

Complications from flu among children in this age group can include:

• Pneumonia: an illness where the lungs get infected and inflamed
• Dehydration: when a child’s body loses too much water and salts, often because fluid losses are greater than from fluid intake)
• Worsening of long-term medical problems like heart disease or asthma
• Brain dysfunction such as encephalopathy
• Sinus problems and ear infections
• In rare cases, flu complications can lead to death.

Flu seasons vary in severity, however every year children are at risk. The CDC estimates that since 2010, flu-related hospitalizations among children younger than 5 years old have ranged from 7,000 to 26,000 in the United States ²⁾. While relatively rare, some children die from flu each year. Since 2004-2005, flu-related deaths in children reported to CDC during regular flu seasons have ranged from 37 to 187 deaths. Even though the reported number of deaths during the 2017-2018 flu season was 187, CDC’s mathematical models that account for the underreporting of flu-related deaths in children estimate the actual number was closer to 600.

Flu vaccines are updated each season as needed to protect against the influenza viruses that research indicates will be most common during the upcoming season. The 2019-2020 influenza vaccine has been updated from last season’s flu vaccine to better match circulating viruses. Immunity from the flu vaccination sets in after about two weeks.

Which children are at especially high risk of serious flu-related complications?

Children at greatest risk of serious flu-related complications include the following:

1. Children younger than 6 months old: These children are too young to be vaccinated. The best way to protect these children is for their mother to get a flu shot during pregnancy and for people around them to get vaccinated, as well. A flu shot given during pregnancy has been shown to not only protect the mother from flu, but also to help protect the baby from flu infection for several months after birth, before he or she is old enough to be vaccinated.
2. Children aged 6 months up to their 5th birthday. Since 2010, CDC estimates that flu-related hospitalizations among children younger than 5 years ranged from 7,000 to 26,000. Even children in this age group who are otherwise healthy are at high risk simply because of their age. Additionally, children 2 years of age up to their 5th birthday are more likely than healthy older children to be taken to a doctor, an urgent care center, or the emergency room because of flu ³⁾, ⁴⁾. To protect their health, all children 6 months and older should be vaccinated against flu each year. Vaccinating young children, their families, and other caregivers can also help protect them from getting sick.
3. American Indian and Alaskan Native children: These children are more likely to have severe flu illness that results in hospitalization or death ⁵⁾.
4. Children aged 6 months old through 18 years old with chronic health problems, including:
   • Asthma and other chronic lung diseases (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis)
   • Neurologic and neurodevelopment conditions [including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy (seizure disorders), stroke, intellectual disability (mental retardation), moderate to severe developmental delay, muscular dystrophy, or spinal cord injury]
   • Chronic lung disease
   • Heart disease (such as congenital heart disease, congestive heart failure and coronary artery disease)
   • Blood disorders (such as sickle cell disease)
   • Endocrine disorders (such as diabetes mellitus)
   • Kidney disorders
   • Liver disorders
   • Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)
   • Weakened immune system due to disease or medication (such as people with HIV or AIDS, or cancer, or those on chronic steroids)
   • Children who are taking aspirin or salicylate-containing medicines
   • Extreme obesity, which has been associated with severe flu illness in some studies of adults, may also be a risk factor for children. Childhood obesity is defined as a body mass index (BMI) at or above the 95th percentile, for age and sex.

Who should be prioritized for flu vaccination during a vaccine shortage?

When the flu vaccine supply is in limited supply, vaccination efforts should focus on delivering vaccination to the following people (no hierarchy is implied by order of listing):

• Children aged 6 months through 4 years (59 months);
• People aged 50 years and older;*
• People with chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus);
• People who are immunosuppressed due to any cause, including immunosuppression caused by medications or by human immunodeficiency virus (HIV) infection;
• Women who are or will be pregnant during the influenza season and women up to two weeks after delivery;
• People who are aged 6 months through 18 years who are receiving aspirin or salicylate-containing medications and who might be at risk for experiencing Reye syndrome after influenza virus infection;
• People who are residents of nursing homes and other long-term care facilities;
• American Indians/Alaska Natives;
• People with extreme obesity (body-mass index [BMI] is 40 or greater);
• Health care personnel;
• Household contacts and caregivers of children under 5 years and adults aged 50 years and older; and
• Household contacts and caregivers of people with medical conditions that put them at increased risk for severe illness and complications from influenza.

Footnote: *Among adults, complications, hospitalizations, and deaths due to influenza are generally most common among those 65 years old and over. However, adults 50 years old and over are a priority group for vaccination because this group may be more likely to have chronic medical conditions that put them at high risk of severe influenza illness.

How effective is the flu vaccine?

How well the flu vaccine works (or its ability to prevent flu illness) can vary from season to season. The vaccine’s effectiveness also can vary depending on who is being vaccinated. At least two factors play an important role in determining the likelihood that flu vaccine will protect a person from flu illness: 1) characteristics of the person being vaccinated (such as their age and health), and 2) the similarity or “match” between the flu viruses the flu vaccine is designed to protect against and the flu viruses spreading in the community. During years when the flu vaccine is not well matched to circulating influenza viruses, it is possible that little or no benefit from flu vaccination may be observed. During years when there is a good match between the flu vaccine and circulating viruses, it is possible to measure substantial benefits from flu vaccination in terms of preventing flu illness and complications. However, even during years when the flu vaccine match is good, the benefits of flu vaccination will vary, depending on various factors like the characteristics of the person being vaccinated, what influenza viruses are circulating that season and even, potentially, which type of flu vaccine was used.

CDC conducts studies each year to determine how well the influenza (flu) vaccine protects against flu illness. While vaccine effectiveness can vary, recent studies show that flu vaccination reduces the risk of flu illness by between 40% and 60% among the overall population during seasons when most circulating flu viruses are well-matched to the flu vaccine. In general, current flu vaccines tend to work better against influenza B and influenza A(H1N1) viruses and offer lower protection against influenza A(H3N2) viruses.

How effective is the flu vaccine in children?

Vaccination has been found in most seasons to provide a similar level of protection against flu illness in children to that seen among healthy adults.

In several studies, flu vaccine effectiveness was higher among children who received two doses of flu vaccine the first season that they were vaccinated (as recommended) compared to “partially vaccinated” children who only received a single dose of flu vaccine. However, in some seasons, partially vaccinated children still receive some protection.

In addition to preventing illness, flu vaccine can prevent severe, life-threatening complications in children, for example:

• A 2014 study showed that flu vaccine reduced children’s risk of flu-related pediatric intensive care unit (PICU) admission by 74% during flu seasons from 2010-2012.
• In 2017, a study in the journal Pediatrics ⁶⁾ was the first of its kind to show that flu vaccination also significantly reduced a child’s risk of dying from the flu. The study, which looked at data from four flu seasons between 2010 and 2014, found that flu vaccination reduced the risk of flu-associated death by half (51 percent) among children with underlying high-risk medical conditions and by nearly two-thirds (65 percent) among healthy children.

Types of flu vaccines for children

Children 6 months and older should get an annual flu vaccine. For the 2019-2020 flu season, CDC recommends annual influenza vaccination for everyone 6 months and older with any licensed, age-appropriate flu vaccine.

1. Injectable influenza vaccine (IIV) is given as an injection (with a needle) and is approved for use in people 6 months and older.
2. Live inactivated influenza vaccine (LAIV) is given as a nasal spray and is approved for use in people 2 through 49 years old. However, there is a precaution against the use of nasal spray flu vaccine (LAIV) in people with certain underlying medical conditions.

Your child’s health care provider will know which vaccines are right for your child.

Table 1. U.S. Influenza Vaccine Products for the 2019-2020 Season

Trade Name [Manufacturer]	Presentation	Age Indication	HA, µG/dose (each virus)	Egg-grown virus, Cell culture-grown virus, or Recombinant HA	Adjuvanted Yes/No	Latex Yes/No	Thimerosal Yes/No If yes, Mercury, μg/0.5mL
Quadrivalent IIVs (IIV4s)
Afluria Quadrivalent* Seqirus	0.25 mL prefilled syringe*	6 through 35 mos*	7.5/0.25 mL	Egg	No	No	No
	0.5 mL prefilled syringe*	≥3 yrs*	15/0.5 mL	Egg	No	No	No
	5.0 mL multi-dose vial*	≥6 mos*(needle/syringe)18 through 64 yrs (jet injector)	See note for dosing*	Egg	No	No	Yes (24.5)
Fluarix Quadrivalent GlaxoSmithKline	0.5 mL prefilled syringe	≥6 mos	15/0.5mL	Egg	No	No	No
FluLaval Quadrivalent ID GlaxoSmithKline	0.5 mL prefilled syringe	≥6 mos	15/0.5mL	Egg	No	No	No
	5.0 mL multi-dose vial	≥6 mos	15/0.5mL	Egg	No	No	Yes (<25)
Flucelvax Quadrivalent Seqirus (ccIIV4)	0.5 mL prefilled syringe	≥4 yrs	15/0.5mL	Cell	No	No	No
	5.0 mL multi-dose vial	≥4 yrs	15/0.5mL	Cell	No	No	Yes (25)
Fluzone Quadrivalent †Sanofi Pasteur	0.25 mL prefilled syringe†	6 through 35 mos†	7.5/0.25 mL	Egg	No	No	No
	0.5 mL prefilled syringe†	≥6 mos†	15/0.5 mL	Egg	No	No	No
	0.5 mL single-dose vial†	≥6 mos†	See note for dosing†	Egg	No	No	No
	5.0 mL multi-dose vial†	≥6 mos†	See note for dosing†	Egg	No	No	Yes (25)
Trivalent IIV (IIV3s)
Fluad Seqirus (aIIV3)	0.5 mL prefilled syringe	≥65 yrs	15/0.5mL	Egg	Yes	No	No
Fluzone High-Dose Sanofi Pasteur (HD-IIV3)	0.5 mL prefilled syringe	≥65 yrs	60/0.5mL	Egg	No	No	No
Quadrivalent RIV (RIV4)
Flublok Quadrivalent Sanofi Pasteur	0.5 mL prefilled syringe	≥18 yrs	45/0.5mL	Recombinant	No	No	No

Footnotes: * for Afluria Quadrivalent, children aged 6 through 35 months should receive 0.25mL per dose. Persons ≥36 months (≥3 years) should receive 0.5mL per dose.

† for Fluzone Quadrivalent, children aged 6 through 35 months may receive either 0.25mL or 0.5mL per dose. Persons ≥36 months (≥3 years) should receive 0.5mL per dose

Abbreviations: IIV=inactivated influenza vaccine; RIV=recombinant influenza vaccine; HA=hemagglutinin; months=months; yrs=years.

[Source ⁷⁾ ]

Who SHOULD NOT get the flu shot

People who SHOULD NOT get the flu shot:

1. Children younger than 6 months of age are too young to get a flu shot.
2. People with severe, life-threatening allergies to flu vaccine or any ingredient in the vaccine. This might include gelatin, antibiotics, or other ingredients.

People who should talk to their health care provider before getting a flu shot:

If you have one of the following conditions, talk with your health care provider. He or she can help decide whether vaccination is right for you, and select the best vaccine for your situation:

• If you have an allergy to eggs or any of the ingredients in the vaccine. Talk to your doctor about your allergy. See Special Considerations Regarding Egg Allergy for more information about egg allergies and flu vaccine.
• If you ever had Guillain-Barre syndrome a severe paralyzing illness (also called GBS). Some people with a history of Guillain-Barre syndrome should not get a flu vaccine. Talk to your doctor about your Guillain-Barre syndrome history.
• If you are not feeling well, talk to your doctor about your symptoms.

Special consideration regarding egg allergy

People with egg allergies can receive any licensed, recommended age-appropriate influenza (flu) vaccine (IIV, RIV4, or LAIV4) that is otherwise appropriate. People who have a history of severe egg allergy (those who have had any symptom other than hives after exposure to egg) should be vaccinated in a medical setting, supervised by a health care provider who is able to recognize and manage severe allergic reactions.

What is Guillain-Barre syndrome?

Guillain-Barré syndrome (GBS) is a rare disorder in which a person’s own immune system — which usually attacks only invading organisms — damages their nerve cells, causing muscle weakness and sometimes paralysis. Guillain-Barre syndrome can cause symptoms that usually last for a few weeks. Most people recover fully from Guillain-Barre syndrome, but some people have long-term nerve damage. In very rare cases, people have died of Guillain-Barre syndrome, usually from difficulty breathing. In the United States, an estimated 3,000 to 6,000 people develop Guillain-Barre syndrome each year.

Once thought to be a single disorder, Guillain-Barre syndrome is now known to occur in several forms. The main types are:

1. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), the most common form in North America and Europe. In AIDP the nerves’ protective covering (myelin sheath) is damaged. The damage prevents nerves from transmitting signals to your brain, causing weakness, numbness or paralysis. The most common sign of AIDP is muscle weakness that starts in the lower part of your body and spreads upward.
2. Miller Fisher syndrome (MFS), in which paralysis starts in the eyes. MFS is also associated with unsteady gait. MFS is less common in the U.S. but more common in Asia.
3. Acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal neuropathy (AMSAN) are less common in the U.S. But AMAN and AMSAN are more frequent in China, Japan and Mexico.

What causes Guillain-Barre syndrome?

The exact cause of Guillain-Barre syndrome is unknown, but about two-thirds of people who develop Guillain-Barre syndrome experience symptoms several days or weeks after they have been sick with diarrhea or a respiratory illness. Infection with the bacterium Campylobacter jejuni is one of the most common risk factors for Guillain-Barre syndrome. People also can develop Guillain-Barre syndrome after having the flu or other infections (such as cytomegalovirus and Epstein Barr virus). On very rare occasions, they may develop Guillain-Barre syndrome in the days or weeks after getting a vaccination.

Rarely, recent surgery can also trigger Guillain-Barre syndrome. Recently, there have been Guillain-Barre syndrome cases reported following infection with the Zika virus.

Risk factors for developing Guillain-Barre syndrome

Guillain-Barre syndrome can affect all age groups. But your risk increases as you age. It’s also more common in males than females.

Guillain-Barre syndrome may be triggered by:

• Most commonly, infection with campylobacter, a type of bacteria often found in undercooked poultry
• Influenza virus
• Cytomegalovirus
• Epstein-Barr virus
• Zika virus
• Hepatitis A, B, C and E
• HIV, the virus that causes AIDS
• Mycoplasma pneumonia
• Surgery
• Trauma
• Hodgkin’s lymphoma
• Rarely, influenza vaccinations or childhood vaccinations

Who is at risk for developing Guillain-Barre syndrome?

Anyone can develop Guillain-Barre syndrome; however, it is more common among older adults. The incidence of Guillain-Barre syndrome increases with age, and people older than 50 years are at greatest risk for developing Guillain-Barre syndrome.

What are symptoms of Guillain-Barre syndrome?

Guillain-Barre syndrome often begins with tingling and weakness starting in your feet and legs and spreading to your upper body and arms. In about 10% of people with the disorder, symptoms begin in the arms or face. As Guillain-Barre syndrome progresses, muscle weakness can evolve into paralysis.

Signs and symptoms of Guillain-Barre syndrome may include:

• Prickling, pins and needles sensations in your fingers, toes, ankles or wrists
• Weakness in your legs that spreads to your upper body
• Unsteady walking or inability to walk or climb stairs
• Difficulty with facial movements, including speaking, chewing or swallowing
• Double vision or inability to move eyes
• Severe pain that may feel achy, shooting or cramplike and may be worse at night
• Difficulty with bladder control or bowel function
• Rapid heart rate
• Low or high blood pressure
• Difficulty breathing

People with Guillain-Barre syndrome usually experience their most significant weakness within two weeks after symptoms begin.

Guillain-Barre syndrome complications

Guillain-Barre syndrome affects your nerves. Because nerves control your movements and body functions, people with Guillain-Barre may experience:

• Breathing difficulties. The weakness or paralysis can spread to the muscles that control your breathing, a potentially fatal complication. Up to 22% of people with Guillain-Barre syndrome need temporary help from a machine to breathe within the first week when they’re hospitalized for treatment.
• Residual numbness or other sensations. Most people with Guillain-Barre syndrome recover completely or have only minor, residual weakness, numbness or tingling.
• Heart and blood pressure problems. Blood pressure fluctuations and irregular heart rhythms (cardiac arrhythmias) are common side effects of Guillain-Barre syndrome.
• Pain. One-third of people with Guillain-Barre syndrome experience severe nerve pain, which may be eased with medication.
• Bowel and bladder function problems. Sluggish bowel function and urine retention may result from Guillain-Barre syndrome.
• Blood clots. People who are immobile due to Guillain-Barre syndrome are at risk of developing blood clots. Until you’re able to walk independently, taking blood thinners and wearing support stockings may be recommended.
• Pressure sores. Being immobile also puts you at risk of developing bedsores (pressure sores). Frequent repositioning may help avoid this problem.
• Relapse. From 2% to 5% of people with Guillain-Barre syndrome experience a relapse.

Severe, early symptoms of Guillain-Barre syndrome significantly increase the risk of serious long-term complications. Rarely, death may occur from complications such as respiratory distress syndrome and heart attacks.

Guillain-Barre syndrome diagnosis

Guillain-Barre syndrome can be difficult to diagnose in its earliest stages. Its signs and symptoms are similar to those of other neurological disorders and may vary from person to person.

Your doctor is likely to start with a medical history and thorough physical examination.

Your doctor may then recommend:

• Spinal tap (lumbar puncture). A small amount of fluid is withdrawn from the spinal canal in your lower back. The fluid is tested for a type of change that commonly occurs in people who have Guillain-Barre syndrome.
• Electromyography. Thin-needle electrodes are inserted into the muscles your doctor wants to study. The electrodes measure nerve activity in the muscles.
• Nerve conduction studies. Electrodes are taped to the skin above your nerves. A small shock is passed through the nerve to measure the speed of nerve signals.

Guillain-Barre syndrome treatment

There’s no cure for Guillain-Barre syndrome. But two types of treatments can speed recovery and reduce the severity of the illness:

• Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then put back into your body, which manufactures more plasma to make up for what was removed. Plasmapheresis may work by ridding plasma of certain antibodies that contribute to the immune system’s attack on the peripheral nerves.
• Immunoglobulin therapy. Immunoglobulin containing healthy antibodies from blood donors is given through a vein (intravenously). High doses of immunoglobulin can block the damaging antibodies that may contribute to Guillain-Barre syndrome.

These treatments are equally effective. Mixing them or administering one after the other is no more effective than using either method alone.

You are also likely to be given medication to:

• Relieve pain, which can be severe
• Prevent blood clots, which can develop while you’re immobile

People with Guillain-Barre syndrome need physical help and therapy before and during recovery. Your care may include:

• Movement of your arms and legs by caregivers before recovery, to help keep your muscles flexible and strong
• Physical therapy during recovery to help you cope with fatigue and regain strength and proper movement
• Training with adaptive devices, such as a wheelchair or braces, to give you mobility and self-care skills

Guillain-Barre syndrome recovery

Although some people can take months and even years to recover, most people with Guillain-Barre syndrome experience this general timeline:

• After the first signs and symptoms, the condition tends to progressively worsen for about two weeks
• Symptoms reach a plateau within four weeks
• Recovery begins, usually lasting six to 12 months, though for some people it could take as long as three years.

Among adults recovering from Guillain-Barre syndrome:

• About 80% can walk independently six months after diagnosis
• About 60% fully recover motor strength one year after diagnosis
• About 5% to 10% have very delayed and incomplete recovery

Children, who rarely develop Guillain-Barre syndrome, generally recover more completely than adults.

When should children get a flu vaccine?

Children should be vaccinated every flu season for the best protection against flu. The best time to get a flu vaccine is before flu season starts in October. For children who will need two doses of flu vaccine, the first dose should be given as early in the season as possible. For other children, it is good practice to get them vaccinated by the end of October. It’s best to get vaccinated as soon as this year’s flu vaccine becomes available, which usually is around September. This gives the body time to build immunity before the winter flu season. However, getting vaccinated later can still be protective, as long as flu viruses are circulating. While seasonal flu outbreaks can happen as early as October, during most seasons flu activity peaks between December and February. Since it takes about two weeks after vaccination for antibodies to develop in the body that protect against flu virus infection, it is best that people get vaccinated so they are protected before influenza begins spreading in their community.

You also can protect yourself against the flu (and many other infections) by washing your hands well and often.

Side effects of flu shot in babies and toddlers

The viruses in a flu shot are killed (inactivated), so you cannot get flu from a flu shot. Some minor side effects that may occur are:

• Soreness, redness, and/or swelling where the shot was given
• Headache (low grade)
• Fever
• Muscle aches
• Nausea
• Fatigue

Common side effects from a flu shot include soreness, redness, and/or swelling where the shot was given, headache (low grade), fever, nausea, muscle aches, and fatigue. The flu shot, like other injections, can occasionally cause fainting.

Life-threatening allergic reactions to influenza shots are very rare. Signs of serious allergic reaction can include breathing problems, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat, or dizziness. If they do occur, it is usually within a few minutes to a few hours after receiving the shot. These reactions can occur among persons who are allergic to something that is in the vaccine, such as egg protein or other ingredients. While severe reactions are uncommon, you should let your doctor, nurse, clinic, or pharmacist know if you have a history of allergy or severe reaction to influenza vaccine or any part of influenza vaccine.

There is a small possibility that influenza vaccine could be associated with Guillain-Barré syndrome. Guillain–Barre syndrome occurs within 6 weeks following a previous dose of influenza vaccine and generally no more than 1 or 2 cases per million people vaccinated. This is much lower than the risk of severe complications from influenza, which can be prevented by influenza vaccine.

How common is Guillain-Barre syndrome among people who have been vaccinated against flu?

The background rate for Guillain-Barre syndrome in the Unites States is about 80 to 160 cases of Guillain-Barre syndrome each week, regardless of vaccination. The data on the association between Guillain-Barre syndrome and seasonal flu vaccination are variable and inconsistent across flu seasons. If there is an increased risk of Guillain-Barre syndrome following flu vaccination it is small, on the order of one to two additional Guillain-Barre syndrome cases per million doses of flu vaccine administered.

Baby co sleep in bed with parents

Co-sleeping also called bed sharing, is when parents bring their babies into bed with them. However, the term ‘co-sleeping’ is broadly used to refer to children who sleep in close proximity to parents and often includes bed sharing (sharing a sleeping surface with a family member for all or a portion of the sleep period ¹⁾. Co-sleeping where parents bring their babies into bed with them can be dangerous for babies. Co-sleeping is associated with an increased risk of sudden unexpected death in infancy (SUDI) including sudden infant death syndrome (SIDS) and fatal sleeping accidents in some circumstances. The safest place for babies to sleep is in a cot next to a parent’s bed, for the first year of life or at least for the first six months. But parents choose to have their babies in bed with them for several reasons. For example, some parents who co-sleep with their babies believe that it helps their babies feel safe and secure. They like the close body contact, feel that it’s rewarding and satisfying, and believe it’s good for their relationships with their babies. Also, some parents co-sleep because they find it more practical. Breastfeeding and resettling during the night can be easier. Some parents feel that it helps with establishing breastfeeding.

Six ways to reduce the risk of sudden unexpected death in infancy (SUDI) and sleep baby safely:

1. Sleep baby on the back from birth, not on the tummy or side
2. Sleep baby with head and face uncovered
3. Keep baby smoke free before birth and after
4. Provide a safe sleeping environment night and day
5. Sleep baby in their own safe sleeping place in the same room as an adult care-giver for the first six to twelve months
6. Breastfeed baby

Babies often wake up because they’re worried about being separated from you. A reassuring touch or cuddle can build your baby’s attachment to you and help her learn that you’re close by, even if she can’t see you. As babies develop they gradually overcome this worry.

Parents sometimes bring a baby into bed because the baby is waking or unsettled at night. For some families, this works well. For others, it might work in the short term but can lead to problems with settling the baby later on. Also, the parents’ bed might not be safely set up for the baby.

Co-sleeping might be a problem if there’s a lack of agreement or tension between partners about co-sleeping.

Finally, a problem could come up if parents want their child to sleep in a separate bed before the child wants to move. Many parents who sleep with their children report that children usually want their own beds by the age of 2-3 years. It can take longer than this, though, and sometimes parents want to stop co-sleeping before their child does.

If you’re experiencing any of these problems, co-sleeping might not be the best option for you and your child. There are other options for settling your baby to sleep.

If you’re concerned that your baby isn’t getting enough sleep, you should discuss your concerns with a health care professional by talking with your doctor. It can also be a good idea to track your baby’s sleep for a week or so. This can help you get a clear picture of what’s going on. You can do this by drawing up a simple chart with columns for each day of the week. Divide the days into hourly blocks, and color the intervals when your baby is asleep. Keep your chart for 5-7 days.

Once completed, the chart will tell you things like:

• when your baby is sleeping
• how much sleep your baby is getting
• how many times your baby is waking during the night over the course of a week
• when your baby is waking at night
• how long your baby is taking to settle after waking.

You can also record how you tried to resettle your baby and what worked or didn’t work.

Then you can compare the information in your chart with the general information about baby sleep needs below:

• How does your child compare to other babies the same age? All babies are different, but if your baby is getting much less sleep than others, your baby might be tired and need more opportunities for sleep.
• How many times is your baby waking up during the night? If your baby is waking only once or twice, your baby isn’t that different from most babies the same age. But if it’s 3-4 times a night or more, you might be feeling very tired. You might want to think about changing your baby’s sleep patterns.

If you decide you need to see a professional for help with your baby’s sleep, take your chart with you.

Keep your chart going as you look into ways to handle your baby’s sleep problems. It will allow you to assess your progress and see just how much change is occurring.

Figure 1. Safe sleeping for newborns

How to safely co sleep?

Separate surface co-sleeping where infants do not have to be in the same bed in order to “co-sleep”, such as using a bassinet next to your bed or a crib, where baby and mother or father are within range of detecting each others signals and cues is all that is necessary.

Do recall that co-sleeping with an infant on a couch, recliner or sofa, though also forms of co-sleeping are dangerous and should be avoided as they increase the chances of suffocation, regardless of your sobriety.

Figure 2. How to safely co sleep

What are baby sleep habits?

Baby sleep habits are the things babies need to settle for sleep. Sleep habits can be pacifiers, music, mobiles, fan noise or other white noise, night-lights, rocking, cuddling, feeding and so on.

Baby sleep habits are usually the same at the start of the night and after waking during the night. So if your baby’s sleep habit is being rocked to sleep at the start of the night, she’ll want to be rocked back to sleep in the middle of the night.

Sleep habits aren’t necessarily something you need to phase out or change. But some babies are difficult to settle or wake a lot at night. If this sounds like your baby and it’s something you’d like to change, you could look at your baby’s sleep habits and think about whether a change might help with sleep and settling.

On the other hand, if you’re happy to resettle your baby each time he wakes during the night, that’s just fine.

But babies and toddlers can have trouble settling to sleep by themselves, so they cry. This can happen for many different reasons. Before trying to settle your crying baby, it’s a good idea to first check whether your baby is hungry, uncomfortable or sick.

• Some babies or toddlers cry when they’re tired or overtired and can’t settle to sleep.
• Many babies or toddlers cry when they need help to settle back to sleep after waking in the night.
• Many babies or toddlers cry when they’re getting used to a new or different way of going to sleep.
• Sometimes happy, healthy babies or toddlers develop rapidly, which means they find it harder than usual to settle.

Babies and toddlers who are crying while trying to settle also need comfort.

Identifying your baby’s sleep habits

If you want to phase out your baby’s sleep habits, the first step is to work out what they are. For example, to settle for sleep your baby might need:

• a pacifier
• music or a mobile above her head
• breastfeeding or bottle-feeding
• cuddling or rocking
• a particular place in your home, like the family room.

When you know what your baby’s sleep habits are, the next step is to work on phasing them out. There are tips below for different baby sleep habits.

It’s important to respond to your baby’s or toddler’s needs for:

• sleep – for example, by putting a baby to sleep when you see baby’s tired signs
• comfort – for example, by not leaving a crying baby alone for long periods.

Consistently responding to your baby’s or toddler’s needs for both sleep and comfort is an important part of bonding with your baby and helping your child grow up feeling safe, secure and cared for.

Working out how to meet your child’s needs and your needs

There are many ways to meet your child’s needs for both sleep and comfort, as well as your own need for rest. You might have to try a few different approaches to sleep, settling and comforting to work out what’s right for you and your child.

It might help to know that all the strategies on this website are thoroughly researched. The evidence says that these strategies are safe. And if you have plenty of warm and loving interactions with your child while they’re awake, these strategies can support your child’s wellbeing and development, and also your relationship with your child.

Phasing out your baby’s sleep habits

Most babies cry while they’re getting used to a new way of going to sleep. That’s because they like their usual way of getting to sleep and might be upset by change. Be prepared for crying for the first few nights.

It might take anything from three days to three weeks to change baby sleep habits, depending on the approach you use and your baby’s temperament.

After that, sleep usually improves for everyone.

Pacifiers

• Pacifiers can be a tricky sleep habit, especially if your baby loses the pacifier during the night and needs you to find it and put it back in.
• One thing you can do is help your baby learn to manage his own pacifier during the night. But if you want to phase out pacifiers, you can help your baby give up the pacifier.

Music and mobiles

• If your baby’s sleep habit is going to sleep with music playing or a mobile moving overhead, it’s probably best to stop using music or mobiles at bedtime – especially if you have to get out of bed to turn the music or mobile back on in the night.
• You can phase out these sleep habits gradually. For example, you could use music as part of your bedtime routine, but turn it off when your baby starts to look drowsy.

Night feeds

• If your baby routinely falls asleep at the breast or with the bottle, she might depend on feeding to help her get to sleep.
• From six months of age, if your baby is developing well, it’s OK to think about night weaning for breastfed babies and phasing out night feeds for bottle-fed babies.
• But if you’re comfortable with feeding your baby during the night, there’s no hurry to phase out night feeds. You can choose what works best for you and your baby.

Rocking, cuddling or going to sleep in the family room

• Some babies are used to being rocked or cuddled to sleep. Or they might want to be with the rest of the family until they fall asleep – for example, in the family room. These babies might find it hard to resettle when they wake up in a different place from where they went to sleep.
• It can help to put your baby to bed drowsy but awake. This gives him the chance to associate falling asleep with being in bed. And it means he’ll be more likely to settle himself when he wakes in his bed in the night.
• The patting settling technique is one way to help babies learn to go to sleep in their own beds.

Looking after yourself

• Phasing out baby sleep habits can be tiring, so it helps to look after yourself. You could try resting during the day when you can, going to bed early and asking family and friends for help.

How healthcare professionals can help with baby sleep and toddler sleep

First, your healthcare professional will talk with you to understand both the problem and your family’s needs. The professional will ask you about your baby, your concerns about your baby’s sleep, and the things you’ve tried so far.

A good professional always finds out what your goals are for your child and your family – there isn’t a one-size-fits-all solution to baby sleep problems.

Your healthcare professional will then work with you to develop and put in place a baby sleep plan. A good plan covers:

• good bedtime and sleep habits
• positive bedtime routines
• settling strategies that you’re comfortable using.

A good sleep plan also covers what to do if the strategies in your baby sleep plan aren’t working.

The settling strategies in your baby’s sleep plan might seem to upset your baby for the first few nights. This will pass as she gets used to the changes. Before too long, you’ll have a more rested, contented baby. You’ll feel better too. If you’re concerned, contact the professional who gave you the sleep plan.

How much sleep do babies need?

Just like grown-ups, babies all sleep for different amounts of time. But your baby’s mood and wellbeing is often a good guide to whether he’s getting enough sleep.

If your baby is:

• wakeful and grizzly, she probably needs more sleep
• wakeful and contented, she’s probably getting enough sleep.

Remember that your baby is unique. He might be doing fine with more or less sleep than other babies the same age.

As children get older, their night-time sleeps get longer and they need fewer naps during the day. Babies and younger children tend to have shorter sleeps at night and more naps during the day. They often wake during the night to feed and might need help to settle themselves to sleep again.

Babies under 12 months sleep needs

• 0-3 months
  • Most newborns don’t have definite day and night sleep patterns. They’re still learning to tell the difference between day and night.
  • Newborns generally sleep for 16-20 hours in a 24-hour period, but they wake every 2-4 hours to be fed. They need lots of feeds because they have tiny tummies.
  • Over the first 12 weeks most newborns start to develop day and night sleep patterns. By three months, babies are averaging 14-15 hours of sleep in each 24-hour period.
• 3-6 months
  • At this age, most babies sleep 10-18 hours in a 24-hour period. On average, they sleep around 14 hours.
  • Although they’re growing quickly, babies still need to wake for feeding at this age.
  • Sleeping patterns vary a lot, but babies generally nap three times during the day. Most babies need help to settle to sleep.
• 6-12 months
  • During these months most babies still sleep for around 14 hours in a 24-hour period.
  • Here’s what to expect during the day:
    • Most babies nap during the day.
    • Naps usually last 1-2 hours. Some babies sleep longer. Up to a quarter of all babies of this age nap for less than an hour.
  • And here’s what to expect at night:
    • Most babies are ready for bed between 6 pm and 10 pm.
    • Most babies take less than 30 minutes to get to sleep.
    • Many babies wake during the night and need an adult to settle them back to sleep. About 1 in 10 babies will do this 3-4 times a night.

More than a third of parents say they have problems with their baby’s sleep at this age.

Babies over 12 months sleep needs

At 12-18 months old, babies generally sleep 13-15 hours over a 24-hour period. Most babies have naps twice a day until around 18 months. Around this time babies often go from having two naps to having one longer daytime nap.

Some babies start to resist going to sleep at night, preferring to stay up with the family. This peaks at around 18 months and tends to go away with age.

Factors that increase co-sleeping risks

Co-sleeping always increases the risk of sudden unexpected death in infancy (SUDI) including SIDS (sudden infant death syndrome) and fatal sleeping accidents. Co-sleeping increases this risk even more if:

• you’re very tired or you’re unwell
• you or your partner uses drugs, alcohol or any type of sedative medication that causes heavy sleep
• you or your partner is a smoker
• your baby is unwell
• your baby is less than three months old, or was premature or smaller than most babies at birth.

Sleeping with a baby on a couch or chair is always unsafe. Move your baby to a safe sleep environment if you think you might fall asleep in a chair or couch while holding your baby.

Risk factors for sudden unexpected death in infancy when co-sleeping

Under certain circumstances, some studies have reported an increased risk of sudden unexpected death in infancy (SUDI) in co-sleeping babies. The following risk factors have been identified:

• Smoking: A baby exposed to cigarette smoke (eg if the mother or father smokes, or the mother smoked during pregnancy) increases the risk of SIDS, regardless of where the baby sleeps. Smoking parents (or a mother who smoked during pregnancy) should never co-sleep with their baby ²⁾. Parents who smoke are encouraged to room-share as long as the room the baby sleeps in is kept smoke-free, as their babies have an increased risk of sudden infant death (SIDS) and therefore require closer observation.
• Alcohol, drugs or extreme fatigue: Babies are at increased risk of a fatal sleeping accident if they co-sleep with someone who is has consumed alcohol or illegal or sleep-inducing drugs or who is experiencing extreme fatigue ³⁾. A parent should not co-sleep with their baby if they have consumed alcohol or illegal or sleep-inducing drugs, or when extremely fatigued.
• Sharing a sleeping surface with a sibling(s) or a pet(s): Babies are at increased risk of death if they co-sleep with more persons than their parents (eg other siblings) ⁴⁾ or with a pet. Co-sleeping with a sibling raises the risk ⁵⁾. Babies should not co-sleep if anyone other than the parents is in the bed.
• Obesity: Parents who are obese may not be able to feel exactly where or how close their baby is and so may wish to room-share with their baby ⁶⁾. Obese parents should not co-sleep with their baby.
• Formula-fed babies: Experts recommend that formula-fed babies room-share with their parents rather than co-sleep, because mothers who formula feed their babies do not demonstrate the same responsive night-time parenting practices as breastfeeding mothers ⁷⁾.
• Sofa-sharing: Using a sofa, couch, beanbag or armchair as a sleeping place for a baby increases the risk of a fatal sleeping accident ⁸⁾.  Caregivers should never co-sleep with a baby on a sofa, couch or armchair. Babies can suffocate against cushions or become wedged between the seat and the back of the sofa whether or not a sleeping adult is present.
• Young baby and overheating or head covering: It has been thought that the risk of death in a young baby who co-sleeps with a parent may be increased if the baby overheats or if the baby’s head becomes covered ⁹⁾. Some studies have reported a higher risk of death when a young baby (ie under the age of 12 weeks) shares a bed with a parent ¹⁰⁾. These studies did not however consider all known risk factors such as alcohol or drug use, or multiple bed-sharers. In addition, the peak age for SIDS has always been within this range no matter where the baby sleeps.
• Baby alone on an adult bed: Leaving a baby unattended on an adult bed also increases the risk of a fatal sleeping accident ¹¹⁾.
• Infant wrapping and swaddling: Do not wrap baby if sharing a sleep surface as this restricts arm and leg movement.

Reducing the risk of sudden unexpected death in infancy including SIDS and fatal sleeping accidents

There are some things you can do to reduce the risk of sudden unexpected death in infancy (SUDI) including SIDS and fatal sleeping accidents if you choose to co-sleep with your baby:

• Put your baby on their back to sleep (never on their tummy or side).
• Make sure the mattress is clean and firm. Don’t use a waterbed, or anything soft underneath – for example, a lamb’s wool underlay or pillows.
• Keep pillows and adult bedding like sheets and blankets away from your baby. Make sure your bedding can’t cover your baby’s face. Consider using a safe infant sleeping bag so your baby doesn’t share adult bedding.
• Use lightweight blankets, not heavy quilts or duvets.
• Never wrap or swaddle your baby if you’re co-sleeping.
• Tie up long hair and remove anything else that could be a strangling risk, including all jewellery and teething necklaces.
• Move the bed away from the wall, so baby can’t get trapped between the bed and wall.
• Make sure your baby can’t fall out of bed. The safest spot is on the side of a big bed, away from the edge. Consider sleeping on your mattress on the floor if it’s possible your baby might roll off the bed.
• Place your baby to the side of one parent, never in the middle of two adults or next to other children or pets. Your baby might get rolled on or overheat.

When do babies roll over

Most babies begin to show sign of being able to roll over from his tummy to his back as early as age 4 months. Some babies begin rolling onto their tummy earlier than this, and some not until later. This is perfectly normal, as babies develop differently. Babies will rock from side to side, a motion that is the foundation for rolling over. They may also roll over from tummy to back. At 6 months old, babies will typically roll over in both directions. It’s common for babies to roll over from tummy to back for a month or two before rolling over from their back to front.

To encourage rolling over, place your baby on a blanket on the floor with a toy or book to one side near him/her to reach toward with her arms.

It can be very nerve racking once baby is starting to roll over. If baby can roll in both directions unaided – that is they are able to roll onto their side/front and then back onto their back themselves, then it is OK to put baby to sleep on their back and let them find their own natural sleeping position.

If baby can only roll unaided in one direction, then you should gently roll them back on to their back whenever you see they have rolled onto their front or side.

It’s essential to stop wrapping your baby as soon as your baby starts showing signs that she/he can begin to roll, usually between 4-6 months. If you wrap your baby, consider baby’s stage of development. Leave arms free once the startle reflex disappears around 3 months.

• If you are using a bassinet, it is time to transfer your baby into a cot as soon as they first show signs of being able to roll.
• Give baby extra tummy time to play when awake and supervised, as this helps baby to develop stronger neck and upper body muscles which enables them to roll back over. It’s best to start giving baby supervised tummy time from birth.
• Consider using a safe baby sleeping bag as these may delay rolling.
• If you use blankets, make sure baby’s feet are touching the bottom of the cot and that the blanket can only reach baby’s chest to prevent baby wriggling under the blanket. Tuck the blanket in securely.
• Make sure baby is on a firm and well-fitting mattress that is flat (never tilted or elevated).
• Make sure baby’s face and head remains uncovered (do not use lambswool, duvet, pillows, cot bumpers or soft toys).

As babies grow and develop they become very active and learn to roll around in the cot.

At this time, continue to put them on the back at the start of sleep time, but let them find their own natural sleeping position. By this stage it is not necessary to wake during the night to turn baby over to the back position.

Do not use any devices designed to keep baby in a particular sleep position. These can be dangerous and they are not recommended.

Make sure you follow our safe sleep advice – put baby down to sleep on their back, make sure their face and head remain uncovered, and make sure the cot is safe with a firm flat mattress and with no additional items in the cot including pillows, loose sheets or blankets.

Six steps to reduce the risk of sudden infant death syndrome (SIDS):

1. Put baby on the back to sleep from birth
2. Sleep baby with head and face uncovered
3. Keep baby smoke free before birth and after
4. Sleep baby in a safe environment: Safe cot, safe mattress, safe bedding, safe environment.
5. Sleep baby in its own safe cot in the same room as the adult caregiver for the first 12 months
6. Breastfeed baby.

How babies learn to roll over?

At about 3 months, when placed on his stomach, your baby will lift his head and shoulders high, using his arms for support. This mini-pushup helps him strengthen the muscles he’ll use to roll over. He’ll amaze you (and himself!) the first time he flips over. While babies often flip from front to back first, doing it the other way is perfectly normal, too.

At 5 months your baby will probably be able to lift his head, push up on his arms, and arch his back to lift his chest off the ground. He may even rock on his stomach, kick his legs, and swim with his arms.

All these exercises help him develop the muscles he needs to roll over in both directions – likely by the time he’s about 6 months old.

While some babies adopt rolling as their primary mode of ground transportation for a while, others skip it altogether and move on to sitting, lunging, and crawling. As long as your child continues to gain new skills and shows interest in getting around and exploring his environment, don’t worry.

When do babies crawl?

At 6 months old, babies will rock back and forth on hands and knees. This is a building block to crawling. As the child rocks, he may start to crawl backward before moving forward. By 9 months old, babies typically creep and crawl. Some babies do a commando-type crawl, pulling themselves along the floor by their arms.

To encourage a child’s crawling development, allow your baby to play on the floor in a safe area away from stairs. Place favorite toys just out of reach as the baby is rocking back and forth. Encourage him/her to reach for his/her toy.

As your baby becomes more mobile, it’s important to childproof your home. Lock up household cleaning, laundry, lawn care and car care products. Use safety gates and lock doors to outside and the basement.

When do babies sit up?

Babies must be able to hold their heads up without support and have enough upper body strength before being able to sit up on their own. Babies often can hold their heads up around 2 months, and begin to push up with their arms while lying on their stomachs.

At 4 months, a baby typically can hold his/her head steady without support, and at 6 months, he/she begins to sit with a little help. At 9 months he/she sits well without support, and gets in and out of a sitting position but may require help. At 12 months, he/she gets into the sitting position without help.

Tummy time helps strengthen the upper body and neck muscles that your baby needs to sit up. Around 6 months, encourage sitting up by helping your baby to sit or support him/her with pillows to allow him/her to look around.

After your baby sits up – what’s next?

Your baby developed his leg, neck, back, and arm muscles while learning to roll over. Now he’ll put those same muscles to work as he learns to sit independently and crawl. Most babies have mastered sitting up sometime between 6 and 8 months; crawling comes a little later.

Motor developmental milestones for children from baby to 5 years of age

Newborn

• Turns head easily from side to side. When lying on back, moves head one way and then another.
• Comforts self by bringing hands to face to suck on fingers or fist.
• Keeps hands mostly closed and fisted.
• Blinks at bright lights.

1 Month

• Raises head slightly off floor when lying on stomach.
• Holds head up momentarily when supported.
• Keeps hands in closed fists.
• Comforts self by sucking on fist or fingers.

2 Months

• Holds head up and begins to push up with arms when lying on stomach.
• Makes smoother movements with arms and legs.
• Moves both arms and both legs equally well.
• Brings hands to mouth.

3 Months

• Lifts head and chest when lying on stomach.
• Moves arms and legs easily and vigorously.
• Shows improved head control.

4 Months

• Holds head steady without support.
• Grabs and shakes toys, brings hands to mouth.
• Pushes down on legs when feet are placed on a hard surface.
• Pushes up to elbows when lying on stomach.
• Rocks from side to side and may roll over from tummy to back.

6 Months

• Rolls over in both directions.
• Begins to sit with a little help.
• Supports weight on both legs when standing, and might bounce.
• Rocks back and forth on hands and knees, may crawl backward before moving forward.

9 Months

• Gets in and out of sitting position, and sits well without support.
  Creeps or crawls.
• Pulls to stand and stands, holding on.
• Begins to take steps while holding on to furniture (cruising).

12 Months

• Pulls to stand and walks holding on to furniture.
• Gets into sitting position without help.
• Begins to stand alone.
• Begins to take steps alone.

18 Months

• Walks alone, and begins to run and walk up steps.
• Walks backward pulling toy.
• Feeds self with spoon and drinks with cup.
• Helps dress and undress self.

2 Years

• Kicks a ball forward.
• Throws a ball overhand.
• Walks up and down stairs holding on.
• Stands on tiptoes.
• Begins to run.
• Climbs on and off furniture without help.
• Puts simple puzzles together.

3 Years

• Climbs and runs well.
• Walks up and down stairs, with one foot on each step.
• Jumps with both feet, and may hop on one foot.
• Pedals tricycle or three-wheel bike.

4 Years

• Catches a bounced ball most of the time.
• Hops and stands on one foot for a few seconds.
• Pours beverages, cuts with supervision and mashes own food.

5 Years

• Hops and may be able to skip.
• Does somersaults.
• Uses a fork and spoon, and sometimes a table knife.
• Stands on one foot for at least 10 seconds.
• Uses the toilet independently.
• Swings and climbs.

How to teach baby to roll over

You can encourage your baby’s new skill through play. If you notice him rolling over spontaneously, see if he’ll try again by wiggling a toy next to the side he customarily rolls to. Or lie down next to him on one side – just out of reach – and see if he’ll roll to get closer to you. Applaud his efforts and smile. Rolling over is fun, but it can also be alarming the first few times.

Although your baby may not be able to roll over until about 5 months, it’s best to keep your hand on him during diaper changes from the very beginning. Never leave your baby, even when he’s a newborn, unattended on a bed or any other elevated surface. You’d hate for his first rolling-over experience to result in a serious injury.

What to do if your baby doesn’t roll over

If your baby hasn’t figured out how to flip one way or the other by the time he’s about 6 months old, and hasn’t moved on to sit and try to scoot and crawl instead, bring it up the next time you talk to his doctor.

Babies develop skills differently, some more quickly than others – and some babies never really take to rolling over. Keep in mind that premature babies may reach this and other milestones later than their peers.

Learning disabilities in children

Learning disabilities are problems with one or more of the following areas of learning such reading, spelling, writing or maths. Learning disabilities are sometimes also called specific learning disabilities, learning difficulties, specific learning difficulties and dyslexia. Federal law states that a learning disability is a permanent neurological disorder that may be subtle to severe. It limits the brain’s ability to store, process, and produce information and affects a person’s ability to speak, listen, read, write, or do math. A child with a learning disability has average to above average intelligence, but he or she falls below his or her academic potential to a significant degree. The current estimates indicate that children with learning disabilities make up 15 percent of the school-age population.

Learning disabilities must be assessed and diagnosed by professionals.

Learning disabilities are present in approximately 5% of school-aged children globally ¹⁾. Some researchers have argued of a true prevalence as high as 15% to 20%. Reportedly, 4.9% of Canadian children in the ages six to fifteen years have a learning disability; this prevalence differed across the age spectrum, from 1.6% in children who are 6-year-olds to 7.2% among children that are 10-year-olds. Public school data in the United States showed an approximated learning disability prevalence of 5% between the school-aged children, accounting for 2.4 million students with learning disabilities ²⁾.

Around 30% of children with learning disabilities have behavioral and emotional problems. There exists a firm relation between inattentiveness and reading disabilities. Depending on the sample taken, 10% up to as much as 60% of children with learning disabilities have concomitant attention deficit hyperactivity disorder (ADHD). There is a high coexistence of learning disabilities in children with depression, as high as 62% ³⁾. Although autism spectrum disorder is not a specific learning disability, it certainly affects learning, because of individuals with autism struggle with nonverbal and verbal communication, social interactions, and motor function, as well as an inappropriate response to sensory information ⁴⁾.

Children with learning disabilities may become frustrated, lose interest in school, and avoid challenges. They may have low self-esteem and emotional problems, such as withdrawal, anxiety, depression, or aggression. It is also common for children with learning disabilities to have social problems. Children with undiagnosed learning disabilities can become angry and frustrated. These feelings may lead to emotional problems.

Children with learning disabilities can suffer from low self-esteem. They’re also at a higher risk of dropping out of school if the disability isn’t picked up early. This means it’s important to identify learning disabilities early, and help your child build resilience. Resilience is the ability to bounce back from problems and setbacks. It’s an important life skill for all children, especially those with learning disabilities.

A child with a learning disability will have a low level of ability in one or more of these areas when his educational opportunities, age and other abilities are taken into account.

Although learning disabilities can be challenging for your child, your child can still learn and be successful. Kids with learning problems are sometimes surprised to find out that one of their parents had similar troubles in school. But kids today have an advantage over their parents. Learning experts now know a lot more about the brain and how learning works — so it’s easier for kids to get the help they need.

Early intervention is essential because learning disabilities can snowball. A child who doesn’t learn to add in elementary school won’t be able to tackle algebra in high school. Children who have learning disabilities can also experience performance anxiety, depression, low self-esteem, chronic fatigue or loss of motivation. Some children might act out to distract attention from their challenges at school.

A child’s teacher, parents or guardian, doctor, or other professional can request an evaluation if there are concerns about learning problems. Your child will likely first have tests to rule out vision or hearing problems or other medical conditions. Often, a child will have a series of exams conducted by a team of professionals, including a psychologist, special education teacher, occupational therapist, social worker or nurse.

The determination of a learning disability and the need for services are based on the results of tests, teacher feedback, input from the parents or guardians, and a review of academic performance. A diagnosis of severe anxiety or attention-deficit/hyperactivity disorders (ADHD) also might be relevant. These conditions can contribute to delays in developing academic skills.

Learning disabilities are treated educationally, preferably with early intervention. An educational specialist can teach effective learning strategies to help a child overcome his or her learning problems. In addition to ensuring that schools provide diagnostic testing, federal laws require that remedial services be provided to all children who qualify for them. Private tutoring may also be beneficial to maximize progress. Repeating a grade is typically not recommended and may be associated with poor long term outcomes.

Children and their families may benefit from psychological counseling. Understanding and emotional support are needed for children with learning disabilities so they can feel good about themselves. It is also essential to provide opportunities for success in areas where the child may shine. Finally, children with learning disabilities sometimes have problems with peer relationships and may benefit from counseling to help improve their social skills.

Learning disabilities are not treated medically; however, children with learning disabilities who are also diagnosed with a co-existing disorder such as attention deficit hyperactivity disorder (ADHD) may benefit from medication. Physicians should follow the academic progress of their patients as part of their overall medical management.

A kid might work with a tutor or specialist or even go to a special class. But often, kids with learning disabilities can continue in their regular classrooms and there’s no reason they can’t do normal stuff, like participate in school activities and sports.

Though some kids might feel shy about having a learning problem, it can be a relief to finally know what’s going on. Then, the kid doesn’t have to feel as worried and upset about school — because he or she is learning how to learn in new ways. The psychologist or learning specialist might even give you a learning plan — then you can see what the strategy is for helping you learn. They can even offer help with organizational skills. If you’re not organized, it’s hard to get any schoolwork done.

The IDEA (Individuals with Disabilities Education Act) guarantees every child with free, appropriate public education that is tailored to each child needs and that allows parents to be able to request a formal educational evaluation by their school district, this way determining if a child has any type of disability and will qualify for special education and related services ⁵⁾.

Interprofessional care is a crucial element for a good outcome. This includes a range of specialists including educators, educational remediation specialists, special services, physicians (general pediatricians, ophthalmologists, geneticists), speech, occupational and physical therapists, clinical psychologists or other mental health providers, in those included developmental/ behavioral and neurodevelopmental pediatricians, educational therapists, developmental nurses, among others. Based on some research evidence, children manifesting school problems and are suspected of having learning disabilities should undergo a comprehensive medical evaluation, in those including a thorough history and physical examination, to be able to identify relevant risk factors for learning disability ⁶⁾.

To help your child be resilient and positive about her ability and disability, you could try the following suggestions:

• Be a role model: You can be a role model for your child by being positive, assertive and resilient yourself. For example, if you’ve baked a cake that doesn’t taste good, you can say, ‘It doesn’t matter. I’ll try another recipe next time’. Or if you get some negative feedback at work, you can say, ‘That’s hard to hear, but I can also learn from it’.
• Praise and encouragement:
  • Always praise your child for having a go at something.
  • Celebrate your child’s abilities and achievements by pointing out the non-academic things your child is good at. It might be sport, music, drama, or being kind and friendly or an excellent cook.
  • Encourage your child to notice the positive things in her life and see that her learning difficulties are only one small part of who she is.
  • Encourage your child to work out what he needs to get over difficulties – for example, do written instructions and diagrams help him, or does he prefer spoken instructions?
  • Make time to be with and listen to your child and to have fun together. This sends the message that she’s special, important and worth spending time with.
  • Encourage your child to try new things. Realizing that he can learn with practice and persistence will help your child keep going when things are hard.
• Responsibilities and expectations:
  • Give your child the chance to take on family responsibilities and make her own decisions and choices. A sense of control is a powerful self-esteem builder.
  • Support but don’t overprotect your child. You can do this by expecting your child to do his best and stick with tasks like homework, despite his extra challenges.
  • Give your child the opportunity to try new things like cooking, chess or photography. If you do these activities with your child, it’s a good way to make sure your child experiences success and has fun as she builds new skills.
• Getting extra support for learning disabilities: Extra support can give your child the best chance of doing well at school. If health professionals recommend extra support, you’ll need to have a professional, documented assessment to prove that your child is eligible for things like extra examination time, tuition from a reading expert, or special computer software. There are lots of different types of support outside school available for children with learning disabilities, including specialist tutors and technology. The best sort of support for your child will depend on your child’s learning disability. You can talk to your child’s teacher or other professionals working with your child to find out what will work best for your child and your family. Software packages can help support your child’s learning. Speak to your child’s teacher about what your child uses at school. You might need to try a few different things before you work out what’s right for your child and family. This also shows your child how to be persistent and not give up.

What are some early signs that my child might have a learning disability?

Early signs of possible learning disabilities include difficulty with language, like rhyming, or difficulty working with smaller sounds inside words, like identifying the ‘k’ sound in the middle of ‘monkey’.

Children might also have difficulty remembering lists of words, numbers, letters or concepts, like a list of instructions you give all in one go. Your child might also show ongoing and significant problems with reading, spelling and maths.

But having some difficulties doesn’t automatically mean your child has a learning disability. Some children can just take longer than others to begin to learn literacy and maths skills.

At what age does a learning disability start to show?

Learning disabilities can usually be diagnosed by the time your child is 7-8 years old. Early signs of learning disabilities are often picked up in the first two years of school.

Children often become quite good at covering up learning difficulties as they get older, so if you think your child might have a learning difficulty, it’s important to have it checked out early.

What should I do if I think my child has a learning disability?

If your child has ongoing and significant problems with reading, spelling or maths – even if your child has had a good start to his education – it might be useful to get a learning disabilities assessment.

If you’re concerned, it’s a good idea to talk to your child’s teacher as a first step. Schools have access to professionals who can provide an educational assessment for your child.

You might also like to talk to a health care professional like a speech pathologist or psychologist about a formal assessment.

Do learning disabilities run in families?

Learning disabilities can run in families. This means that parents, siblings, uncles and aunts might have problems with reading, spelling or maths skills that are similar to your child’s problems. If other members of your family have managed their learning disability in active and effective ways, they can be great role models for your child.

Do more boys than girls have learning disabilities?

Boys and girls are equally likely to have learning disabilities.

My child writes letters back to front. Does this mean my child has dyslexia?

Writing letters back to front in the early years is a normal developmental stage. It’s not always a sign of dyslexia. But it might be a concern if a child continues to reverse letters and numbers in the middle and later years of primary school.

My child has trouble reading. Does my child have a learning disability like dyslexia?

On its own, trouble with reading doesn’t mean that a child definitely has a learning disability. There can be lots of reasons why a child has trouble reading, including a lack of opportunity to learn to read, or hearing or vision problems.

Can a learning disability be ‘cured’?

Learning disabilities can’t be ‘cured’. But with time and support, many people with learning disabilities learn to improve their skills. The earlier a child with learning disabilities gets expert help, the better the child’s chance of making good progress.

People with learning disabilities often manage well, particularly those who have learning disabilities that affect reading. It can sometimes be harder to improve spelling and maths skills, especially those that involve learning lists and tables of information. But there are ways around this, like using specially designed predictive typing software.

Does using a computer help?

Computers can help children who have learning disabilities. There are different types of software that can help with word prediction, spell-checking, and changing text to speech and speech to text. These software programs can help children get information without needing to read printed pages. They can also help your child with writing.

Literacy and maths software can get your child motivated about learning and reinforce what your child learns at school.

Another bonus of computer use is that printed pages are neat and easy to read. This is especially useful because messy handwriting is often a part of learning disabilities.

Are people who have learning disabilities often gifted?

People who have learning disabilities are no more likely to be gifted than other people. But people with all sorts of abilities can have learning difficulties, so there will be some who are gifted in different ways. For example, some have mechanical, academic, sporting and creative abilities.

How can I know whether a treatment or therapy for learning disability I saw advertised will be useful?

Looking carefully and critically at any advertised treatments or therapies will help you work out whether to believe their claims. In particular, you can look to see whether the claims are backed up by reliable and solid scientific research. Search out the evidence before committing your child to a program or spending any money on a treatment.

There is no ‘wonder cure’ for learning disabilities, despite what some ads say. But there are many simple, supportive and productive ways to help children with learning difficulties.

It’s a good idea to talk to teachers and other professionals, as well as non-profit organizations like the National Center for Learning Disabilities (https://www.ncld.org) and Learning Disabilities Online (http://www.ldonline.org). These people should be able to give you reliable advice about worthwhile options.

What is the outlook for children with learning disabilities?

Learning and attention issues are lifelong conditions involving differences in brain structure and function. Symptoms may change over time, and the right support helps address weaknesses. But age doesn’t make these issues “go away.”

Even though children don’t outgrow learning disabilities, they can learn to adapt and improve their weak skills. If learning disabilities are identified and treated early, children with these disabilities are more likely to learn to overcome their difficulties while maintaining a positive self-image. They can also learn to develop their personal strengths and become very productive and successful adults.

How can I help my child with a learning disability succeed?

When it comes to learning and attention issues, trying harder is not the answer. Children with these issues need targeted interventions and accommodations to help them work on or work around their weaknesses.

Children with learning and attention issues are as smart as their typically developing peers, and many have average or above-average intelligence. There are many children who are gifted and have learning disabilities. Many schools refer to these children as “twice-exceptional.”

Successful people who have learning disabilities:

• are self-aware – they know about their learning disability but also know their strengths
• ask for help and know where and when to do so
• have good resources to help them with their difficulties – for example, apps and computer programs
• are flexible and creative in finding ways around the challenges of having a learning disability
• keep trying, even when things are hard
• have good coping strategies to deal with emotions like frustration and embarrassment
• respond to problems by coming up with solutions.

There are lots of very successful people with learning disabilities who can be examples for your child. They include Richard Branson, Steve Jobs, Daniel Radcliffe and Keira Knightley.

What are barriers to success for children with learning disabilities?

Children with learning and attention issues often don’t receive early or effective interventions. A third of students with learning disability or other health impairment have been held back a year, which increases the risk of dropping out.

Students with disabilities are more than twice as likely to be suspended as those without disabilities, and the loss of instructional time increases the risk of course failure and school aversion.

Students with specific learning disability drop out of high school at nearly three times the rate of all students. The top reason students with specific learning disability drop out? 57% cited disliking school or having poor relationships with teachers or peers.

Unaddressed learning and attention issues lead to conditions that push students into the school-to-prison pipeline. A large study found that half of young adults with specific learning disability or other health impairment had been involved at some point with the justice system.

Young adults with learning disabilities enroll in four-year colleges at half the rate of the general population. Their completion rate for any type of college is 41%, compared to 52% of all students.

Only 46% of working-age adults with learning disabilities are employed. Compared with adults who do not have learning disabilities, adults with these issues are twice as likely to be jobless.

Children’s learning disabilities types

Common learning disability affect a child’s abilities in reading, written expression, math or nonverbal skills. It’s important to keep in mind that many children have more than one learning or attention issue. For example, researchers have found that dyslexia and learning disability in math (dyscalculia) co-occur in 30% to 70% of children who have either disorder ⁷⁾. Studies also indicate as many as 45% of children with ADHD also have a learning disability ⁸⁾.

Reading

Learning disabilities in reading are usually based on difficulty perceiving a spoken word as a combination of distinct sounds. This can make it hard to understand how a letter or letters represent a sound and how letter combinations make a word.

Problems with working memory — the ability to hold and manipulate information in the moment — also can play a role.

Even when basic reading skills are mastered, children may have difficulty with the following skills:

• Reading at a typical pace
• Understanding what they read
• Recalling accurately what they read
• Making inferences based on their reading
• Spelling

A learning disability in reading is usually called dyslexia, but some specialists may use the term to describe only some of the information-processing problems that can cause difficulty with reading.

What is Dyslexia?

Dyslexia is a brain-based type of learning disability that specifically impairs a person’s ability to read. These individuals typically read at levels significantly lower than expected despite having normal intelligence. Although the disorder varies from person to person, common characteristics among people with dyslexia are difficulty with phonological processing (the manipulation of sounds), spelling, and/or rapid visual-verbal responding. In individuals with adult onset of dyslexia, it usually occurs as a result of brain injury or in the context of dementia; this contrasts with individuals with dyslexia who simply were never identified as children or adolescents. Dyslexia can be inherited in some families, and recent studies have identified a number of genes that may predispose an individual to developing dyslexia.

What are the signs of dyslexia?

The early signs of dyslexia include:

• A delay in spoken language
• Difficulty “finding” the right word
• Difficulty with rhyming
• Difficulty with short-term auditory memory
• Subtle mispronunciations, particularly of words with more than one syllable

After a child enters school, the following signs of dyslexia may appear:

• Difficulty learning the names of the letters of the alphabet
• Difficulty learning how to write the letters of the alphabet
• Difficulty learning whole words for reading and spelling
• Difficulty using phonics
• Difficulty with comprehension related to difficulty reading words

How is dyslexia treated?

The main focus of treatment should be on the specific learning problems of affected individuals. The usual course is to modify teaching methods and the educational environment to meet the specific needs of the individual with dyslexia.

What is dyslexia prognosis?

For those with dyslexia, the prognosis is mixed. The disability affects such a wide range of people and produces such different symptoms and varying degrees of severity that predictions are hard to make. The prognosis is generally good, however, for individuals whose dyslexia is identified early, who have supportive family and friends and a strong self-image, and who are involved in a proper remediation program.

Written expression

Writing requires complex visual, motor and information-processing skills. A learning disability in written expression also known as dysgraphia may cause the following:

• Slow and labor-intensive handwriting
• Handwriting that’s hard to read
• Difficulty putting thoughts into writing
• Written text that’s poorly organized or hard to understand
• Trouble with spelling, grammar and punctuation.

Math

A learning disability in math also known as dyscalculia may cause problems with the following skills:

• Understanding how numbers work and relate to each other
• Calculating math problems
• Memorizing basic calculations
• Using math symbols
• Understanding word problems
• Organizing and recording information while solving a math problem.

Nonverbal skills

A child with a learning disability in nonverbal skills (also called dyspraxia or Developmental Coordination Disorder) appears to develop good basic language skills and strong rote memorization skills early in childhood. Difficulties are present in visual-spatial skills, visual-motor skills, and other skills necessary in social or academic functioning ⁹⁾.

A child with a learning disability in nonverbal skills may have trouble with the following skills:

• Interpreting facial expressions and nonverbal cues in social interactions
• Using language appropriately in social situations
• Physical coordination
• Fine motor skills, such as writing
• Attention, planning and organizing
• Higher-level reading comprehension or written expression, usually appearing in later grade school.

What causes of learning disabilities?

Scientists don’t yet fully understand the exact causes of learning disabilities. But researchers do know that when a child has a learning disability, parts of that child’s brain have difficulty handling information, this is called ‘neurologically based processing difficulties’.

Common ‘processing difficulties’ include difficulties working out the sounds in words, or trouble remembering unrelated pieces of information, like a new list of numbers or letters.

Learning disabilities have been associated with particular genes and can be inherited. If other people in your family have trouble with reading or spelling or have been diagnosed with learning disabilities, there’s a chance that children in the next generation might have learning disabilities.

Some studies of the brain of patients with dyslexia have shown scattered small malformations mainly on the left cerebral hemisphere at the cerebral cortex ¹⁰⁾.

Due to the confirmation of anomalies in the function and structure of corticostriatal systems in the process of developmental language disorders, there has been a probable hypothesis that a disorder of corticostriatal systems may result in problems in learning language. Problems with corticostriatal systems have also been recognized in other neurodevelopmental and psychiatric disorders, such as obsessive-compulsive disorders, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), and Tourette disorder ¹¹⁾.

Factors that might influence the development of learning disabilities include:

• Family history and genetics. A family history of learning disabilities increases the risk of a child developing a disorder.
• Prenatal and neonatal risks. Poor growth in the uterus (severe intrauterine growth restriction or IUGR), exposure to alcohol or drugs before being born, premature birth, and very low birthweight have been linked with learning disorders.
• Psychological trauma. Psychological trauma or abuse in early childhood may affect brain development and increase the risk of learning disorders.
• Physical trauma. Head injuries or nervous system infections might play a role in the development of learning disorders.
• Environmental exposure. Exposure to high levels of toxins, such as lead, has been linked to an increased risk of learning disorders.

Risks factors for learning disability

The most common risk factor is family history. Less common risk factors include poor nutrition, severe head injuries, child abuse, and pregnancy-related factors. (National Center for Learning Disabilities)

Lead poisoning, infections of the central nervous system, or treatment for cancers, such as leukemia, can also increase the risk for learning disabilities.

Factors are not considered risk factors for developing learning disability

Blindness, visual problems, deafness, physical or motor handicaps can cause difficulties with learning, but are not a cause of learning disabilities. Likewise, intellectual disabilities (formerly called mental retardation), autism spectrum disorders, or low intelligence quotient (IQ) all may be associated with learning difficulties, but are not considered learning disabilities. Environmental, cultural or economic disadvantages do not cause learning disabilities but may co-occur with learning disabilities. Similarly, behavioral disorders or emotional disturbances may also be present with learning disabilities.

Learning disabilities signs

If you think your child might have a learning disability, you can look out for some common signs. Having one or more of these signs doesn’t mean your child definitely has a learning disability. But if you’re worried, it’s a good idea to talk to your child’s teacher or your family doctor.

If your child has a learning disability, your child might:

• dislike reading and/or find reading hard
• doesn’t master skills in reading, spelling, writing or math at or near expected age and grade levels
• have lots of trouble spelling common words
• find it hard to spot the sounds and syllables in words
• tell you lots of interesting ideas but find writing them down slow and difficult
• have very messy handwriting
• difficulty with math
• difficulty organizing thoughts to express what they want to say
• memory problems, has trouble remembering what someone just told him or her
• lacks coordination in walking, sports or skills such as holding a pencil
• difficulty with language such as following directions, remembering words, rhyming, and expressing oneself
• difficulty with reasoning
• difficulty with spelling
• history of delayed speech
• not feel very confident about schoolwork
• has difficulty understanding and following instructions
• easily loses or misplaces homework, schoolbooks or other items
• has difficulty understanding the concept of time
• resists doing homework or activities that involve reading, writing or math, or consistently can’t complete homework assignments without significant help
• acts out or shows defiance, hostility or excessive emotional reactions at school or while doing academic activities, such as homework or reading

Children who have learning disabilities can’t do things like reading as easily as their peers can. This can lead to them thinking of themselves as ‘dumb’ or ‘stupid’.

Telling your child that she has a learning disability can help her overcome this way of thinking. You can tell your child that having a learning disability means her brain thinks about information differently, but it doesn’t mean she’s not as smart as other children.

Your child’s psychologist or speech therapist can give you advice and help you explain the disability to your child in a way that he can understand.

You can also highlight the positive things your child can do to live and learn with the learning disability. You might mention that lots of really successful people have learning disabilities.

Learning disabilities complications

Learning difficulties can have bad outcomes in important parts of language, such as learning and reading.

In recent data from the Individuals with Disabilities Education Act shows that these children tend to have more challenges in educational performance, and they also tend to have more negative academic results; these can include lower grades, less than average exam results, and an increased number of school failure. It is also shown that around one-third of children with learning disabilities have had a grade held in the school at least once in their lifetime. Barely around 68% of children with learning disabilities get to graduate from high school with a regular diploma, and with only 12% obtaining a diploma of completion and 19% dropping out of school.

Individuals with learning disabilities in their adult life tend to sign-up for post-secondary schooling less frequently than adults without learning disabilities and that individuals with learning disabilities are also less likely to get employed than individuals without this disorder ¹²⁾.

There is an increased risk of low academic performance in children with learning disabilities that can affect their professional life. Children with a learning disability that are mindful of their condition can feel less in comparison to the other children, and this can result in low self-esteem and a feeling of vulnerability. When they experience a lack of success and embarrassment in the school continuously, it can lead to irritation, self-hatred, and an increased grade of repressed anger. These dysfunctions can promote depression, children with learning disabilities may even abstain from making friends and going to school, and they may also become detached affecting their development in the future ¹³⁾.

Learning disabilities diagnosis

It’s very hard for a kid to know if your child has a learning disability. But kids don’t have to figure all this out on their own. What a kid needs to do is tell someone. Start with your teacher and your mom or dad.

Even if you feel a little shy about it, tell them what kinds of problems you’re having in school. Maybe you read a chapter for homework and then can’t remember anything you read. Or in class, maybe everyone else seems to follow along easily, but you get stuck and don’t know what page everyone is on. You might open your book to do an assignment and have no idea where to start.

Kids with a learning problem also might answer “yes” to many of these questions:

• Do you struggle in school?
• Do you think you should be doing better than you are in school?
• Is reading harder for you than it should be?
• Does your head think one thing but your hand writes something else?
• Is writing slow and really hard for you?
• Do you make spelling and other errors when you write?
• Are you having trouble with math?
• Is it hard for you to keep your notebooks and papers organized? Do you end up losing or forgetting them?

But even if you say “yes” to some of these questions, you won’t know for sure that there’s a problem until you visit a school psychologist or a learning specialist. They can give you some tests to spot any learning problems you might have. They’ll also be able to identify what your strengths are — in other words, what you’re good at. Once a psychologist or learning specialist figures out what your learning problem is, you both can start working on solutions.

As per the the American Psychiatric Association – Diagnostic and Statistical Manual of Mental Disorders (DSM–5), the following symptoms are comprised as part of the diagnosis of a specific learning disorder:

1. Constant struggles with arithmetic, writing, reading, or mathematical reasoning skills throughout the school years.
2. Must have current below-average grade parameters in suitable linguistic and cultural tests in the subject of writing, reading, and mathematics.
3. The patient’s learning difficulties must begin during the school years
4. It cannot be explained by any neurological, developmental, motor, or sensory (hearing or vision) disorder and should remarkably impede academic achievement, activities of daily living, or occupational performance ¹⁴⁾.

Talk with your child’s teacher

If you’re worried that your child is having trouble at school and might have a learning disability, you could start by talking with your child’s teacher.

You can ask questions about whether your child is progressing as expected with reading, writing and maths. It might also be worth talking about the teacher’s impression of your child’s self-esteem and engagement at school.

The teacher can test your child and go through the results with you. This can help you see whether there’s a pattern of problems.

Ask for an assessment

If you’re still concerned, ask for a formal assessment through your school.

A speech therapist or a psychologist could be involved at this point. They’ll help to check all the possible causes. If there’s a long wait, or the assessment isn’t available through your school, you can arrange to see a specialist privately, but there will be a cost to you.

Another option that might be available, depending on where you live, is to contact your local university. Most universities have psychology and speech therapy clinics where postgraduate students assess children under the supervision of an expert professional.

Learning disability test for child

The evaluation of a child presenting learning disabilities routinely needs conjoint work between the medical and the non- medical professionals, including psychologists, educators, audiologists, and occupational and speech-language therapists.

The medical team will work on ruling out hearing and vision impairments and establishing that the learning deficits are not due to limited access to appropriate guidance. Also, the pediatrician can work in the diagnosis and treatment of associated developmental or behavioral disorders, such as attention deficit hyperactivity disorder or autism, in addition to recognizing psychosocial factors to the child’s difficulties.

Blood, urine, and imaging studies are usually not indicated or useful for the evaluation of learning disabilities. Exceptions include neurological findings suggestive of a focal brain lesion, skin lesions suggestive of a neurocutaneous syndrome, and findings on physical exam or past medical history that would suggest nutritional disorders or syndromes that could have a genetic or metabolic cause. Hearing and vision screening should always be documented.

The formal diagnostic process to know the presence and extent of a learning disability is domain-specific academic and cognitive testing. In some cases, it is appropriate for the testing to be done as part of the individualized education program (IEP) process through the school district. In other cases, parents may prefer to have the testing performed by private psychological services. This evaluation tests a child’s cognitive abilities, the areas of language processing, attention, memory, and nonverbal reasoning, in addition to specific academic achievement in core areas, such as mathematics, reading, and written expression.

Some of the most commonly used tests for the evaluation of suspected learning disabilities are the Woodcock-Johnson-III and Wide Range Achievement Test to evaluate academic achievement; the Adaptive Behavior Assessment System-II and the Vineland Adaptive Behavior Scale-II to assess adaptive behavior; the Conners Rating Scale, ADHD Rating Scale-IV (formerly DuPaul scale) and NICHQ Vanderbilt Parent and Teacher Assessment Scales to evaluate for attention and hyperactive disorders; the Wechsler Intelligence Scales for Children—Fourth Edition (WISC-IV) for evaluation of general cognition; the Achenbach Child Behavior Checklist (CBCL) for assessment of general behavior; the Clinical Evaluation of Language Fundamentals (4th Ed.) (CELF) for language evaluation; and the Beery Test of Integration (5th Ed) for visual-motor evaluation.

The usual criteria for diagnosing reading disability include deficient word recognition and decoding skills identified through specific testing. Other evaluations will also assess spelling, reading comprehension, and fluency; some will test the deficiencies in phonologic processing in reading disability, which is those found in children having issues learning the similarity between the written symbols and the oral sounds on a text.

In the past, academic testing was compared with the student’s estimated potential, as measured by an intelligence quotient (IQ) test, diagnosing learning disability when there was a significant difference between IQ and reading scores. This was an issue because children with IQ scores below average would not meet such discrepancy criteria, and children who had high IQ scores could be considered to have learning disabilities despite reading scores being within the normal range for age.

Recently the Response to Intervention (RTI) has been used as a valid standard approach to the diagnosis of learning disability. This model is a process of evaluation that is followed by a restorative instruction in the child’s specific area of deficits during a specific period before reassessing. The assessment- instruction-assessment model is progressive and intensive educational support. It can aid in differentiating the lack of proper instruction from true learning disability by demonstrating if there is an improvement with a small increase intensity of instruction or if it requires repeated cycles of Response to Intervention, with the result of a very specified and personalized instructional program ¹⁵⁾.

Helping children with learning disabilities

The diagnosis and treatment of a child with learning disabilities depend on the coordinated and ongoing collaboration of an inter-professional team that can be composed of educators, educational remediation specialists, psychologists, special services, and physicians. Speech therapists can help evaluate and treat any underlying oral language difficulties that are often associated with dyslexia. Occupational and physical therapists will treat fine motor, gross motor, proprioceptive, balance, and sensory-processing disorders that can coexist in some children with learning disabilities. Clinical psychologists or other mental health providers, including developmental/behavioral and neurodevelopmental pediatricians, can help children better cope with the social challenges associated with learning disabilities. Educational therapists or educators trained in learning disabilities are also part of the multidisciplinary team treating children with learning disabilities ¹⁶⁾.

If your child has a learning disability, your child’s doctor or school might recommend:

• Extra help. A reading specialist, math tutor or other trained professional can teach your child techniques to improve his or her academic, organizational and study skills.
• Individualized education program (IEP). Public schools in the United States are mandated to provide an individual education program for students who meet certain criteria for a learning disability. The IEP sets learning goals and determines strategies and services to support the child’s learning in school.
• Accommodations. Classroom accommodations might include more time to complete assignments or tests, being seated near the teacher to promote attention, use of computer applications that support writing, including fewer math problems in assignments, or providing audiobooks to supplement reading.
• Therapy. Some children benefit from therapy. Occupational therapy might improve the motor skills of a child who has writing problems. A speech-language therapist can help address language skills.
• Medication. Your child’s doctor might recommend medication to manage depression or severe anxiety. Medications for attention-deficit/hyperactivity disorder may improve a child’s ability to concentrate in school.
• Complementary and alternative medicine. Further research is needed to determine the effectiveness of alternative treatments, such as dietary changes, use of vitamins, eye exercises, neurofeedback and use of technological devices.

Your child’s treatment plan will likely evolve over time. If your child isn’t making progress, you can seek additional services or request revisions to an individualized education program (IEP) or accommodations.

In the meantime, help your child understand in simple terms the need for any additional services and how they may help. Also, focus on your child’s strengths. Encourage your child to pursue interests that give him or her confidence.

Together, these interventions can improve your child’s skills, help him or her develop coping strategies, and use his or her strengths to improve learning in and outside of school.

Specific educational strategies in management

Several remedial programs are established, they frequently work with children having reading and writing difficulties ¹⁷⁾.

Reading

In children with dyslexia (decoding problems), phonological awareness needs to be increased, which includes the ability to manipulate and hear individual phonemes (the sound structure of words), such as ‘k’ in kit, or ‘b’ in bat. Besides phonemic awareness, letter-sound proficiency is remediated. The repeated practice of oral reading may aid in improving fluency. Reading comprehension skills are associated with larger language comprehension skills, and that needs to be developed.

Writing

This is a more complex skill than reading, and it can present independently or with a reading disorder. Eye-hand coordination and being able to segment phonemes are essential, it can be enhanced by using hand exercises, for example, working with clay, finger tapping, and beading.

Mathematics

In children, dyscalculia is the deficiency in number sense. Educational strategies comprise practicing number syntax such as linking numbers to related digits; for example, 1234, number one corresponds to thousand, number two to hundreds, number three corresponds to tens and number 4 to units). Repeated additions may aid in internalizing the number line.

Learning disability prognosis

The prognosis of children with learning disabilities will depend on the severity of the disability, also on specific strengths and weaknesses of the child affected, and on the amount, appropriateness, timing, and intensity of the intervention provided. Although challenging, these children presenting with learning disabilities can overcome many barriers to enhance their reading and writing with adequate remediations, assistance, and educational accommodations. Children who have a severe deficiency in basic reading skills or the ones who have both a phonologic deficit and also a quick automated naming issue are harder to correct than the ones with mild or moderate deficiency ¹⁸⁾.

Heimlich for baby or infant younger than age 1

The Heimlich Maneuver be employed only when a person is choking and his or her life is endangered by a windpipe obstruction. Choking is signaled by an inability to speak, cough or breathe, and may result in a loss of consciousness and death. Choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. Young children often swallow small objects. Because choking cuts off oxygen to the brain, give first aid as quickly as possible. Avoid using excessive force in employing the Heimlich Maneuver to avoid injury to the ribs or internal organs. Given the potentially life-or-death nature of the situation, use your best judgment.

If the baby can cough or make sounds, let him or her cough to try to get the object out. If you are worried about the baby’s breathing, call your local emergency number.

WARNING: Do not begin the Heimlich Maneuver unless you are certain that the baby is choking.

Heimlich maneuver Conscious Infant (Under one year old)

1. Assume a seated position and hold the infant facedown on your forearm, which is resting on your thigh. Support the infant’s head and neck with your hand, and place the head lower than the trunk.
2. Thump the infant gently but firmly five times on the middle of the back using the heel of your hand. The combination of gravity and the back blows should release the blocking object. Keep your fingers pointed up to avoid hitting the infant in the back of the head.
3. Turn the infant faceup on your forearm, resting on your thigh with the head lower than the trunk if the infant still isn’t breathing. Using two fingers placed at the center of the infant’s breastbone, give five quick chest compressions. Press down about ½ to 1 inch, and let the chest rise again in between each compression. Avoid the tip of the sternum.
4. Repeat the back blows and chest thrusts if breathing doesn’t resume – until the foreign body is expelled or the infant becomes unconscious. Call for emergency medical help.
5. Begin infant CPR if one of these techniques opens the airway but the infant doesn’t resume breathing.

Alternative method: Lay the infant face down on your lap, head lower than torso and firmly supported. Perform up to five back blows. Turn the infant on his or her back as a unit and perform up to five chest thrusts.

Figure 1. Heimlich maneuver baby or infant under one

Heimlich maneuver infant Unconscious Infant (under one year old)

1. Shout for help. Call your local emergency number.
2. Perform the tongue-jaw lift. (Grip on the jaw by placing your thumb in the infant’s mouth and grasping the lower incisor teeth or gums; the jaw then lifts upward.) If you see the foreign body, remove it.
3. If trained to do so, begin rescue breathing.
4. Perform the sequence of back blows and chest thrusts as described for a conscious infant.
5. After each sequence of back blows and chest thrusts, look for the foreign body and, if visible, remove it.
6. Resume rescue breathing.
7. Continue with the sequence of back blows and chest thrusts, and, after each sequence continue to check for the foreign body, which should be removed.
8. If the foreign body is removed and the infant is not breathing, begin CPR.

CPR for babies under 12 months

• Step 1: If a baby is unconscious, check her mouth for airway blockages – for example, tongue, food, vomit or blood. If there’s a blockage, use your little finger to clear it. Place baby on her back to open her airway.
• Step 2: Check for breathing. Listen for the sound of the breath, look for movements of the chest or feel for the breath on your cheek.
• Step 3: If baby is breathing, place him in the recovery position by lying him face down on your forearm. Phone your local emergency services number. Check baby regularly for breaths and responses until the ambulance arrives.
• Step 4: Position two fingers in the center of baby’s chest and give 30 compressions at a rate of about 100 compressions per minute. Each compression should depress the chest by about one third.
• Step 5: Tilt the baby’s head back very slightly with the chin lifted to bring the tongue away from the back of the throat, opening her airway. Take a breath and seal her mouth and nose with your mouth. Blow gently and steadily for about one second. Watch for the rise and fall of the chest. Take another breath and repeat the sequence.
• Step 6: Continue giving 30 compressions followed by 2 breaths until medical help arrives. If the child starts breathing and responding, turn her into the recovery position. Keep watching her breathing and be ready to start CPR again at any time.

Figure 2. CPR for babies under 12 months

Heimlich for toddlers

For a child aged over one year do the following:

• If you can see the object, try to remove it. Don’t poke blindly or repeatedly with your fingers. You could make things worse by pushing the object further in and making it harder to remove.
• If your child’s coughing loudly, encourage them to carry on coughing to bring up what they’re choking on and don’t leave them.
• If a child shows signs of choking, stay calm and encourage the child to lean forward and to cough to help remove the object while you’re waiting for the ambulance to arrive. If this doesn’t work, follow the steps to clear a blockage (shown below).
• If your child’s coughing isn’t effective (it’s silent or they can’t breathe in properly), shout for help immediately and decide whether they’re still conscious.
• If your child’s still conscious, but they’re either not coughing or their coughing isn’t effective, use back blows shown below.

Choking first aid: clearing a blockage for children and teens

• Step 1: Bend the child forward and use the heel of your hand to give a sharp back blow between the shoulder blades. Check to see if the blockage has cleared before giving another blow. If the blockage hasn’t cleared after five blows, try chest thrusts.
• Step 2: Place one hand in the middle of the child’s back and the other hand in the center of his chest. Using the heel of the hand on the chest, do five chest thrusts – like cardiopulmonary resuscitation (CPR) compressions but slower and sharper. Check to see if the blockage has cleared between each thrust.
• Step 3: If the child is still choking, call your local emergency services number and alternate five back blows and five chest thrusts until emergency help arrives. If at any point the child becomes unconscious, start child CPR.
• Even if the object has come out, get medical help. Part of the object might have been left behind, or your child might have been hurt by the procedure.

Heimlich maneuver Conscious Toddler or Child (Over one year old)

To dislodge an object from the airway of a child:

• Perform the Heimlich Maneuver (abdominal thrusts) as described for adults. Avoid being overly forceful in order to avert injury to ribs and internal organs (use your best judgment).

Heimlich maneuver Unconscious Toddler or Child (Over one year old)

• If the child becomes unconscious, continue as for an adult, except:
• Do not perform a blind finger sweep in children up to 8 years old. Instead, perform a tongue-jaw lift and remove the foreign body only if you can see it.

Figure 3. Choking first aid – clearing a blockage for children and teens

CPR for for children over 1 year

• Step 1: If a child is unconscious, the first step is to check his mouth for anything blocking the airway. This could include his tongue, food, vomit or blood.
• Step 2: If you find a blockage, roll him onto his side, keeping his top leg bent. This is the recovery position. Clear blockages with your fingers, then check for breathing.
• Step 3: If you find no blockages, check for breathing and look for chest movements. Listen for breathing sounds, or feel for breath on your cheek.
• Step 4: If the child is breathing, gently roll him onto his side and into the recovery position. Phone your local emergency services number and check regularly for breathing and response until the ambulance arrives. If the child is not breathing and responding, send for help. Phone local emergency services number and start CPR: 30 chest compressions, 2 breaths.
• Step 5: Put the heels of your hands in the center of the child’s chest. Using the heel of your hand, give 30 compressions. Each compression should depress the chest by about one third.
• Step 6: After 30 compressions, take a deep breath, seal your mouth over the child’s mouth, pinch his nose and give two steady breaths. Make sure the child’s head is tilted back to open his airway.
• Step 7: Keep giving 30 compressions then 2 breaths until medical help arrives. If the child starts breathing and responding, turn him into the recovery position. Keep watching his breathing and be ready to start CPR again at any time.

Figure 4. CPR for for children over 1 year

What is a breech baby

Breech baby also called breech birth, means your baby is lying bottom-first or feet-first in the uterus (womb) instead of in the usual head-first position. Right before birth, most babies are in a headfirst position in the mother’s uterus. Babies can be breech early in pregnancy. Most of them turn on their own to be headfirst by the time of delivery. As you get closer to your due date, your doctor will be able to tell if your baby is breech. They can check by a physical exam, ultrasound, or both.

Babies are more likely to be breech if:

• They are early, or premature.
• They are part of a multiple birth (two or more babies).
• There is an abnormal level of amniotic fluid.
• The mother has an abnormal shaped uterus.

Babies born in the breech position (bottom first) are at increased risk of complications at birth because of a delay in birth of the head. Turning a breech baby to head first in late pregnancy may reduce these complications. A procedure called external cephalic version (ECV) describes when obstetricians use their hands on the woman’s abdomen to gently try to turn the baby from the breech position to head first presentation at birth so as to avoid the adverse effects of breech vaginal birth or caesarean section. A number of treatments may help the success of external cephalic version (ECV). These include using tocolytic drugs (drugs like beta stimulants and calcium channel blockers that relax the womb), stimulating the baby with sound through the mother’s abdomen (acoustic stimulation), increasing the fluid surrounding the baby (transabdominal amnioinfusion), injecting pain‐relieving drugs into the mother’s lower back to produce regional analgesia (epidural or spinal analgesia), giving the mother opioid drugs to help her relax, using hypnosis and applying gel or talcum powder to the mother’s abdomen ¹⁾. Clinical studies involving 2786 women showed that babies are more likely to turn head first during external cephalic version (ECV) and to remain head first for the start of labor, if women receive beta stimulants ²⁾. These drugs also reduced the number of caesarean sections, but insufficient data on possible adverse effects were collected. Little information on other types of tocolytic drugs was available, although nitric oxide donors were associated with an increase in headaches. In addition, too little evidence was available to show whether the other ways of trying to help external cephalic version (ECV) are effective. Further research is needed if to increase the success of external cephalic version (ECV).

If your baby is breech at 36 weeks of pregnancy, your healthcare professional will discuss the following options with you:

• trying to turn your baby in the uterus into the head-first position by external cephalic version (ECV)
• planned caesarean section
• planned vaginal breech birth.

It is not always possible to turn your baby from being breech. Some breech babies can be safely delivered through the vagina, but usually doctors deliver them by C-section (caesarean section). Risks involved with a C-section C-section (caesarean section) include bleeding and infection. There also can be a longer hospital stay for both the mother and her baby.

Other risks can occur for breech babies who are born vaginally. These include:

• An injury during or after delivery.
• An injury where the baby’s hip socket and thigh bone become separated.
• Problems with the umbilical cord. For example, the umbilical cord can be flattened during delivery. This can cause nerve and brain damage due to a lack of oxygen.

Key points to remember

• Breech is very common in early pregnancy, and by 36–37 weeks of pregnancy most babies will turn into the head-first position. If your baby remains breech, it does not usually mean that you or your baby have any problems ³⁾.
• Towards the end of pregnancy, only 3–4 in every 100 (3–4%) babies are in the breech position ⁴⁾.
• Turning your baby into the head-first position so that you can have a vaginal delivery is a safe option ⁵⁾.
• The alternative to turning your baby into the head-first position is to have a planned Caesarean section or a planned vaginal breech birth.

Why turn my baby head-first?

Successful external cephalic version (ECV) lowers your chances of requiring a caesarean section and its associated risks. If your external cephalic version (ECV) is successful and your baby is turned into the head-first position you are more likely to have a vaginal birth.

Is there anything else I can do to help my baby turn?

There is no scientific evidence that lying down or sitting in a particular position can help your baby to turn. There is some evidence that the use of moxibustion (burning a Chinese herb called mugwort) at 33–35 weeks of pregnancy may help your baby to turn into the head-first position, possibly by encouraging your baby’s movements. This should be performed under the direction of a registered healthcare practitioner.

Some people think that you might be able to encourage your baby to turn by holding yourself in certain positions, such as kneeling with your bottom in the air and your head and shoulders flat to the ground. Other options you might hear include acupuncture and chiropractic treatment. There is no good evidence that these work. Discuss with your doctor or midwife before undergoing any treatment during pregnancy.

Natural methods

Some people look to natural ways to try and turn their baby. These methods include exercise positions, certain stimulants, and alternative medicine. They may help but there is no scientific evidence that they work.

• Breech tilt, or pelvic tilt: Lie on the floor with your legs bent and your feet flat on the ground. Raise your hips and pelvis into a bridge position. Stay in the tilt for about 10 to 20 minutes. You can do this exercise three times a day. It may help to do it at a time when your baby is actively moving in your uterus.
• Inversion: There are a few moves you can do that use gravity to turn the baby. They help relax your pelvic muscles and uterus. One option is to rest in the child’s pose for 10 to 15 minutes. A second option is to gently rock back and forth on your hands and knees. You also can make circles with your pelvis to promote activity.
• Music: Certain sounds may appeal to your baby. Place headphones or a speaker at the bottom of your uterus to encourage them to turn.
• Temperature: Like music, your baby may respond to temperature. Try placing something cold at the top of your stomach where your baby’s head is. Then, place something warm (not hot) at the bottom of your stomach.
• Webster technique: This is a chiropractic approach. It is meant to align your pelvis and hips, and relax your uterus. The goal is to promote your baby to turn.
• Acupuncture: This is a form of Chinese medicine. It involves placing needles at pressure points to balance your body’s energy. It can help relax your uterus and stimulate your baby’s movement.

What are my options for birth if my baby remains breech?

Depending on your situation, your choices are:

• planned caesarean section
• planned vaginal breech birth.

There are benefits and risks associated with both caesarean section and vaginal breech birth, and these should be discussed with you so that you can choose what is best for you and your baby.

Caesarean section

If your baby remains breech towards the end of pregnancy, you should be given the option of a caesarean section. Research has shown that planned caesarean section is safer for your baby than a vaginal breech birth ⁶⁾. Caesarean section carries slightly more risk for you than a vaginal birth.

Caesarean section can increase your chances of problems in future pregnancies. These may include placental problems, difficulty with repeat caesarean section surgery and a small increase in stillbirth in subsequent pregnancies.

If you choose to have a caesarean section but then go into labor before your planned operation, your healthcare professional will examine you to assess whether it is safe to go ahead. If the baby is close to being born, it may be safer for you to have a vaginal breech birth.

Vaginal breech birth

After discussion with your healthcare professional about you and your baby’s suitability for a breech delivery, you may choose to have a vaginal breech birth. If you choose this option, you will need to be cared for by a team trained in helping women to have breech babies vaginally. You should plan a hospital birth where you can have an emergency caesarean section if needed, as 4 in 10 (40%) women planning a vaginal breech birth do need a caesarean section. Induction of labor is not usually recommended.

While a successful vaginal birth carries the least risks for you, it carries a small increased risk of your baby dying around the time of delivery ⁷⁾. A vaginal breech birth may also cause serious short-term complications for your baby. However, these complications do not seem to have any long-term effects on your baby. Your individual risks should be discussed with you by your healthcare team.

Before choosing a vaginal breech birth, it is advised that you and your baby are assessed by your healthcare professional. They may advise against a vaginal birth if:

• your baby is a footling breech (one or both of the baby’s feet are below its bottom)
• your baby is larger or smaller than average (your healthcare team will discuss this with you)
• your baby is in a certain position, for example, if its neck is very tilted back (hyper extended)
• you have a low-lying placenta (placenta previa: a low-lying placenta after 20 weeks)
• you have pre-eclampsia or any other pregnancy problems.

What if I go into labor early?

If you go into labor before 37 weeks of pregnancy, the balance of the benefits and risks of having a caesarean section or vaginal birth changes and will be discussed with you.

What can I expect in labor with a breech baby?

With a breech baby you have the same choices for pain relief as with a baby who is in the head-first position. If you choose to have an epidural, there is an increased chance of a caesarean section. However, whatever you choose, a calm atmosphere with continuous support should be provided.

If you have a vaginal breech birth, your baby’s heart rate will usually be monitored continuously as this has been shown to improve your baby’s chance of a good outcome.

In some circumstances, for example, if there are concerns about your baby’s heart rate or if your labor is not progressing, you may need an emergency caesarean section during labor. A pediatrician (a doctor who specializes in the care of babies, children and teenagers) will attend the birth to check your baby is doing well.

What if I am having more than one baby and one of them is breech?

If you are having twins and the first baby is breech, your healthcare professional will usually recommend a planned caesarean section.

If, however, the first baby is head-first, the position of the second baby is less important. This is because, after the birth of the first baby, the second baby has lots more room to move. It may turn naturally into a head-first position or a doctor may be able to help the baby to turn.

If you would like further information on breech babies and breech birth, you should speak with your healthcare professional.

Breech position of baby

A breech baby may be lying in one of the following positions:

1. Frank or extended breech – the baby is bottom first, with the thighs against its chest and feet up by its ears. Most breech babies are in this position.
2. Flexed or complete breech – the baby is bottom first with its feet right next to its bottom. The thighs are against its chest and the knees are bent.
3. Footling or incomplete breech – when one or both of the baby’s feet are below its bottom.

Figure 1. Breech position of baby

Breech baby causes

Breech presentation may be caused by an underlying fetal or maternal abnormality, or may be an apparently chance occurrence, or may be related to an otherwise benign variant such as the placenta situated in an upper lateral corner of the uterus (cornual placental position) ⁸⁾. In the latter two instances, breech presentation places a healthy baby and mother at increased risk of a complicated vaginal birth or caesarean section.

It may just be a matter of chance that your baby has not turned into the head-first position. However, there are certain factors that make it more difficult for your baby to turn during pregnancy and therefore more likely to stay in the breech position. These include:

• if this is your first pregnancy
• if your placenta is in a low-lying position (also known as placenta praevia); see the RCOG patient information A low-lying placenta (placenta previa) after 20 weeks
• if you have too much (polyhydramnios) or too little fluid (amniotic fluid) (oligohydramnios) around your baby
• if you are having more than one baby.

Very rarely, breech may be a sign of a problem with the baby. If this is the case, such problems may be picked up during the ultrasound scan you are offered at around 20 weeks of pregnancy.

How to turn a breech baby

External cephalic version (ECV) should be carried out by a doctor or a midwife trained in external cephalic version (ECV). It should be carried out in a hospital where you can have an emergency caesarean section if needed.

External cephalic version (ECV) can be carried out on most women, even if they have had one caesarean section before ⁹⁾.

During an external cephalic version (ECV), obstetricians use their hands on the woman’s abdomen to gently try to turn the baby from the breech position to the head-down position. External cephalic version (ECV) involves applying gentle but firm pressure on your abdomen to help your baby turn in the uterus to lie head-first.

• A cardiotocograph (CTG), will monitor your baby’s wellbeing for 20-30 minutes before the procedure.
• A small needle will be inserted into your hand so that medication to relax your uterus can be administered directly into your vein.
• An obstetrician will then perform an ultrasound to confirm the position of the baby, and then attempt to turn the baby by pressing their hands firmly on your abdomen. Some women find this uncomfortable, while others don’t. The pressure on your abdomen lasts a few minutes. If the first attempt is unsuccessful, the obstetrician might try again.
• The CTG might be applied again after the procedure to assess your baby’s wellbeing before you leave.
• It usually takes about 3 hours from start to finish.

Relaxing the muscle of your uterus with medication has been shown to improve the chances of turning your baby ¹⁰⁾. This medication is given by injection before the external cephalic version (ECV) and is safe for both you and your baby. It may make you feel flushed and you may become aware of your heart beating faster than usual but this will only be for a short time.

Before the external cephalic version (ECV) you will have an ultrasound scan to confirm your baby is breech, and your pulse and blood pressure will be checked. After the external cephalic version (ECV), the ultrasound scan will be repeated to see whether your baby has turned. Your baby’s heart rate will also be monitored before and after the procedure. You will be advised to contact the hospital if you have any bleeding, abdominal pain, contractions or reduced fetal movements after external cephalic version (ECV).

External cephalic version (ECV) is usually performed after 36 or 37 weeks of pregnancy. However, it can be performed right up until the early stages of labour. You do not need to make any preparations for your external cephalic version (ECV).

External cephalic version (ECV) can be uncomfortable and occasionally painful but your healthcare professional will stop if you are experiencing pain and the procedure will only last for a few minutes. If your healthcare professional is unsuccessful at their first attempt in turning your baby then, with your consent, they may try again on another day.

If your blood type is rhesus D negative, you will be advised to have an anti-D injection after the external cephalic version (ECV) and to have a blood test.

Figure 2. Turning a breech baby

Footnote: Counterclockwise external cephalic version (ECV). In case of engaged fetus, each hand takes one fetal pole and fetal buttocks pushed out of the maternal pelvis. Fetal head gently pushed toward direction of fetal face, counterclockwise in this figure.

[Source ¹¹⁾]

External cephalic version contraindications

External cephalic version (ECV) should NOT be carried out if:

• you need a caesarean section for other reasons, such as placenta previa (a low-lying placenta after 20 weeks)
• you have had recent vaginal bleeding
• your baby’s heart rate tracing (also known as cardiotocography [CTG]) is abnormal
• your waters have broken
• you are pregnant with more than one baby (multiple pregnancy: having more than one baby).

Is external cephalic version safe for me and my baby?

External cephalic version (ECV) is generally safe with a very low complication rate ¹²⁾. Overall, there does not appear to be an increased risk to your baby from having external cephalic version (ECV). After external cephalic version (ECV) has been performed, you will normally be able to go home on the same day.

• About 1 in 1,000 women go into labor after an external cephalic version (ECV).
• About 1 in 200 women need an immediate caesarean section.

When you do go into labor, your chances of needing an emergency caesarean section, forceps or vacuum (suction cup) birth is slightly higher than if your baby had always been in a head-down position ¹³⁾.

Immediately after external cephalic version (ECV), there is a 1 in 200 chance of you needing an emergency caesarean section because of bleeding from the placenta and/or changes in your baby’s heartbeat ¹⁴⁾.

Is external cephalic version always successful?

External cephalic version (ECV) is successful for about 50% of women ¹⁵⁾. It is more likely to work if you have had a vaginal birth before. Your healthcare team should give you information about the chances of your baby turning based on their assessment of your pregnancy.

If your baby does not turn then your healthcare professional will discuss your options for birth (see below). It is possible to have another attempt at external cephalic version (ECV) on a different day.

If external cephalic version (ECV) is successful, there is still a small chance that your baby will turn back to the breech position. However, this happens to less than 5 in 100 (5%) women who have had a successful external cephalic version (ECV) ¹⁶⁾.

How to teach your child to talk

Learning to talk is a process that starts at birth, when your baby experiences how voices can sound. By 2 years old, most babies have a large vocabulary and can put words together to express their needs and ideas. Learning to talk is a complex skill. When you’re helping your child express himself, try to focus on having fun together, rather than seeing it as just a teaching opportunity.

In the toddler years, your child’s language starts to explode, as your child moves from using single words to putting together simple sentences. Your child is also starting to understand and follow simple requests, like ‘Bring me your book’ or ‘Wave bye-bye’. But toddlers often don’t have the words to express big emotions or talk about complex experiences. With your help, your child will start learning how to use words to communicate better.

You don’t need to ‘teach’ your toddler to talk. He’ll learn through everyday interactions, especially with you. However, speak with a child health professional if your toddler isn’t using gestures like head nods or pointing, or if she isn’t using words to communicate.

When you’re with your child, it’s all about tuning in and noticing what your child is interested in. Then you can make a comment or ask a question, and give your child time to respond. For example, if your toddler points to a beetle in the garden, you could say, ‘Look at the little green beetle. I wonder what it’s doing’. Then wait and see how your child responds.

When you share moments like these with your child, it’s important to give your child time to find words for her ideas. This is about waiting to hear what your child says, rather than trying to put words into her mouth.

And when your child responds, it’s important to show you’re really listening. You can do this by making lots of eye contact and saying things like ‘You think the beetle is going for a walk? Yes, there it goes!’ When you do this, you send the message that what your child is saying is important to you.

Simple and meaningful interactions like these encourage your child to talk more and use more words. They also help your child learn about the pattern of conversations.

What to expect from your toddler talking

Your toddler will probably start to:

• speak in correct sentences from 24-30 months
• be understood more by strangers from 26-36 months
• use pronouns (I, you, me, we, they) and some plurals from 26-36 months
• understand most of what adults say by about three years.

By birthday number two, your toddler will probably enjoy naming everyday things, like ‘doggie’ and ‘drink’. She’ll also be able to understand and follow a simple request, like ‘Bring me your book’ or ‘Wave bye-bye’.

By the age of three, your child will probably move on to simple sentences, like ‘Where doggie gone?’ By now strangers will probably be able to understand most of what your child says, even though he’ll still struggle to express some words clearly.

Talking can be frustrating for toddlers – they can have so much to tell you but can’t quite get the words out. If you give your toddler time, she’ll get there eventually. Trying and making mistakes are important parts of learning.

Toddlers respond best to encouragement and interest, rather than correction or being made fun of, so try to avoid correcting your toddler’s mistakes too often.

Tips to get toddlers talking

Here are some practical, everyday ideas to get your toddler talking and help her learn more words:

• Read together and share stories. Stories that have word patterns, rhymes and colorful pictures often capture toddler interest and attention.
• Sing songs or say rhymes with your child. This helps him to understand different word sounds – and it’s fun.
• When you play with your toddler, use words to describe what’s happening – for example, ‘Push the ball back to Mummy’ and ‘You got the ball!’
• Give your child choices using words and objects. For example, you could hold up two pairs of shoes and say, ‘We’re going outside. Would you rather wear your red boots or your blue shoes?’
• When your child uses ‘made-up’ verbs like ‘goed’, repeat the sentence back with the correct word. For example, ‘Yes, the man went out the door’.
• When your toddler uses simple word combinations like ‘Dog go away’ or ‘Daddy come here’, repeat the words back to your child in full sentences. For example, ‘You want Daddy to make the dog go away?’

Play ideas to encourage toddler talking

The more words you expose your child to, the more words she’ll learn. Here are some play ideas to encourage toddler talking:

• Read with your child.
• Talk about the ordinary things you do each day – for example, ‘I’m hanging these clothes to dry outside because it’s a nice day’.
• Respond to and talk about your child’s interests. For example, if your child is pretending to drive a car, ask him where he’s going.
• Recite nursery rhymes and sing songs. Play rhymes, stories and songs in the car.
• Copy your child’s attempts at words to encourage two-way conversation. Also build on basic words – for example, when your toddler says ‘train’, you can say, ‘Yes, it’s a big red train’.
• When your child is ‘talking’, show that you’re listening by smiling and looking at her. Also praise your child’s efforts to talk.
• Leave time after you talk to give your child a chance to reply. He might not always have the right words, but he’ll still try to respond. This helps children learn about conversation.
• Point to and name body parts, or make it into a game – for example, ‘Where is your mouth?’

Screen time and toddler talking

Screen time isn’t recommended for children under 18 months, other than video-chatting. After 18 months, your child can have some screen time, but it’s best to watch or play with your child.

Long periods of screen time have been associated with a range of health issues in toddlers and preschoolers, as well as the slower development of language skills, short-term memory and poorer social skills.

Tips to help toddlers understand words

It’s easy to forget that children don’t understand everything we say. Here are some ideas to try when your toddler seems puzzled by something you’ve said:

• Try saying it in different ways. For example, ‘Put the blocks in the box’, or ‘Here’s the box. Put the blocks in it’, or ‘Take the blocks to the box, and put them in’.
• Try to use the same words to describe things. If you repeat the same words, your child will start to understand them. For example, you might always use the word ‘pyjamas’ when you talk about what your toddler wears to bed.
• When you need to give instructions or requests, make them clear and limit them to one or two steps – for example, ‘Lids on the markers. Then put the markers in the tub’.

How do kids learn how to talk

The more words children hear, the more words they can learn. Babies start cooing and making vowel sounds between 6 weeks and 3 months, but most won’t start using basic words until they’re 9 to 14 months old. From 3 to 18 months, your baby’s speech develops dramatically. Simple, enjoyable interactions and play ideas – like reading and singing – will encourage your baby’s talking and language skills.

Babies develop language at different rates – some learn quickly and others might need a bit more time.

As your baby starts to learn about language you might hear him:

• cooing, gurgling and babbling
• putting together simple sounds – for example, ‘ba-ba’
• copying words
• communicating ‘no’ with a shake of the head.

At 12-18 months, most babies say their first words. But at this age, you and other close family members might be the only people who know what these words mean! Even though your baby’s words might not sound quite right yet, she still enjoys babbling happily when you talk. She also likes pointing out familiar objects when you name them.

By birthday number two, your baby has become better at talking but some sounds might still be hard for him to say correctly, like the letter ‘r’. He might say it as ‘w’ instead – for example, it might sound like your child is saying ‘wed’ instead of ‘red’.

Here are some fun things to do together to encourage baby talking and language:

• Chat to your baby about the things you’re doing around the house, even if you think they’re boring – for example, ‘Daddy’s vacuuming the carpet to get rid of the dust that makes you sneeze’.
• Repeat your baby’s attempts at words to encourage two-way conversation. For example, if she says ‘mama’ you could say ‘mama’ back to her. You can also repeat and build on your toddler’s words. For example, when baby says, ‘train’, you say, ‘Yes, it’s a big red train’.
• Show interest in your baby’s babbling and talking by looking him in the eye and giving lots of smiles.
• Respond to and talk about your baby’s interests. For example, if your baby starts playing with a toy train, you could say ‘Toot, toot’.
• Read and tell stories with your baby.
• Share songs and nursery rhymes.
• Praise your baby’s efforts to talk. For example, if your baby points to a dog and names it, you could say, ‘Well done for pointing out the dog, Georgie!’

From birth to 3 months

Your baby listens to your voice. He coos and gurgles and tries to make the same sounds you make. You can help your baby learn how nice voices can be when you:

• Sing to your baby. You can do this even before he is born! Your baby will hear you.
• Talk to your baby. Talk to others when she is near. She won’t understand the words, but will like your voice and your smile. She will enjoy hearing and seeing other people, too.
• Plan for quiet time. Babies need time to babble and play quietly without TV or radio or other noises.

Encouraging talking skills is as easy as listening and responding to your baby. Sharing stories, songs, rhymes – even talking about your day – will all help your baby learn and practice language. Sharing these experiences with your baby also helps to build your relationship. Nappy-changing is a great time for some face-to-face conversation with your baby. You could try talking, singing and looking at baby’s face as you change nappies.

From 3 to 6 months

Your baby is learning how people talk to each other. You help him become a “talker” when you:

• Hold your baby close so he will look in your eyes.
• Talk to him and smile.
• When your baby babbles, imitate the sounds.
• If he tries to make the same sound you do, say the word again.

From 6 to 9 months

Your baby will play with sounds. Some of these sound like words, such as “baba or “dada.” Baby smiles on hearing a happy voice, and cries or looks unhappy on hearing an angry voice. You can help your baby understand words (even if she can’t say them yet) when you:

• Play games like Peek-a-Boo or Pat-a-Cake. Help her move her hands along with the rhyme.
• Give her a toy and say something about it, like “Feel how fuzzy Teddy Bear is.”
• Let her see herself in a mirror and ask, “Who’s that?” If she doesn’t respond, say her name.
• Ask your baby questions, like “Where’s doggie?” If she doesn’t answer, show her where.

From 9 to 12 months

Your baby will begin to understand simple words. She stops to look at you if you say “no-no.” If someone asks “Where’s Mommy?” she will look for you. She will point, make sounds, and use her body to “tell” you what she wants. For example she may look up at you and lift her arms up to show you she “wants up.” She may hand you a toy to let you know she wants to play. You can help your baby “talk” when you: Show her how to wave “bye-bye.”

From 12 to 15 months

Babies begin to use words. This includes using the same sounds consistently to identify an object, such as “baba” for bottle or “juju” for juice. Many babies have one or two words and understand 25 or more. He will give you a toy if you ask for it. Even without words, he can ask you for something—by pointing, reaching for it, or looking at it and babbling. You can help your child say the words he knows when you:

• Talk about the things you use, like “cup,” “juice,” “doll.” Give your child time to name them.
• Ask your child questions about the pictures in books. Give your child time to name things in the picture.
• Smile or clap your hands when your child names the things that he sees. Say something about it. “You see the doggie. He’s sooo big! Look at his tail wag.”
• Talk about what your child wants most to talk about. Give him time to tell you all about it.
• Ask about things you do each day—“Which shirt will you pick today?” “Do you want milk or juice?”
• Build on what your child says. If he says “ball,” you can say, “That’s your big, red ball.”
• Introduce pretend play with your child’s favorite doll or toy animal. Include it in your conversations and your play. “Rover wants to play too. Can he roll the ball with us?”

From 15 to 18 months

Your child will use more complex gestures to communicate with you and will continue to build her vocabulary. She may take your hand, walk you to the bookshelf, point to a book and say “buk” to say, “I want to read a book with you.” You can help your child talk with you when you:

• Tell her “Show me your nose.” Then point to your nose. She will soon point to her nose. Do this with toes, fingers, ears, eyes, knees and so on.
• Hide a toy while she is watching. Help her find it and share in her delight.
• When he points at or gives you something, talk about the object with her. “You gave me the book. Thank you! Look at the picture of the baby rolling the ball.”

From 18 months to 2 years

Your baby will be able to follow directions and begin to put words together, such as “car go” or “want juice.” He will also begin to do pretend play which fosters language development. You can spur your child’s communication skills when you:

• Ask your child to help you. For example, ask him to put his cup on the table or to bring you his shoe.
• Teach your child simple songs and nursery rhymes. Read to your child. Ask him to point to and tell you what he sees.
• Encourage your child to talk to friends and family. He can tell them about a new toy.
• Engage your child in pretend play. You can talk on a play phone, feed the dolls, or have a party with the toy animals.

From 2 to 3 years

Your child’s language skills will grow by leaps and bounds. He will string more words together to create simple sentences, such as “Mommy go bye-bye.” He will be able to answer simple questions, such as “Where is your bear?” By 36 months he will be able to answer more complicated questions such as, “What do you do when you are hungry?” He will do more and more pretend play, acting out imaginary scenes such as going to work, fixing the toy car, taking care of his “family” (of dolls, animals).

You can help your child put all his new words together and teach him things that are important to know when you:

• Teach your child to say his or first and last name.
• Ask about the number, size, and shape of the things your child shows you.
• Ask open-ended questions that don’t have a “yes” or “no” answer. This helps them develop their own ideas and learn to express them. If it’s worms, you could say: “What fat, wiggly worms! How many are there?…Where are they going? Wait, watch and listen to the answer. You can suggest an answer if needed: “I see five. Are they going to the park or the store?”
• Ask your child to tell you the story that goes with a favorite book. “What happened to those three pigs?” Reading spurs language development. Take him to storytime at your local library. Your toddler will enjoy sharing books with you as well as peers.
• Do lots of pretend play. Acting out stories and role-playing create rich opportunities for using, and learning, language.
• Don’t forget what worked earlier. For example, your child still needs quiet time. This is not just for naps. Turn off the TV and radio and let your child enjoy quiet play, singing, and talking with you.

Helping toddlers turn body language and feelings into words

Understanding feelings and being able to talk about them are important steps towards self-regulation.

In the toddler years, children often use body language when they don’t have the words to express ideas and feelings. For example, your child might tug on your pants to be picked up, shake or nod his head, or reach for something he wants.

This is a great time to encourage your child to use words. You can do this by repeating back what you think your child wants. For example, ‘You look hungry. Do you want more apple?’

You can help your child understand how words, feelings and body language go together by talking about them and making connections. For example, ‘Thanks for showing me the paint is knocked over. I can see you’re really sad your picture got messed up’. This links the feeling with the word ‘sad’.

What is bed wetting

Bed wetting also known as nighttime incontinence or nocturnal enuresis, is very common in childhood. Bed wetting happens when children do not wake up when their bladder is full at night, and the bladder automatically releases the urine (pee). Bed-wetting is involuntary urination while asleep after the age at which staying dry at night can be reasonably expected. Bed wetting is more common for boys to have poor bladder control while asleep than girls and it often runs in the family.

Soggy sheets and pajamas — and an embarrassed child — are a familiar scene in many homes. But don’t despair. Bed-wetting isn’t a sign of toilet training gone bad. It’s often just a normal part of a child’s development. Bed wetting is not your child’s fault. Bed wetting is not caused by laziness or a desire to get attention. Bed wetting is something that a child has no control over.

Night time dryness usually occurs by the time children reach 5 to 7 but happens at different ages for different children. Night time dryness is a natural development that occurs when the mechanism controlling that part of the body matures.

Most kids are fully toilet trained by age 5 to 5 and a half, but there’s really no target date for developing complete bladder control. Between the ages of 5 and 7, bed-wetting remains a problem for some children. After 7 years of age, a small number of children still wet the bed. At this age, your child may still be developing nighttime bladder control. Seek medical advice to be sure there is no physical cause.

Up to the age of 5, wetting the bed is normal. It usually stops happening as your child gets older without the need for any treatment.

• up to 1 in 5 5-year-olds wet the bed
• 1 in 20 10-year-olds wet the bed
• about 1 in 50 teenagers wet the bed
• about 1 in 100 teenagers continue to wet the bed into adulthood

The exact mechanism behind bed wetting is not clearly understood, but is thought to result from a combination of three key factors:

• Difficulty rousing from deep sleep (arousal difficulties);
• Producing too much urine at night (nocturnal polyuria); and
• Overactivity of the detrusor muscle, which makes up part of the bladder wall.

For most children who wet the bed, there is a family history of bedwetting. This means the child has at least one sibling, parent or extended family member, such as an aunt, uncle or grandparent who also wet the bed after the age of 5.

Children who wet their beds are usually normal and happy in all other ways.

If bed-wetting continues, treat the problem with patience and understanding. Lifestyle changes, bladder training, moisture alarms and sometimes medication may help reduce bed-wetting.

If the child is usually dry by day and passes urine normally, bed wetting is very unlikely to be the result of any bladder or kidney disease. However, if the child is ill or feverish, dribbles urine day and night or has pain, you should consult your doctor.

A child’s self-esteem can be damaged by punishing or embarrassing the child. It also hurts when siblings or friends make fun of them so:

• praise your child for dry nights and be understanding after wet nights
• do not punish your child for wetting the bed
• be patient and supportive, and remember that it is not the child’s fault
• do not get angry – it does not help and may make your child more anxious
• do not shame your child – it does not help the child gain bladder control.

Key point to remember

• Reassure your child that bed wetting is a common part of growing up and you should encourage them to not feel embarrassed or ashamed.
• Don’t punish, criticize, tease or offer rewards for something your child cannot control.
• In some children, the nervous system can take a little longer to develop, so the brain and bladder may not fully communicate with each other until the child is older.
• Bed wetting is rarely caused by a medical problem such as a urinary tract infection, diabetes or a nerve or muscle problem. Although if a child has not wet the bed for a long time and starts to do it again, you should take your child to a doctor for a check-up.
• Consider using a bladder training or alarm program if your child is over 5 and 7.
• Help your child to feel as comfortable as possible about going to school camps and sleepovers.

What happens in primary nocturnal enuresis?

Children with primary nocturnal enuresis lack night-time bladder control at an age when this would be expected.

• True bed wetters do not waken after wetting. They are not necessarily heavy sleepers nor are they being lazy and it has nothing to do with dreaming. Wetting the bed is quite unconscious; from the child’s point of view it is a matter of going to bed dry and waking up wet, with no recollection of it happening.
• Some children who wet the bed produce more urine at night than others, due to a low level of a hormone which controls how much urine is made while the child is asleep.
• Some children who wet the bed have bladders that cannot hold a large amount of urine.
• Sometimes bedwetting can be due to a medical problem, so it is wise to check with your doctor
• Sometimes children who wet the bed at home are dry when sleeping in a strange place. They may be a bit worried when sleeping away from home, and sleep more lightly for the first few nights.
• Stressful events in a child’s life may interfere with the normal development of night time dryness. These events could include a new baby in the family, being unwell, family separation or break-up.

When should child stop wetting bed?

Most kids are fully toilet trained by age 5 to 5 and a half, but there’s really no target date for developing complete bladder control. Between the ages of 5 and 7, bed-wetting remains a problem for some children. After 7 years of age, a small number of children still wet the bed. At this age, your child may still be developing nighttime bladder control. Seek medical advice to be sure there is no physical cause.

Up to the age of 5, wetting the bed is normal. Bed wetting usually stops happening as your child gets older without the need for any treatment.

• up to 1 in 5 5-year-olds wet the bed
• 1 in 20 10-year-olds wet the bed
• about 1 in 50 teenagers wet the bed
• about 1 in 100 teenagers continue to wet the bed into adulthood

Bed wetting at night complications

Although frustrating, bed-wetting without a physical cause doesn’t pose any health risks. However, bed-wetting can create some issues for your child, including:

• Guilt and embarrassment, which can lead to low self-esteem
• Loss of opportunities for social activities, such as sleepovers and camp
• Rashes on the child’s bottom and genital area — especially if your child sleeps in wet underwear

What causes bed wetting

No one knows for sure what causes bed-wetting, but various factors may play a role:

• A small bladder. Your child’s bladder may not be developed enough to hold urine produced during the night.
  Inability to recognize a full bladder. If the nerves that control the bladder are slow to mature, a full bladder may not wake your child — especially if your child is a deep sleeper.
• A hormone imbalance. During childhood, some kids don’t produce enough anti-diuretic hormone (ADH) to slow nighttime urine production.
• Urinary tract infection. This infection can make it difficult for your child to control urination. Signs and symptoms may include bed-wetting, daytime accidents, frequent urination, red or pink urine, and pain during urination.
• Sleep apnea. Sometimes bed-wetting is a sign of obstructive sleep apnea, a condition in which the child’s breathing is interrupted during sleep — often due to inflamed or enlarged tonsils or adenoids. Other signs and symptoms may include snoring and daytime drowsiness.
• Type 1 Diabetes. For a child who’s usually dry at night, bed-wetting may be the first sign of type 1 diabetes. Other signs and symptoms may include passing large amounts of urine at once, increased thirst, fatigue and weight loss in spite of a good appetite.
• Chronic constipation. The same muscles are used to control urine and stool elimination. When constipation is long term, these muscles can become dysfunctional and contribute to bed-wetting at night.
• A structural problem in the urinary tract or nervous system. Rarely, bed-wetting is related to a defect in the child’s neurological system or urinary system.
• Emotional problems. In some cases, bed wetting can be a sign your child is upset or worried. Starting a new school, being bullied, or the arrival of a new baby in the family can be very stressful for a young child. If your child has started wetting the bed after being dry at night for a while, there may be an emotional issue behind it.

Risk factors for bed wetting at night

Bed-wetting can affect anyone, but it’s twice as common in boys as in girls. Several factors have been associated with an increased risk of bed-wetting, including:

• Stress and anxiety. Stressful events — such as becoming a big brother or sister, starting a new school, or sleeping away from home — may trigger bed-wetting.
• Family history. If one or both of a child’s parents wet the bed as children, their child has a significant chance of wetting the bed, too.
• Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in children who have ADHD.

Bed wetting at night diagnosis

Depending on the circumstances, your doctor may recommend the following to identify any underlying cause of bed-wetting and help determine treatment:

• Physical exam
• Discussion of symptoms, fluid intake, family history, bowel and bladder habits, and problems associated with bed-wetting
• Urine tests to check for signs of an infection or diabetes
• X-rays or other imaging tests of the kidneys or bladder to look at the structure of the urinary tract
• Other types of urinary tract tests or assessments, as needed

Bed wetting treatment

Most children outgrow bed-wetting on their own. If treatment is needed, it can be based on a discussion of options with your doctor and identifying what will work best for your situation.

If your child isn’t especially bothered or embarrassed by an occasional wet night, lifestyle changes — such as avoiding caffeine entirely and limiting fluid intake in the evening — may work well. However, if lifestyle changes aren’t successful or if your grade schooler is terrified about wetting the bed, he or she may be helped by additional treatments.

If found, underlying causes of bed-wetting, such as constipation or sleep apnea, should be addressed before other treatment.

Options for treating bed-wetting may include moisture alarms and medication.

What you can do

Children need to know that bedwetting is a common childhood problem.

If a preschooler still wets the bed:

• Make sure the mattress has an adequate waterproof cover – a length of plastic, covered by a bath towel, over the bottom sheet
• Ensure the bed is warm and comfortable
• Try using ‘pull ups’ (a type of nappy) on your child.
• Establish a morning routine to deal with wet pyjamas and bedding. Have your child help with the clean-up, but do not make the child feel ashamed for a wet bed.
• Encourage double voiding before bed. Double voiding is urinating at the beginning of the bedtime routine and then again just before falling asleep. Remind your child that it’s OK to use the toilet during the night if needed. Use small night lights, so your child can easily find the way between the bedroom and bathroom.
• Make sure the bed is low enough to get in and out easily
• Keep a low-powered globe or night light on
• Consider a potty close to or in the bedroom.
• Encourage an adequate and regular fluid intake throughout the day. This may help produce more urine and help enlarge the bladder.
• Encourage your child try to wait an extra 15 minutes before using the toilet during the day. Try to slowly make the waiting times longer and longer. This can help stretch an unusually small bladder to hold more urine.
• Avoid soft drinks containing caffeine – these can cause more urine to be produced, meaning your child may need to go to the toilet more often.
• Avoid beverages and foods with caffeine. Beverages with caffeine are discouraged for children at any time of day. Because caffeine may stimulate the bladder, it’s especially discouraged in the evening.
• Limiting drinks or ‘lifting’ during the night does not help to achieve bladder control.
• Encourage regular toilet use throughout the day. During the day and evening, suggest that your child urinate every two hours or so, or at least often enough to avoid a feeling of urgency.
• Prevent rashes. To prevent a rash caused by wet underwear, help your child rinse his or her bottom and genital area every morning. It also may help to cover the affected area with a protective moisture barrier ointment or cream at bedtime. Ask your pediatrician for product recommendations.

Small children are unlikely to be worried by wetting the bed unless Mum or Dad (or other extended family) makes a big issue of it.

It is not helpful to punish children who wet the bed, no matter how desperate you feel about the extra washing. There is no instant cure for wet beds when the child concerned just hasn’t reached that stage of development yet.

Coping and support

Children don’t wet the bed to irritate their parents. Try to be patient as you and your child work through the problem together. Effective treatment may include several strategies and may take time to be successful.

• Be sensitive to your child’s feelings. If your child is stressed or anxious, encourage him or her to express those feelings. Offer support and encouragement. When your child feels calm and secure, bed-wetting may become less problematic. If needed, talk to your pediatrician about additional strategies for dealing with stress.
• Plan for easy cleanup. Cover your child’s mattress with a plastic cover. Use thick, absorbent underwear at night to help contain the urine. Keep extra bedding and pajamas handy. However, avoid the long-term use of diapers or disposable pull-up underwear.
• Enlist your child’s help. If age-appropriate, consider asking your child to rinse his or her wet underwear and pajamas or place these items in a specific container for washing. Taking responsibility for bed-wetting may help your child feel more control over the situation.
• Celebrate effort. Bed-wetting is involuntary, so it doesn’t make sense to punish or tease your child for wetting the bed. Also, discourage siblings from teasing the child who wets the bed. Instead, praise your child for following the bedtime routine and helping clean up after accidents. Use a sticker reward system if you think this might help motivate your child.

With reassurance, support and understanding, your child can look forward to the dry nights ahead.

Bedwetting alarms

Bedwetting or moisture alarms are widely used and are considered the most effective and safe method of treatment. These small, battery-operated devices — available without a prescription at most pharmacies — connect to a moisture-sensitive pad on your child’s pajamas or bedding. When the pad senses wetness, the alarm goes off.

Success depends on the bedwetting treatment being part of a supervised self-management program using high quality and reliable equipment.

Bedwetting alarms work by conditioning the child to wake when they want to pass urine.

Ideally, the moisture alarm sounds just as your child begins to urinate — in time to help your child wake, stop the urine stream and get to the toilet. If your child is a heavy sleeper, another person may need to listen for the alarm and wake the child.

When the child begins to wet, a bell rings and the child wakes. Because the feeling of a full bladder and the sound of the bell happen at the same time, the child’s brain associates one with the other. Eventually the child wakes when they feel the need to pass urine. The treatment programme takes approximately 6 to 16 weeks.

If you try a moisture alarm, give it plenty of time. It often takes one to three months to see any type of response and up to 16 weeks to achieve dry nights. Moisture alarms are effective for many children, carry a low risk of relapse or side effects, and may provide a better long-term solution than medication does. These devices are not typically covered by insurance.

Other interim treatment methods that may suit your child include positive reinforcement and star charts (for under school age) or your doctor may suggest short term medication therapy (for school camps and sleepovers).

Bed wetting medication

As a last resort, your child’s doctor may prescribe medication for a short period of time to stop bed-wetting. Certain types of medication can:

• Slow nighttime urine production. The drug desmopressin (a synthetic form of the natural substance vasopressin) reduces urine production at night. But drinking too much liquid with the medication can cause problems, and desmopressin should be avoided if your child has symptoms such as a fever, diarrhea or nausea. Be sure to carefully follow instructions for using this drug. Desmopressin is given orally as a tablet and is only for children over 5 years old. 30% of children treated with desmopressin remain completely dry and 40% wet the bed less, but still have some wet nights. The average child treated with desmopressin wets the bed 1.34 nights fewer per week, when compared to placebo. Desmopressin needs to be taken 1 hour before going to sleep to optimise its effect. The main side effects associated with desmopressin are that of low sodium levels in the blood which can result in seizures. To prevent this it is advised that your child doesn’t drink in the 2 hours before going to bed or overnight. According to the Food and Drug Administration, nasal spray formulations of desmopressin (Noctiva, others) are no longer recommended for treatment of bed-wetting due to the risk of serious side effects.
• Calm the bladder. If your child has a small bladder, an anticholinergic drug such as oxybutynin (Ditropan XL) works to stop the bladder wall from contracting which results in the bladder being able to store a larger volume of urine, especially if daytime wetting also occurs. Anticholinergic medication should be considered in combination with other medications in children who do not become dry with either a bed wetting alarm or desmopressin. This medication is usually used along with other medications and is generally recommended when other treatments have failed. The current evidence suggests that anticholinergic medication should be used in combination with either desmopressin or tricyclic antidepressants in children who wet the bed. The combination of desmopressin and anticholinergic medication can reduce the risk of bed wetting by 66% when compared to placebo. Similarly, the combination of desmopressin and the tricyclic antidepressant, imipramine, was found to reduce the number of wet nights from 6.1 to 1.7 per week. Anticholinergic medication can take up to 2 months to achieve its optimal effect. Side effects are common, affecting up to 76% of patients. The most serious side effects are those that affect the brain and this can occur in up to 33% of children. These side effects include agitation, drowsiness, confusion, memory loss, nightmares and hallucinations.
• Tricyclic antidepressants. Tricyclic antidepressants (TCAs) are used when other medications have not been successful. Imipramine (for example, sold as Tofranil and Tolerade) is the name of the most commonly used agent. Imipramine can have serious effects on the heart and if taken in an overdose can cause death. Other common side effects include mood changes, nausea and difficulty sleeping. For this reason your child will be started on the lowest effective dose and should be reassessed at regular intervals.

Sometimes a combination of medications is most effective. There are no guarantees, however, and medication doesn’t cure the problem. Bed-wetting typically resumes when medication is stopped, until it resolves on its own at an age that varies from child to child.

Alternative medicine

Some people may choose to try complementary or alternative medicine approaches to treat bed-wetting. For approaches such as hypnosis, acupuncture, chiropractic therapy and herbal therapy, evidence of effectiveness for bed-wetting is weak and inconclusive or such efforts have proved to be ineffective. In some cases, the studies were too small or not rigorous enough, or both.

Be sure to talk to your child’s doctor before starting any complementary or alternative therapy. If you choose a nonconventional approach, ask the doctor if it’s safe for your child and make sure it won’t interact with any medications your child may take.

Nocturnal enuresis summary

Despite bed wetting being a very common condition, it is still poorly understood making strategies to prevent the disease difficult. There are, however, several treatment options available to either cure or minimise bed wetting episodes. Before embarking on a treatment regime simple measures should be addressed including ensuring adequate fluid intake, regular toileting and the option of using a reward system. Once you and your child are willing and motivated to commence treatment, either a bed wetting alarm or desmopressin therapy should be considered as the initial treatment of choice. Where these measures are not successful, your doctor will consider trialling other medications including anticholinergic and tricyclic antidepressants.

Adult bed wetting

Bed-wetting that starts in adulthood also known as secondary enuresis, is uncommon and requires medical evaluation.

Causes of adult bed-wetting may include:

• A blockage (obstruction) in part of the urinary tract, such as from a bladder stone or kidney stone
• Bladder problems, such as small capacity or overactive nerves
• Diabetes
• Enlarged prostate
• Medication side effect
• Neurological disorders
• Obstructive sleep apnea
• Urinary tract infection

Tests and procedures used to determine the cause of adult bed-wetting include:

• Physical exam
• Urine tests
• Urologic tests
• Neurological evaluation

Treatment of adult bed-wetting is directed at the underlying cause, when possible.

Why do kids lie?

Most parents think children lie to get something they want, avoid a consequence or get out of something they don’t want to do. These are common motivations, but there are also some less obvious reasons why kids might not tell the truth or at least the whole truth.

Children might lie to:

• cover something up so they don’t get into trouble
• see how you’ll respond
• make a story more exciting
• experiment – for example, by pretending something that happened in a story was real
• get attention or make themselves sound better
• get something they want – for example, ‘Mum lets me have lollies before dinner’
• avoid hurting someone’s feelings – this sort of lie is often called a ‘white lie’
• to test out a new behavior – one reason children lie is because they’ve discovered this novel idea and are trying it out, just as they do with most kinds of behaviors, to see what happens. “They’ll wonder, what happens if I lie about this situation?”. “What will it do for me? What does it get me out of? What does it get me?’”
• to enhance self-esteem and gain approval – children who lack confidence may tell grandiose lies to make themselves seem more impressive, special or talented to inflate their self-esteem and make themselves look good in the eyes of others.
• to get the focus off themselves – children with anxiety or depression might lie about their symptoms to get the spotlight off them. Or they might minimize their issues, saying something like “No, no I slept fine last night” because they don’t want people worrying about them.
• speaking before they think or lie out of impulsivity – one of the hallmarks of the impulsive type of ADHD is to talk before they think
• white lies – in certain situations parents might actually encourage children to tell a white lie in order to spare someone’s feelings. In this case, the white lie and when to use it fall under the umbrella of social skills.

Parents should expect kids to lie at some point and try to resist the urge to simply get upset (and punish). Children can learn to tell lies from an early age, usually around three years of age. This is when your child starts to realize that you aren’t a mind reader, so he can say things that aren’t true without you always knowing.

Children lie more at 4-6 years. Your child might get better at telling lies by matching her facial expressions and the tone of her voice to what she’s saying. If you ask her to explain what she’s saying, she’ll usually own up.

The University of Toronto study ¹⁾ shows that lying is common from age 4 to 17, and by age 7, kids can tell a lie so well that often their parents can’t even tell they’re being untruthful.

As children grow older, they can lie more successfully without getting caught out. The lies also get more complicated, because children have more words and are better at understanding how other people think.

By adolescence, children regularly tell white lies to avoid hurting other people’s feelings, avoid punishment, disappointing their parents or an unpleasant outcome. But after age 17, lying decreases, so it’s not necessarily a problem that will follow your kids into adulthood.

Pretending and imagining are important to your child’s development, and it’s good to encourage this kind of play. ‘Tall tales’ don’t need to be treated as lies, especially for children under four years.

If your child is making up a story about something, you can respond by saying something like, ‘That’s a great story – we could make it into a book’. This encourages your child’s imagination without encouraging lying.

Lying about serious issues

Sometimes children lie or keep secrets about serious issues. For example, a child who has been abused by an adult or bullied by another child will often lie because she fears that she’ll be punished if she tells.

Here’s what to do if you suspect your child is lying to protect someone else:

• Reassure your child that he’ll be safe if he tells the truth.
• Let your child know you’ll do everything you can to make things better.

Some children might lie frequently as part of a larger pattern of more serious, negative or even illegal behavior like stealing, lighting fires or hurting animals.

If you have concerns about your child’s behavior, safety or wellbeing, think about getting professional help. Talk to your doctor or school counselor for advice on who to contact.

When should you get help for a child who’s a habitual liar?

Children lie for many reasons. Sometimes they do it to avoid consequences. Sometimes they do it when feeling inadequate, insecure, or anxious. Sometimes they are simply copying a peer’s or an adult’s bad behavior. Lying, however, is a symptom, not a diagnosis. If a child is habitually lying and then experiencing distress or dysfunction, it is time to seek professional help and a psychiatric evaluation.

How to stop kids from lying

Once children are old enough to understand the difference between true and not true, it’s good to encourage and support them in telling the truth.

You can do this by emphasizing the importance of honesty in your family and helping children understand what can happen if you lie.

Skill building and not punishment should be the goal

Here are some tips:

• Have conversations about lying and telling the truth with your children. For example, ‘How would mum feel if dad lied to her?’ or ‘What happens when you lie to a teacher?’
• Help your child avoid situations where he feels the need to lie. For example, if you ask your child if he spilled his milk, he might feel tempted to lie. To avoid this situation you could just say, ‘I see there’s been an accident with the milk. Let’s clean it up’.
• Praise your child when she owns up to doing something wrong. For example, ‘I’m so glad you told me what happened. Let’s work together to sort things out’.
• Be a role model for telling the truth. For example, ‘I made a mistake in a report I wrote for work today. I told my boss so we could fix it’.
• Use a joke to encourage your child to own up to a lie without conflict. For example, your preschooler might say, ‘My teddy bear broke it’. You could say something like, ‘I wonder why teddy did that?’ Keep the joke going until your child owns up.

It might seem like no matter what you do, your child keeps lying. But if you keep praising your child for telling the truth and you also use consequences for lying, your child is less likely to lie as he gets older.

What parents shouldn’t do

• Don’t corner your child. Putting a child on the spot can set him up to lie. If parents know the true story, they should go right to the issue and discuss it. Instead of asking a child if he didn’t do his homework a parent could just say, “I know you didn’t do it. Let’s talk about why that’s not a good idea.”
• Don’t label your child a liar. It’s a big mistake to call a child a liar. The wound it creates is bigger than dealing with what he lied about in the first place. He thinks, “Mom won’t believe me.” It makes him feel bad about himself and may set up a pattern of lying.

How to deal with a child that lies

If your child tells a deliberate lie, the first step is to let him know that lying isn’t OK. He also needs to know why not. You might like to make a family rule about lying.

The next step is to use appropriate consequences. And when you use consequences, try to deal separately with the lying and the behavior that led to it. For example, if your child drew on the walls and then lied about it, you might have a consequence for each of these things. But if your child is lying to cover up a mistake like spilling a drink, you might just decide to use a consequence for the lying and then clean up the mess together.

Here are some more ideas to handle deliberate lying:

• Make a time to talk calmly with your child and tell her how her lying makes you feel, how it affects your relationship with her, and what it might be like if family and friends stop trusting her. Watch how you respond to misbehavior and mistakes in your home, whether it’s spilled juice on the carpet or unfinished chores. If your kids worry about being yelled at or punished when they mess up, they won’t want to come to you with the truth. Focus on using a calm voice – yes, it can be tough, but it’s possible. That doesn’t mean kids are off the hook for lying. But instead of getting angry and assigning blame, discuss solutions to the problem with your child.
• Don’t set up a lie. If you can see piles of laundry on your daughter’s floor, don’t ask her if she’s cleaned up her room yet. When you ask questions to which you already know the answer, you’re giving your child the opportunity to tell a lie. Instead, emphasize ways to address the situation. If you know John hasn’t done his homework, ask him, “What are your plans for finishing your homework?” Instead of “Where did all this mud come from?” ask, “What can we do to clean this up and make sure it doesn’t happen next time?” This can help head off a power struggle and allows your child to save face by focusing on a plan of action instead of fabricating an excuse. It also teaches a lesson of what they can do next time – sitting down with homework right after school or taking off their shoes in the mudroom instead of the living room – to avoid problems.
• Share your own experiences and reward honesty. Let your child know that everyone makes mistakes or mishandles a situation once or twice. But talk to your child about how if this becomes a repeated thing, there will be consequences. And lay those out up front, so there’s no debate about it later. Offer positive rewards when your child tells the truth, especially in a tough situation.
• Celebrate honesty. Even if you’re upset that there’s a sea of water on the bathroom floor because your daughter tried to give her dolls a bath in the sink, commend her for coming to you and telling the truth. Tell her, “I really appreciate you telling me what really happened. That must have been difficult for you, but I really appreciate you telling the truth and taking responsibility.”
• Always tell your child when you know that he isn’t telling the truth. But try to avoid asking him all the time if he’s telling the truth, and also avoid calling him a ‘liar’. This might lead to even more lying. That is, if your child believes he’s a liar, he might as well as keep lying. You could say something like ‘You’re usually very honest with me. But I just can’t understand what else would have happened to the last cupcake’.
• Get the whole truth. While you may want to put your child on the spot when you catch him in a lie, accusing or blaming him will only make things worse. Getting to the root of the problem and understanding why he couldn’t be honest with you will help you encourage your child to tell the truth in the future. Open up a conversation gently, saying, “that sounds like a story to me. You must be worried about something and afraid to tell the truth. Let’s talk about that. What would help you be honest?” You can use the information you glean to help him be more truthful in the future.
• Make it easier for your child not to lie. You can start by thinking about why your child might be telling lies. For example, if your child is lying to get your attention, consider more positive ways you could give her attention and boost her self-esteem. If she’s lying to get things she wants, consider a rewards system that lets her earn the things instead.
• Use truth checks. Let’s say parents have been told by a teacher their child didn’t do her homework. You give your kid a chance to tell the truth. If she doesn’t at first, you could say, “I’m going to walk away and give you 10 minutes and then I’m going to come back and ask you again. If you change your mind and want to give me a different answer, it’s just a truth check and you won’t get in trouble.” This way, if a child gives an off-the-cuff answer because she’s scared of consequences or she doesn’t want to disappoint a parent, she has the chance to really think about whether she wants to lie or fess up without the consequences. NOTE: this technique isn’t for a child who chronically lies.
• Use the preamble method. Parents can also set up kids to tell the truth by reminding them that they don’t expect perfection. Parents could say, “I’m going to ask you a question and maybe you’re going to tell me something I don’t really want to hear. But remember, your behavior is not who you are. I love you know matter what, and sometimes people make mistakes. So I want you to think about giving me an honest answer.” Giving kids a chance to reflect on this may lead to them telling the truth.
• Delight in do-overs. Think of mistakes as a way to learn how to make better choices. When you stay calm and avoid yelling or punishing your kids for mistakes, your kids will be more likely to admit their slip-ups in the future. Turn the mistake into a learning opportunity. Ask, “If you could have a do-over, what would you do differently?” and brainstorm different ideas. If someone else was affected – maybe he broke his sister’s scooter – ask what he can do to make it right with the other party.
• Show the love. Let your kids know you love them unconditionally, even when they make mistakes. Make sure they know that while you don’t like their poor behavior, you will never love them any less because of the mistakes they might make. This helps your kids feel safe opening up to you.
• Walk the talk. Remember that your kids are always looking to you and learning from your actions. Those little white lies you tell, whether it’s to get out of dog sitting for the neighbors or helping with the school fundraiser, aren’t harmless – they’re showing your kids that it’s okay to lie.

These tips will help start your family on a path for a more honest household. But remember it takes time to build up trust. Be patient.

However, if your child continues to lie often or lies with the intention of hurting others, you may want to consider counseling or other professional help.

How to handle lying in toddlers (ages 2-3)

Lying is common in young children, who are just beginning to understand the difference between fantasy and reality.

Take a common scenario: Your daughter sneaks a chocolate chip cookie. The telltale chocolate smear is on her face. When you question her, she denies it. Why?

Children this age are too young to understand lying as a moral choice. They don’t always think before acting, so they don’t anticipate consequences. So, the lie is how they’re responding to the fact that you look mad or sound upset. They want to make everything OK again. They’re not trying to deceive.

With toddlers, respond to lies with facts. Don’t punish. In this instance, point out her dirty face and the open package on the table. When you lay out the evidence in simple but concrete terms, you can start to help your child understand right from wrong.

How to handle lying during the preschool years (ages 4-5)

Talk with a slightly older child about the importance of telling the truth. For extra reinforcement, read an age-appropriate book about lying to your child. And make sure to set a good example by telling the truth yourself.

If you catch your preschooler in a lie, don’t make a big deal out of it, they are still exploring and testing at that age. Make use of their increased language skills to teach them about choices.

Say that lying’s not an OK choice, but here’s how you could have handled that instead. You still need to be very concrete at this age.

How to handle lying during the elementary school years

By the time your child enters kindergarten, she’s a bit more savvy. She understands that lying is wrong, but she also knows that lying can help her avoid consequences and chores. She’d rather have fun than do her science project or clean her room. She’ll lie to mislead or manipulate and to avoid an uncomfortable situation. At this age, skill building not punishment should be the goal.

Kids usually want to do the right thing, but when they lack skills to handle a situation, they just choose the path of least resistance.

If your child lies about not having homework, find out why. Maybe they don’t understand or can’t keep track of their assignments.

Pinpoint what’s behind the lie, whether it’s a lack of problem-solving skills or a feeling of not fitting in. Focus on teaching your child how to solve problems, get through uncomfortable situations and think ahead to consequences for their behavior.

Look at the gaps in your child’s skills as an opportunity to reduce the need to lie. Share experiences from your past instead of punishing and shaming. But don’t let them get away with it. Tell them it’s not OK, or they’ll see lying as an easier way to avoid consequences or hurt feelings.

Modeling is even more important at this age. If you lie in everyday situations — “I wish I could talk, but I have to get going. I have somewhere to be” — older school kids will start to notice that and think it’s OK.

How to handle lying during the middle school years and beyond

During the middle school years, your child is even more likely to lie to fit in with peers, to get out of trouble or to regain control after you’ve told them no. Help him understand the impact of his choices.

Explain to older kids and teens why lying can lead to dangerous consequences. Often, they’re not thinking ahead. For instance, if your son lies about where he is, help him understand that you couldn’t get in touch with him if something went wrong. Helping him see why limits are put in place will eventually help him make better choices.

Parents need to talk with their child, explaining their concerns (whether moral or safety issues) and perhaps finding a compromise. This isn’t giving in. This is helping ensure you’re not seen as overly strict, which could just result in more lying.

Older kids start to understand when it’s OK to tell a ‘white lie’ to spare someone’s feelings. It’s best to reinforce the importance of telling the truth, though there are some times when it’s better to keep your thoughts to yourself.

You can also help them understand that lying can affect their reputation. Discuss questions like ‘How do you want others to view you? How do you want to view yourself? Do you feel proud of yourself when you lie, or rather when you’re honest and kind?’.