How to clean baby ears

The inside of your baby’s ear doesn’t need to be cleaned because earwax is the cleaner. You can clean your baby’s eyes, ears and nose when you’re bathing him. Warm water is all you need. Avoid using soap because your baby’s skin is sensitive, and soap can dry it out. Get some cotton balls. Soak one cotton ball in some warm water. Wipe behind your baby’s ears and around the outside of each ear. Be careful not to stick anything (including cotton buds) inside her ear, because it’s very easy to cause damage.

Earwax also known as cerumen, is secreted by glands in the skin that lines the outer half of your ear canal. Earwax contains enzymes that help prevent bacteria and fungus from growing in the ear. Earwax creates a barrier to protect the ear canal from water from traveling deeper into your ear canal. The earwax and tiny hairs in these passages also trap dust and dirt particles that enter the ear which could damage deeper structures, such as your eardrum. Earwax normally regulates itself by migrating from the inside of the ear canal to the outside (to the opening of the ear) on its own, where it’s washed away or falls out as new wax is secreted to replace it. If you secrete an excessive amount of wax or if earwax isn’t cleared effectively, it may build up and block your ear canal. Earwax blockages commonly occur when people try to clean their ears on their own by placing cotton swabs or other items in their ears. This often just pushes wax deeper into the ear, rather than removing it. Earwax only needs to be removed from the ear for two reasons:

1. When a doctor needs to move ear wax out of the way to see the eardrum
2. When it is so tightly packed and is compromising hearing

Do not put anything inside your child’s ear canal this includes cotton swabs. Soft objects even like cotton swamps can puncture an ear drum. You can also push wax further toward the eardrum, causing it to clump together and block hearing.

Your body already has a way to deal with earwax it no longer needs. Chewing, other jaw movements, and skin growing inside your ear will push old earwax out naturally. Using cotton swabs, however, can push the wax deeper into your ear canal. You might also seriously damage sensitive ear canal skin or your eardrum.

Earwax buildup is not very common. According to the American Academy of Otolaryngology—Head and Neck Surgery ¹⁾, just 1 in 10 children and 1 in 20 adults have this problem. Some people may be more susceptible to earwax build up. About 3 in 10 elderly adults and developmentally disabled adults might have more of a problem with earwax.

Impacted earwax can cause symptoms like ear pain, itching, feeling of fullness in the ear, ringing in the ear (tinnitus), hearing loss, discharge coming from the ear, odor coming from the ear, cough, and/or change in hearing aid function.

Signs of too much earwax or earwax that is stuck and blocking the ear canal include:

• Earache or itching in the affected ear
• A feeling that your ear is full
• Ringing or noises in the ear (tinnitus)
• Decreased hearing in the affected ear or hearing loss (or a change in how well hearing aids work, for those who use them)
• Odor or discharge
• Dizziness
• Cough

If you or your child have any of these symptoms, see a doctor.

Ear anatomy

Before you dive in to how to properly care for your child’s ears, it helps to know how the ear is constructed. Ears are divided into three main parts:

1. Outer ear, which is the fleshy external part made of cartilage also called the pinna that you can see. This includes the ear canal (external acoustic meatus) inside that leads up to the eardrum (tympanic membrane) and is responsible for directing sound to the middle ear. When people talk about cleaning the ears, they are referring to the pinna as well as the ear canal (external acoustic meatus).
2. Middle ear, which is composed of the eardrum (tympanic membrane) that creates vibrations, which will be transmitted into sound.
3. Inner ear, which is responsible for converting vibrations from the middle ear into nerve impulses that are sent to the brain and allow you to hear sound. The inner ear also regulates your balance.

Figure 1. Ear anatomy

How to remove earwax in toddlers

Here are helpful tips to use when it comes time clean your child’s ears at home.

• Use a cloth or tissue to wipe away any wax that has migrated out of the ear canal.
• If your child’s eardrum doesn’t contain a tube or have a hole in it, these self-care measures may help you remove excess earwax that’s blocking your ear canal:
  • Soften the wax. Use an eyedropper to apply a few drops of baby oil, mineral oil, glycerin or hydrogen peroxide in your ear canal.
  • Use warm water. After a day or two, when the wax is softened, use a rubber-bulb syringe to gently squirt warm water into your ear canal. Tilt your head and pull your outer ear up and back to straighten your ear canal. When finished irrigating, tip your head to the side to let the water drain out.
  • Dry your ear canal. When finished, gently dry your outer ear with a towel or hand-held dryer.
  • NOTE: You may need to repeat this wax-softening and irrigation procedure a few times before the excess earwax falls out. However, the softening agents may only loosen the outer layer of the wax and cause it to lodge deeper in the ear canal or against the eardrum. If your symptoms don’t improve after a few treatments, see your doctor.
• To dry ears after a bath or a shower, instruct your child tilt their ear to one side against a towel, and then tilt their head to the other, allowing water to drip out on its own.
• Unfortunately kids sometimes put little things in their ear canals such as beads, beans, little toys or even play dough. Never put anything in your child’s ear canal to remove a foreign body. Removal should only be attempted by a professional with the proper equipment such as your child’s pediatrician or a pediatric ear, nose, and throat (ENT) specialist. It’s good to have a conversation with young children about never putting anything inside their ears.
• Remind your preteen or teenager to clean behind their ears with soap and warm water to remove oil and dirt that can cause acne back there.
• If you think too much ear wax is causing your child to have difficulty hearing, discuss this with your child’s pediatrician or a pediatric ENT. There are over the counter products available to dissolve wax but it is best to discuss what is best with your child’s doctor.
• Refrain from using cotton swabs in your own ears, particularly in front of your child. Kids like to mimic what parents (and other adults) do and you certainly don’t want to teach your child that it is okay to put anything in their ear or a sibling’s ear.

Don’t try to dig it out

Never attempt to dig out excessive or hardened earwax with available items, such as a paper clip, a cotton swab or a hairpin. You may push the wax farther into your ear and cause serious damage to the lining of your ear canal or eardrum.

Earwax removal kits available in stores also can be effective at removing wax buildup. Ask your doctor for advice on how to properly select and use alternative earwax removal methods.

There is an old saying that goes, “Never put anything smaller than your elbow inside your ear or your child’s.” It’s obvious this is an impossible action in itself, but the saying makes sense because you don’t want to cause ear wax build up or damage in your child’s ears. If you know of parents that use cotton swabs as part of their ear hygiene for their family, forward this blog post to them. Let’s keep ears clean and healthy.

How doctors remove excess earwax

Your doctor can remove excess wax using a small, curved instrument called a curet or by using suction while inspecting the ear. Your doctor can also flush out the wax using a water pick or a rubber-bulb syringe filled with warm water.

If earwax buildup is a recurring problem, your doctor may recommend that you use a wax-removal medication, such as carbamide peroxide (Debrox Earwax Removal Kit, Murine Ear Wax Removal System). Because these drops can irritate the delicate skin of the eardrum and ear canal, use them only as directed.

How to teach a child to write

Even though many children and adults use computers, tablets and phones at home, school and work, handwriting is still an important part of literacy and an essential skill for life. For toddlers and preschoolers, handwriting is about drawing and scribbling with crayons and chalk. Older children learn formal handwriting at school.

Drawing and scribbling lay the foundations for handwriting. Handwriting starts with scribbling and drawing then moves on to forming letters and words.

You can encourage your child to develop an interest in handwriting by giving him opportunities to draw, scribble and write. This prepares him for the formal handwriting he’ll learn at school.

Writing is a complex process that requires a wide range of skills — a strong vocabulary; an understanding of genre, text structure, and voice; basic mechanical skills (grammar and punctuation); organizational skills; and higher order thinking.

Creative and pretend play can improve your child’s literacy. It also puts some of your child’s drawing skills into practice.

A child’s writing development parallels the child’s development as a reader. Part of early print awareness is the realization that writing can be created with everyday tools such as pens, pencils, crayons, and markers. Children begin to imitate the writing that they see in the environment. What often starts as scribbling ends up being important clues to a child’s understanding that print carries meaning. For example, children who can write smoothly and clearly are better able to use writing to record their thoughts and ideas. When handwriting is automatic, their ideas can flow. Children also need to write to do homework, tests and assignments.

You also need handwriting skills to do many tasks later in life like writing birthday cards, filling in forms and signing important documents.

As with reading skills, writing grows through explicit instruction. Writing is a skill with rules and structures. Across multiple grade levels, good writers are created through systematic, explicit instruction, combined with many opportunities to write and receive feedback.

Writing may be the most complex process that you expect your child to learn.

How children learn handwriting

Handwriting is a complex skill that develops over time. To learn handwriting children need to combine fine motor skills, language, memory and concentration. They also need to practise and follow instructions.

Handwriting starts with scribbling and drawing then moves on to forming letters and words.

You can encourage your child to develop an interest in handwriting by giving her opportunities to draw, scribble and write. This prepares young children for the formal handwriting they’ll learn at school.

Left-handed writing in children

Most children choose to write and draw with their right hands. But some children choose their left hands. This is OK. If your child chooses his left hand to write with, there’s no need to make him swap hands.

Children who write with their left hands might find it hard to see their writing because their left hands cover their writing as it moves across the page. By tilting your child’s page so that the left-hand corner is highest, you can help her more easily see what she’s writing or drawing.

What you need for drawing, scribbling and writing with your child

Set up your child at a table with some chunky crayons, pencils or markers, as well as some paper or card.

It’s best for your child to draw and write sitting at a table. The stable, flat surface can make it easier for your child to draw, and it also encourages your child to hold the crayon or pencil correctly.
How to do drawing, scribbling and writing activities with your child

Give your child lots of opportunities to draw and write. This helps your child develop the skills she needs for handwriting.

Here are some ideas:

• Have drawing materials handy so that your child can draw and scribble any time he feels like it. You can even take materials with you when you go out.
• Encourage your child to sit at a table to draw. You can put a cushion on your child’s chair so that her elbows are just above the height of the table. This makes it easier for her to hold the crayon or pencil.
• Let your child decide what to draw or write. Any practice he gets holding a crayon or pencil and drawing pictures, lines or circles helps him with learning to write.
• Talk with your child about her drawing or writing – for example, ‘Tell me about your picture’. Praise your child’s efforts, even if her ‘writing’ or ‘drawing’ is more like scribble – for example, ‘Well done! That looks like an ‘M’ and a ‘W’. Great writing’.
• Encourage your child to sign his work, even if it’s just the first letter of his name or a scribble. Then write his name underneath so he gets used to seeing it.
• Display your child’s work. For example, put it on the fridge and point it out to people who visit.

Adapting drawing, scribbling and writing activities for children of different ages

Make sure your younger child has thick chunky crayons to draw with until she’s developed the finger and thumb grip she needs to hold a thin pencil.

Help your older child to write words to go with a drawing. He might want to write a story or write people’s names underneath their pictures. If your child is just learning to write, you could also ask whether he wants to write a letter or help you write the shopping list.

How to teach toddler to write

Drawing is the start of handwriting for toddlers. Toddlers generally begin to show an interest in drawing with a crayon or chalk from about two years.

Here are a few ideas to get your toddler drawing, scribbling and ‘writing’:

• Have crayons and paper, or chalk and blackboard, handy. Small chunks of chalk or crayons encourage your child to use a fingertip grip. This helps him learn to hold a pencil.
• Encourage your child to draw things that interest her. For example, if your child likes insects, you could draw a centipede and your child could add lots of legs. Or on a rainy day you could draw a big cloud and she could draw rain falling down.
• Give your child lots of activities that involve squeezing and pinching things. This could be threading big beads, squeezing and pinching playdough into shapes, and building with blocks and Duplo. This helps your child develop the hand muscles he needs for using pencils.
• Prop up your child’s drawing surface so that it’s on an angle. You could use an easel or blackboard. This helps your child make a downward stroke, which she needs to be able to do for writing later on.
• Avoid felt-tip markers and pencils. It can be hard for your toddler to hold these until he has developed the small hand muscles he needs for a better grip.

The following activities are simple you can do to help your toddler to get ready for writing and require very few supplies and are a great way to spend quality time with your child. As an added bonus, they’ll help prepare your child’s hands and eyes for writing.

Name Tracing

Materials you will need: paper, highlighter, marker or pencil

What to do

• This fun activity will provide an opportunity for your child to learn how to write his/her name. Write your child’s name on paper with a marker.
• Remember to write the first letter using a capital letter then the rest in lower case.
• Let your child trace over the name with a highlighter. By repeating this activity, your child will begin to understand how to write his/her own name!
• It will take time for your child to write his/her name legibly.

Cutting Practice

Materials you will need: pair of child sized scissors, pictures from magazines

What to do

• Have your child work on fine motor and pre-writing skills by inviting your child to cut out pictures from old magazines. Your child may choose to cut out toys, food, or just pictures of interest.
• Your child may also cut out letters or numbers that he/she recognizes. This activity is easier than trying to cut on lines, but still requires hand strength and more advanced fine motor skills.

Playdough Letters

Materials you will need: Play Doh

What to do

• Have your child roll medium sized balls of Play Doh into 6 inch ropes. Ask your child to choose a letter to make, then see if your child can use the rope of Play Doh to do so.
• If this is challenging for your child, write the letter on paper first, then let your child form the Play Doh on top to match.

Dot to Dot

Materials you will need: piece of paper, markers

What to do

• Write your child’s name on paper using dots, (5 or 6 per letter), instead of lines. Have your child start with the first dot and connect the dots.
• Hopefully your child will recognize his/her name! Try this with the names of other family members if your child enjoys this activity.

Tally Marks

Materials you will need: small number of objects, paper and pencil

What to do

• Today’s activity will introduce tally marks to your child as a new way to represent quantities. This is especially good for a child who is challenged by writing numerals. Tally marks to show the numeral 4: ////
• Place 4 blocks or objects in front of your child. Show your child how to make a tally mark for each block. It’s not important that you use a slash for the 5th object at this point, if you are counting that high.

How to teach preschool kids to write

Children usually start to draw straight and circular lines in the preschool years. Your preschooler might even be putting these lines and shapes together to draw people and objects. She might also be starting to form letters.

Lots of opportunities to draw will help your child keep developing the skills he needs for handwriting. Here’s how to help:

• Keep giving your child chunky crayons and chalk until she has developed the finger and thumb grip she needs to hold a pencil.
• Encourage your child to trace simple top-to-bottom and left-to-right lines on a page, trying to stay on the lines all the way to the end. Make up a story to add interest to the activity – for example, ‘Help this puppy find the way home’.
• Practice drawing anticlockwise circles that start at the top of the page. This is the pattern we use to form letters.
• As your child gets more control over the crayon or pencil, encourage him to draw simple stick figure people. If you put your child’s pictures on the fridge or wall, he’ll feel proud of his work.
• Help your child to recognize and write her name by helping her to trace over the letters of her name. At first you might need to put your hand over your child’s hand to help her.
• Help your child learn the alphabet sequence. A fun way to learn is by clapping your hands in a steady rhythm while you say the letters together.
• Give your child opportunities to write and draw with other materials – for example, drawing lines in sand or mud, tracing over letters on signs with his finger, forming 3D letters from playdough, and so on. Take photos of these drawings if you want to print them out and display them.

How to teach school-age child to write

During the first two years of school, your child will learn to:

• form letters
• recognize and spell frequently used words
• put spaces between words
• write letters and words in a similar size and in a line
• write about familiar events.

Children develop their handwriting ability at different rates, but most children have mastered these basic skills within the first two years of school. From Year 2 on, children start to write more complex sentences and write about their experiences.

To write well, students must develop a broad set of skills:

• Basic writing skills: These include spelling, capitalization, punctuation, handwriting/keyboarding, and sentence structure (e.g., elimination of run-ons and sentence fragments). Basic writing skills are sometimes termed “mechanics” of writing.
• Text generation: Text generation involves translating one’s thoughts into language, what might be thought of as the “content” of writing. Text generation includes word choice (vocabulary), elaboration of detail, and clarity of expression.
• Writing processes: Especially beyond the earliest grades, good writing involves planning, revising, and editing one’s work. These processes are extremely important to success in writing, and increasingly so as students advance into the middle and secondary grades.
• Writing knowledge: Writing knowledge includes an understanding of discourse and genre — for example, understanding that a narrative is organized differently than an informational text. Another example of writing knowledge includes writing for an audience, that is, the writer’s understanding of the need to convey meaning clearly and appropriately to the people who will be reading a particular piece of writing.

Learning to write well is challenging to most students, but students with reading difficulties often have particular difficulty with writing. Underlying weaknesses that affect reading — such as limited vocabulary knowledge, lack of understanding of text structure, poor phonemic awareness, lack of letter-sound knowledge — typically affect writing as well.

In addition, poor readers usually do not read widely, which deprives them of useful models for writing. Finally, if a child’s reading difficulties are severe, so much time and effort may have gone into providing reading intervention that writing instruction may have gotten short shrift.

Here are a few tips to encourage your school-age child’s handwriting:

• Make a place for writing at home. Have a stable chair and a surface at the level of your child’s belly button. If your kitchen table is too high, you could use a cushion or tall chair to raise your child higher, with a footstool to support her feet.
• Ask your child’s teacher for a sample sheet with the starting points for each letter clearly marked. This can help your child practice at home what he’s learning at school.
• To help your child learn to form a letter, write it lightly and correctly yourself and get her to trace over your letter. Show your child where to start drawing the letter by putting a green dot at the starting point and a red one at the finishing point.
• Say the letter’s name and practice saying the letter sound with your child as he’s drawing or tracing the letter.
• Use everyday opportunities to practice writing. For example, get your child to add items to the family shopping list, write notes to grandparents, help with birthday and other cards, or make labels with post-it notes.
• Make it fun. Use a stick to draw large letters in the ground or at the beach and fill the letters with pebbles or shells. You could use non-permanent markers on a window to trace a letter over many times. Bath crayons are also good for this activity.

Learning to write is hard work! Praise your child’s efforts. Help her spot her best letters and encourage her to write more like them. Focus on the letters she writes well rather than the mistakes.

Signs of handwriting problems in early school-age children

Learning to write involves a combination of skills and abilities and an understanding of language. If your child is having difficulty with one or more of these skills, he might have some trouble with learning handwriting.

Here are some early signs that your child is having difficulty developing the skills she needs for handwriting at school. Your child:

• still swaps hands while drawing or handwriting during the first year of school. Most children prefer using one hand for drawing before they reach school, but some children have started school when this happens
• writes slowly or has difficulty drawing letters correctly. Your child might need some help developing motor skills so that she can make smooth, careful movements
• grips a pencil differently from the way she was taught or doesn’t have a strong pencil grip. Poor pencil grip can slow down your child’s handwriting progress and make it hard for her to complete work in a reasonable time
• lacks interest in or avoids drawing and handwriting. Your child might lose interest in writing if she isn’t confident about drawing or her writing isn’t as advanced as her classmates’ writing
• has untidy handwriting. This might look like reversed letters, letters not correctly closed, inconsistent letter size, letters that don’t sit on the line and inconsistent spacing between letters and words
• doesn’t seem to follow the teacher’s instructions while learning to write. Your child might have trouble concentrating, paying attention or understanding the teacher’s instructions.

If you notice these signs, it’s possible that your child can’t clearly see the board, his own writing or print in books. Or he might have additional learning needs that affect his handwriting development.

Getting help with handwriting

Talk with your child’s teacher or your doctor if you’ve noticed your child having difficulty with handwriting skills. Your doctor might recommend you make an appointment with an occupational therapist, audiologist or optometrist.

Children with handwriting difficulties might need extra help and aids. These might include:

• angled writing boards
• chunky pencils
• pencil grips
• paper with colored dotted lines, bold lines or raised tactile lines.

An occupational therapist can let you know what aids will help your child.

Handwriting apps

You can get handwriting apps for tablets and smartphones. Handwriting apps can be useful, so long as your child uses them only as an extra option for handwriting practice, rather than as a replacement.

It’s also important to make sure that any apps you’re interested in use the handwriting script that’s taught in your child’s school. It might be a good idea to talk with your child’s teacher before you decide on a handwriting app for your child.

Newborn heel stick procedure

Heel stick is a minimally invasive and easily accessible way of obtaining capillary blood and is the most common way to draw newborn’s blood for various laboratory tests, especially newborn screens and glucose levels. Heel-stick technique is used to collect blood for newborn screening tests, usually before the baby leaves the hospital. Heel sticks are the most commonly performed invasive procedure in neonatal intensive care units. Thanks to improved laboratory techniques that require smaller sample volumes and improved automated heel lancing devices that minimize trauma and pain ¹⁾, heel stick is a viable method of obtaining blood for many routine blood tests ²⁾. Heel stick sampling can also help preserve venous access for future intravenous (IV) lines.

Adequate quantities of serum may be obtained via heel stick in almost any neonate. If done properly, hemolysis should not be a significant problem. The skin’s blood supply is located at the junction of the dermis and subcutaneous tissue, 0.35 to 1.6 mm from the skin surface.

Due to the special technical requirements of this procedure, it is ideal to have experienced staff who perform heel sticks frequently. It is also important to have a program in place to maintain this special skill set. Some evidence exists that in term neonates, skilled venipuncture may result in fewer total punctures and less pain than heel stick. A Cochrane review first published in 1999 and updated in 2011 suggests that it may in fact be the procedure of choice in this population ³⁾. However, these results may not be extrapolatable to preterm infants or infants who require multiple or frequent blood sampling ⁴⁾. In addition, the development of newer, more effective, and less painful lancing devices may increase the relative utility of heel stick.

Prewarming with the commercially-available heel warmers or with a diaper which has been warmed under a warm faucet and taped around the heel often increases the blood supply and arterializes the sample. The area should be cleaned thoroughly with alcohol swab. The person performing the procedure should wear appropriately fitting gloves.

The heel puncture should be done on the most medial or lateral portions of the plantar surface of the heel, not on the posterior curvature, to avoid the calcaneous. The lancets are designed to enter no deeper than 2-3 mm. If using a scalpel blade, the blade should enter the skin no more than 2-3 mm. After the puncture, wipe the first small drop off to rid the skin of the tissue juices that may increase clotting at the site.

Hold the ankle area with the 3 fingers on your ulnar side while placing your thumb behind the heel and your second finger just below the ventral surface of the toes. By alternately pressing the lateral three fingers , followed by a milking motion of the second finger, blood can be expressed. The fingers should be relaxed for a few seconds periodically to allow refilling. To prevent bruising, caution should be used to limit squeezing with the finger tips. To prevent hemolysis, allow large droplets to form, collecting the drops as they form into the microtube, not scraping the blood into the tube.

Figure 1. Heel stick location

Footnote: Safest sites for heel stick are outer edges of heel (dark areas). Lighter gray area between outer edges may be used as secondary site if outer areas have been accessed frequently. To avoid damage to calcaneus, posterior pole of heel should not be used.

Figure 2. Infant heel stick positioning

Footnote: Infant positioning for heel stick procedure. Note heel warming device in place.

Figure 3. Apply mild pressure between thumb and fingers to hold ankle in dorsiflexion. Do not excessively squeeze heel.

Figure 4. Placement of heel lancing device on outer portion of plantar surface of heel. 

Figure 5. Collection of blood sample from heel stick site. Capillary tube collection is pictured. First drop of blood after incision should be wiped away and not used in sample. 

Figure 6. Newborn screening

Newborn heel stick technique and location

Anesthesia

Standard local or systemic pharmacologic anesthesia is not required for heel stick sampling. Local anesthetics may interfere with the quality of the blood sample.

Anesthesia for heel stick in infants can involve oral sucrose, ambient light and noise reduction, and swaddling. Sucrose has been shown to have a substantial anesthetic effect in multiple trials, though an optimal dose has not been definitively established ⁵⁾. It may be administered with a dropper, a needleless syringe, or a pacifier dipped in a dose of approximately 0.1-1 mL.

Swaddling, bringing the infant’s hands to the midline, and minimizing environmental stimulation has also been shown to have an effect on how infants tolerate this painful procedure ⁶⁾.

Positioning

Developmentally appropriate positioning, should be implemented when possible. The heel stick sample is obtained most easily with the infant supine (see Figure 2 above).

Proper site selection (see Figure 1 above) is important for minimizing pain and avoiding contact with the calcaneus. The posterior pole of the heel should not be used for a heel stick, because this site is where the calcaneus is in its most superficial position ⁷⁾.

Heel stick sampling

If heel warming is desired, apply a heel warmer according to the manufacturer’s directions for approximately 5 minutes before performing the heel stick. Some studies have found heel warming to offer no improvement in blood volume collected ⁸⁾.

Put on gloves. Prepare the automated heel-lancing device according to the manufacturer’s directions. A heel-lancing device (eg, Tenderfoot [ITC Medical, Edison, NJ] or Quikheel Lancet [BD, Franklin Lakes, NJ]), sized appropriately for the infant’s weight – A 0.65 mm incision depth is appropriate for infants weighing 1 kg or less; a 0.85 mm incision depth is appropriate for small-for-gestational-age (SGA) infants and premature infants who weigh more than 1 kg; and a 1 mm incision depth is appropriate for term infants aged 6 months or younger.

Prepare an adequate area around the heel stick site with antiseptic solution.

Position the heel between thumb and forefinger, with the fingers underneath the calf and posterior ankle and the thumb over the ball of foot or arch (see Figure 3 above). Apply a small amount of pressure to place the foot in a comfortable dorsiflexed position.

Place the automated lancing device on the appropriate area on the side of the heel (see Figure 4 above), then activate it.

Apply mild pressure with thumb and fingers. Avoid excessive squeezing or milking of the heel; this may lead to greater hemolysis and more pain.

Wipe away the first drop of blood, and collect the sample. Fill the capillary tube by touching the open tip of the tube to a blood drop, which is drawn into the tube by capillary action. Collect blood drops into hematology or chemistry tubes (see Figure 5 above), taking care to avoid excessive scooping of blood from the adjacent skin with the lip of the collection tube, which can interfere with test results.

Blot blood drops onto appropriate areas on the filter paper according to the laboratory’s instructions (see Figure 6 above); methods of collecting filter paper samples for newborn screens have strict guidelines and vary between laboratories. If blood stops flowing, try to wipe away any clot that may have formed at the incision site with gauze or an alcohol wipe. Release pressure to allow capillary refill, then reapply pressure to allow a blood drop to form again.

When sampling is complete, apply pressure to the incision site until bleeding stops. Apply gauze or a bandage.

Heel stick indications

Heel stick blood sampling is indicated whenever capillary blood is an acceptable source. Such situations include the following:

• The sample required is relatively small
• Another acceptable source of blood (eg, central venous catheter, umbilical catheter, arterial line) is not already available

Heel stick samples can be used for general chemistries and liver function tests, complete blood counts (CBCs), toxicology, newborn screening, bedside glucose monitoring, and blood gas analysis ⁹⁾.

Heel stick contraindications

Heel stick should not be performed if any significant injury, infection, anomaly, or edema is present on the sampling area of the heel ¹⁰⁾.

At present, coagulation studies may not be performed with capillary samples. Blood tests that require relatively larger sample volumes may not be feasible with heel stick samples. Blood cultures require perfectly sterile technique and, therefore, may not be done with samples obtained via heel stick. Certain other sophisticated tests may also not be performed on heel stick samples (eg, chromosomal analyses and certain immunoglobulins and titers).

When ordering a laboratory test that is sent to another facility or is out of the ordinary, check with the laboratory to determine which type of blood sample is required.

When is the heel-stick method used to draw blood from infants?

The answer to this question depends on the baby’s developmental milestones. While fingers are the site of choice after infancy, heel sticks are appropriate for most babies, including premature infants, neonates, and even babies 4 to 7 months old. The only caveat is that babies discover other parts of their bodies, such as their feet and toes, as they grow older.

A bandage placed on a baby’s heel can pose a safety risk when the child is able to place its feet in its mouth. By 8 to 12 months, babies are pulling themselves up, standing, and preparing to walk or walking; so heel sticks are not recommended at this developmental stage because the heels are bearing weight to varying degrees. Premies may not reach such milestones on the same schedule as full-term babies, so parents should be questioned about their child’s development before performing a heel stick.

Heel sticks complications

Complications of heel stick include the following:

• Pain ¹¹⁾
• Infection (cellulitis, abscess, osteomyelitis)
• Scarring
• A too-deep incision (potentially making contact with calcaneus)
• Inaccurate results (eg, hemolysis causing hyperkalemia, air bubbles causing erroneous blood gas results, platelet clumping)

Improper heel-stick technique can damage the structures of the foot, including the calcaneus bone and soft tissues. In fact, some reports have documented difficulties walking later in life. It is safe to perform a heel stick if the puncture site is limited to the medial and lateral planter aspects of each heel pad, specifically medial to a visual line drawn from the middle of the big toe extending posterior to the heel or lateral to a line drawn from between the fourth and fifth toes and extending posterior to the heel. Repeated punctures, bruising, or redness (erythema) limit the available area for punctures, especially in premature infants who may have blood drawn multiple times or very tiny heels.

Are there other safety risks associated with heel sticks?

Yes, there is also a risk of burning the baby’s skin while warming its heel before the blood is drawn. Heel warming is used to increase blood flow in the capillaries. If the heel is to be warmed, using warm water submersion is risky unless you tightly control the temperature.

Chemical heat packs are single-use, and offer a temperature-controlled, safer, but more expensive alternative. Though heel warming is commonly performed to increase blood flow, this protocol is actually based more on theoretical grounds than on any solid evidence that it works. Two studies have claimed that heel warming does not increase blood flow; however, the studies were not blinded ¹²⁾. It is costly in terms of time and consumables, so a well-designed study to resolve this question would be welcome.

Are finger sticks on infants safe?

Yes, they can be performed with special safety measures. Special lancets less than 1.5-mm thick can be used once heel sticks are no longer an option and after 6 months of age. At that age, distance from the skin surface to bone and cartilage in the middle finger is only 2.5 mm ¹³⁾.

Finger stick sampling is used for capillary blood gas analysis in neonatal intensive care unit (NICU) and may be used for additional laboratories as well. The technique is similar to heel stick in that only the medial and lateral aspects of the finger are stuck. The milking motion includes the whole finger and even portions of the hand.

Vernix caseosa

Vernix also known as vernix caseosa is a white cheesy waxy substance that protects your baby’s skin from the constant exposure to amniotic fluid in the womb and, as it later exits the birth canal, from bacterial and environmental insults ¹⁾. Vernix caseosa, the waxy substance that coats the skin of newborn babies, has an extremely complex lipid composition and is produced during the third trimester of gestation ²⁾. The vernix is washed off with the baby’s first bath.

Vernix caseosa is a complex biofilm composed of water in hydrated corneocytes (80%), surrounded by a matrix of lipids (10%) and proteins (10%) ³⁾. The lipid fraction is extremely rich and not yet fully characterized despite the efforts of numerous researchers ⁴⁾. The most abundant lipid classes (wax esters, cholesteryl esters, diol diesters and triacylglycerols) are known, but they are characterized typically only with respect to their fatty acids composition, investigated from hydrolyzed lipid fractions.

Other babies are born very wrinkled. And some, especially premature babies, have a soft, furry appearance because of lanugo, a fine hair that develops while in the womb. Lanugo usually comes off after a week or two. The lanugo will rub off and disappear after a week or two if they were full-term; if your baby was premature, the lanugo will take longer to completely disappear.

Vernix benefits

Vernix caseosa is a cheese-like substance that coats the fetal skin from the middle of gestation ⁵⁾. Vernix caseosa protects the skin of a human fetus during the last trimester of pregnancy and of a newborn after the delivery. Vernix caseosa protects the fetus from the amniotic fluid, prevents the loss of water and electrolytes, and aids in postbirth adaptation of a newborn’s skin ⁶⁾. The main components of the vernix caseosa are water, sebum, desquamated epithelial cells, and shed lanugo hair. Chemically, it is a rich mixture of lipids and proteins. Even though it has been studied for many decades, the chemical constituents of vernix caseosa have not been comprehensively characterized yet. The enormous chemical complexity of vernix caseosa lipids has fascinated scientists, but they are still far from completely understanding the biological roles of individual lipid classes. Earlier studies of lipid composition focused on abundant neutral (nonpolar) species ⁷⁾, with significantly less attention being paid to polar lipids, mostly represented by ceramides ⁸⁾.

Virtually nothing is known about the chemical variability of vernix caseosa lipids depending on the gestational age and health conditions, the changes in the chemical composition during fetal development or the possible diagnostic value of vernix caseosa components. All this information is of importance for current neonatology and medicine in general. Sex-related aspects of the early skin development are not well understood either. Certain differences between vernix caseosa lipids of newborn boys and girls were reported in early eighties ⁹⁾ using analytical methodology available at that time and a limited number of samples. The data relied either on semi-quantitation of lipid classes separated by thin layer chromatography or lipid hydrolysis followed by analysis of fatty acid methyl esters. The structures of intact lipids involved in sex-related differences have not been disclosed. Recent advances in analytical instrumentation, namely in mass spectrometry, allow us to have a closer look at the chemistry of vernix caseosa and the human skin ontogeny from a different perspective.

Vernix caseosa purpose

Vernix caseosa, the waxy substance that coats the skin of newborn babies, has an extremely complex lipid composition and is produced during the third trimester of gestation ¹⁰⁾. In utero, vernix caseosa serves as a waterproofing film and modulator of transepidermal water flux ¹¹⁾, facilitates the final stages of the skin and gastrointestinal system development and protects the skin from some of the agents present in amniotic fluid ¹²⁾. After the birth, vernix caseosa acts as an antibacterial shield ¹³⁾ and helps the neonate to adapt to the dry environment ¹⁴⁾. Very low birth-weight preterm infants lack vernix caseosa and are susceptible to invasive infections because of insufficient formation of the stratum corneum (outer layer of the skin) ¹⁵⁾. The skin of prematurely born babies suffers from excessive water loss, resulting in dangerous dehydration and heat loss ¹⁶⁾. Vernix caseosa also shows a remarkable ability to enhance wound healing, which promises new therapies for patients with altered skin integrity after burn injuries or skin diseases. Because a therapeutic use of native vernix caseosa from mature newborns is impossible, clinically relevant artificial substitutes of vernix caseosa are yet to be developed ¹⁷⁾.

Baby soft spot on the skull

Baby soft spot on the skull is also called the fontanels (fontanelles), which are the open “soft spots” between the bones of the baby’s skull. If you run your fingers gently over your newborn’s head, you may feel a couple of soft spots instead of bone. These soft spots, where your baby’s skull bones haven’t fused together, are called fontanels (fontanelles). The fontanelles are a part of normal development. However, changes in the fontanelle can sometimes indicate a health issue.

Unlike adults, babies have skull bones that are not firmly joined together. The spaces between the skull bones are important as they allow the bones to move, and even overlap, when the baby passes through the birth canal. These spaces also allow room for the baby’s brain to grow.

You may notice one such space, or fontanelle, at the front on top of the head called the anterior fontanelle and another smaller fontanelle at the back of the head called the posterior fontanelle.

Over time, the fontanelles harden and close. The fontanelle at the back of your baby’s head usually closes by the time your baby is 2 months old. The fontanelle at the top usually closes sometime between the ages of 7 months and 18 months of age (normal range is 5 to 24 months of age).

Some parents may feel anxious about touching the fontanelles. However, there is no need to worry or to avoid touching the fontanelles, as they are protected by a tough membrane or layer of tissue. The front “soft spot” is diamond-shaped. It is covered by a thick fibrous layer. Touching this area is quite safe. The purpose of the soft spot is to allow rapid growth of the brain.

The back “soft spot” is smaller and triangular-shaped. It closes between 2 and 3 months. The soft spot normally looks flat or a little sunken. It may pulsate with each beat of the heart. This is normal. The only abnormal soft spot is one that is bulging (swollen).

Changes or abnormalities in the fontanelles may provide clues about your baby’s development and health. This is why it’s normal for your baby’s doctor or nurse to examine your baby’s fontanelles during check-ups. For instance, delayed fontanelle closure or an enlarged fontanelle can be associated with a range of medical conditions.

A sunken soft spot is not a sign of illness unless the baby is dehydrated. Then it would be very depressed and the baby would not act well.

Figure 1. Normal skull of newborn

Sunken fontanelle

When you touch the fontanelle, it should feel firm with a slight inward curve. Many parents will worry about the fontanelle being ‘sunken’ (drawn in) and that this is a sign of being dehydrated (does not have enough fluid in their body). However, while a sunken fontanelle can occur when your baby is severely dehydrated there are many other signs of dehydration that happen before a fontanelle becomes sunken, such as fewer wet nappies and being less alert and responsive, and usually dehydration occurs when the baby is not feeding well or losing fluid through vomiting or diarrhea. See your doctor right away if your baby has any of these signs of dehydration.

Bulging fontanelle

Your baby’s fontanelle may bulge or look raised when they cry but return to flat or slightly curved in when your baby is not crying and is in a head-up position. This is not a cause for concern.

A bulging fontanelle that does not return to normal may be a sign of a serious condition, such as an infection or swelling in the brain. See your doctor immediately, especially if your baby has a fever or is unusually sleepy.

Toddler bedtime

Many toddlers have settling and sleep problems. Common toddler sleep problems include having trouble settling to sleep and not wanting to stay in bed at bedtime. A consistent bedtime routine helps toddlers get ready for sleep.

Toddlers need about 12-13 hours of sleep every 24 hours. That’s usually 10-12 hours at night and 1-2 hours during the day. Once asleep, most toddlers sleep through most nights without waking mum or dad. But toddlers love to test their independence, so getting them to bed in the first place can be a challenge.

Young children also get overtired easily. When they do, they find it harder to get to sleep. Once you can spot your child’s signs of tiredness, you’ll be able to settle your child to sleep before grumpiness sets in. A firm and consistent bedtime routine will be a big help.

Sleep problems key points

• All children can sometimes have trouble getting to sleep and staying asleep.
• Some sleep problems are related to children’s bedtime routines and sleep environments. You can manage these sleep problems by promoting good sleep habits.
• Some sleep problems are caused by things like unhealthy eating habits and lack of physical activity. You can often sort out these problems by making some simple lifestyle changes.
• Some sleep behavior can look like a problem but is actually quite typical. This includes night terrors, nightmares and sleepwalking. It might also include bedwetting and toileting.
• And other sleep problems are caused by illnesses, health conditions or anxiety. You might need to talk with your doctor about these kinds of sleep problems.

Sleep medications aren’t usually the solution to children’s sleep problems – there are better ways to deal with these difficulties.

Talk with your child’s doctor if you’ve been trying good sleep habits and lifestyle changes, and they don’t seem to be helping. You might be referred to a pediatrician, psychologist or other health professional who is experienced in treating children’s persistent sleep problems.

Understanding sleep problems and sleep patterns is an important starting point for helping your child develop healthy habits and a positive attitude towards sleep.

Sleep problems often start to get better after the first week of getting into good sleep habits. If you don’t see any improvement, there might be medical or psychological reasons for your child’s sleep problems. It’s worth talking with your child’s doctor in this situation.

Toddler sleep schedule

A common daily sleep schedule for toddlers might look like this:

• 7 am: wake up
• 1 pm: nap of no more than 2 hours
• 3 pm: wake up
• 7 pm: bedtime.

If your toddler’s day nap is too long or too late in the day, they might not be ready for bed until late at night.

Some toddlers like to wake at 5.30 am or 6 am. There isn’t much you can do about this. Putting your toddler to bed later at night in the hope of later waking in the morning doesn’t tend to work. Your toddler might still wake up early then be grumpy from too little sleep.

If you live with an early riser, you might want to make your bedtime earlier too.

Night terrors

A night terror is when your child suddenly gets very upset while sleeping deeply. Night terrors can be scary for you, but they don’t hurt your child, and your child won’t remember them in the morning.

Lack of sleep can cause night terrors in some children. If you think your child isn’t getting enough sleep, a positive bedtime routine might help.

A night terror usually settles down in 10-15 minutes, but they can last longer than this.

Teeth-grinding

Many children grind their teeth at some stage. Children won’t usually be woken up by the sound of their own teeth-grinding – but other people in the room might be!

Bedtime routines for kids

A consistent bedtime routine helps prepare toddlers for sleep. Most toddlers are ready for bed between 6.30 pm and 7.30 pm. This is a good time, because they sleep deepest between 8 pm and midnight. It’s important to keep the routine consistent on weekends as well as during the week.

A bedtime routine might look something like this:

• 6.30 pm: brush teeth and change nappy
• 6.45 pm: quiet time (read a book or tell a story)
• 7 pm: into bed and kiss goodnight.

Before you turn out the light, it’s a good idea to do a quick check of your child’s room to make sure the sleeping environment is safe.

If your child takes a pacifier (dummy) to bed, you might consider encouraging your child to let go of the dummy.

Taking a bottle of milk to bed isn’t a good idea either, because it can cause tooth decay and lead to more problems with sleep. It’s better for your child to finish their milk at least 30 minutes before going to bed.

Calling out and getting up after bedtime

Your toddler might go through a stage of calling out or getting out of bed after you’ve said goodnight.

Try these tips:

• Avoid boisterous play before bedtime. This can make it harder for your child to settle.
• Turn off the TV, computers and tablets an hour before bedtime, and avoid letting your child watch scary or exciting things close to bedtime.
• Set up a consistent, calming bedtime routine.
• Before leaving your child’s bedroom, check that your child has everything they need. Remind your child to stay quietly in bed.

If your toddler shares a bedroom with a brother or sister, you might need to delay your other child’s bedtime by half an hour until your toddler is settled and asleep. If you’re firm and consistent, your toddler will quickly get the message that bedtime is for sleeping.

Check whether your child actually needs something when they call out. If your child has done a poo, change the nappy with the lights dim and no talking. If your child is scared of a monster under the bed, quickly check (with the light off) to confirm the room is free of monsters. If your child is scared of the dark, think about using a night-light.

Positive bedtime routines

A positive bedtime routine involves your child going through a few pleasurable activities about 20 minutes before bedtime. A good bedtime routine helps soothe and calm your child in the 20 minutes or so before bed so she’s ready for sleep. It also helps your child develop good sleep habits now and for the future.

A bedtime routine involves doing similar activities in a similar way each night. These activities can include having a bath, brushing teeth and reading.

If your child is settling to sleep later than you’d like, start the routine a bit earlier every few days, gradually moving towards your preferred time.

Without a good bedtime routine, it can be hard for a baby to settle to sleep.

If you’re working on getting your baby or young child to settle better at bedtime, a positive bedtime routine will help. Child health professionals will almost always recommend a positive bedtime routine if you’re using behavior strategies like controlled comforting or camping out.

What a positive bedtime routine looks like?

A bedtime routine can have quite a few activities. The key is that you do similar activities in roughly the same way each night, starting around 20 minutes before your child’s bedtime.

Most bedtime routines include pre-bed tasks like having a bath and brushing teeth, as well as quiet, enjoyable activities like reading a book or listening to a story. The aim is to keep the atmosphere calm and positive, using positive attention and praise.

Here’s an example of a bedtime routine that could start after dinner and a bath:

• Your child plays quietly for 15-20 minutes – this could include reading with you.
• You and your child go into the bedroom.
• You and your child have a brief cuddle and kiss.
• You put your child into bed.

At the end of the 20-minute ‘positive period’, say goodnight to your child. This is the time to be firm if your child resists. Be clear that it’s now time for sleep, then leave the room straight away.

Choosing a bedtime

You might have an ideal bedtime in mind somewhere between 7 pm and 8 pm often works for young children. But when you’re dealing with settling problems, it’s best to start with the bedtime that’s closest to when your child naturally falls asleep. This increases the chance that the bedtime routine will become strongly linked to sleep time for your child. For example, if you find that your child finally falls asleep around 9 pm, start with this as a temporary bedtime.

Moving your child’s actual bedtime towards your ideal bedtime

About a week after you introduce the positive bedtime routine, you can start gradually making your child’s bedtime earlier.

This involves making bedtime about 15 minutes earlier every couple of days. You do this until you reach the ideal bedtime for your child.

For example, your child has been falling asleep at 9 pm, but you want an 8 pm bedtime. Here’s what to do:

1. Start by putting your child to bed at 8.45 pm.
2. Do this for two nights.
3. Move bedtime back to 8.30 pm for the next two nights.
4. Continue this gradual ‘fading’ process until your child is going to bed at the time you want.

It can take a few weeks but a positive bedtime routine will improve settling problems, decrease the number of times your child calls out to you at night, and lead to better parent-child relationships.

Moving to a big bed

Most children move from a cot to a bed when they’re around 2-3½ years old. But there’s no hurry, particularly because some young toddlers might try to get out of a big bed more often.

You might need to move your child if your child has started climbing out of the cot or needs to use the potty at night, or if you need the cot for a new baby.

How to help toddler fighting at bedtime

A good night’s sleep is about getting to sleep and staying asleep. Most children wake up by themselves in the morning if they’re getting enough good-quality sleep. A routine that includes relaxing time before bed and regular bedtimes and wake times can help your child settle better.

Make sure your child has enough food at the right time, sunlight during the day, and no caffeine in the afternoon and evening.

When children don’t sleep well, parents are likely to experience poor sleep, high levels of stress and depression. So there are good reasons for working on your child’s sleep habits and sleep problems.

Getting to sleep

Most children fall asleep within 20 minutes of going to bed. How long it takes to get to sleep can depend on how sleepy your child’s body is, and also on her daytime and bedtime routine. Some bedtime routines help your child wind down before bedtime, so she can fall asleep more easily.

Help your child settle for sleep with a sleep environment that’s quiet and dimly lit.

Staying asleep

During the night, your child cycles between light sleep, deep sleep and dream sleep.

Your child has most of his deep sleep during the first few hours after falling asleep. During the second half of the night, his sleep consists of light sleep and dream sleep.

Your child wakes briefly as she cycles between light and dream sleep, but she might not be aware of being awake. To stay asleep, your child needs to be able to fall back to sleep by herself after these brief waking episodes.

Bedtime routine

Too much noise and activity before bed can get children overexcited and make it harder for them to settle down for sleep. You can work on this with a positive bedtime routine that includes up to an hour of quiet time for your child to wind down for sleep.

Sometimes changes to children’s normal bedtime routine can affect how well they settle down – for example, daylight saving, jet lag or a new bedroom. These sleep problems usually sort themselves out within a week or so, as your child’s sleep cycle adjusts to a new routine.

Sleep environment

Some sleep environments can make it harder for children to get to sleep. Check that your child’s sleep space is quiet, dimly lit and neither too hot nor too cold.

Eating habits

What and when your child eats and drinks can affect her ability to settle down at night.

Here are some ideas if you think your child’s eating habits during the day might be causing sleep problems:

• Make sure your child avoids caffeine – for example, in energy drinks, coffee, tea, chocolate and cola – especially in the late afternoon or evening.
• Plan the evening meal so that your child is satisfied but not too full when he goes to bed.

Physical activity

If your child isn’t doing enough physical activity during the day, she might not be feeling physically tired enough to settle down for sleep at night.

It’s a good idea to encourage your child to be more active during the day – for example, even a family walk before dinner can make a difference.

It’s great if your child can be active outside, because plenty of natural light during the day also helps with sleep.

Health guidelines recommend that children aged 5-18 years have at least 60 minutes of moderate to vigorous physical activity every day.

Night terrors, nightmares and sleepwalking

If your child sometimes wakes up screaming or crying, it could be a night terror or a nightmare. Some children might also sleepwalk. Although night terrors, nightmares and sleepwalking are all pretty normal, it’s best to talk to your child’s doctor if you’re worried or if your child’s behavior seems severe.

Bedwetting and toileting

If your child isn’t dry at night, he might wake because he’s wetting the bed. Or he might wake to go to the toilet and then find it hard to get back to sleep.

You can talk with your child’s doctor if toilet training and bedwetting are problems for your child.

Common childhood illnesses

Common childhood illnesses like colds or ear infections can sometimes make it hard for children to settle or sleep well. This is normal.

But if your child has been sick, you’ve probably been getting up in the night to soothe and settle her. Once she’s better, she might like to keep having all that extra night-time attention. If this sounds like your situation, you might need to be firm about getting back into your child’s normal bedtime routine.

Chronic health conditions

Chronic health conditions like asthma or epilepsy can also affect children’s sleep.

It’s a good idea to talk with your child’s doctor if your child has sleep problems and a chronic condition.

Some children snore. If your child snores all the time, even when he’s well, consider talking with your child’s doctor. Snoring can sometimes be a sign of sleep apnea.

Worries and anxiety

If your child is worried about something, she might find it hard to get to sleep, or get back to sleep if she wakes in the night.

You can deal with some worries straight away. For example, ‘Yes, you can have Isla over to play on the weekend even though Grandma is staying with us’.

For other worries it’s probably best to acknowledge your child’s feelings and gently plan to sort things out in the morning. For example, ‘I understand that you’re worried about doing a speech in front of the class next week. Let’s talk about it in the morning and work out what to do’.

Big problems like bullying can worry your child and affect his sleep over a longer period. If your child knows what you’re doing to work on the problem, it might help him sleep better. During the day, tell your child how you plan to help, and remind him again if he starts to worry at bedtime.

Anxiety can affect children’s sleep too. You might consider seeing your doctor or another health professional if your child’s anxiety seems unusually severe.

Getting help

Caring for your baby or toddler can be hard work when your baby or toddler isn’t settling or sleeping well and you’re not getting enough sleep either.

Problems with sleep can affect your child’s mood, schoolwork or relationships. You should seek help from your doctor if your child has sleep problems that go on for more than 2-4 weeks or that affect your child’s daily life.

To get help with baby or toddler sleep problems, you can talk to:

• your doctor
• pediatricians
• some child and family psychologists.

How professionals can help with baby sleep and toddler sleep.

First, the 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.

The 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. 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.

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

As you start putting these strategies into practice, it can help to keep the following points in mind:

• Be patient. It takes time to get used to new routines. Resist the temptation to give up or change things too early. Agree with the professional on how long you’ll try something before deciding that it isn’t working and trying something else. Do your best to stick to what you and the professional decided will work best for your baby, even if it seems hard.
• Don’t be surprised if your baby goes back to old habits for a short time. If you’re consistent with the new approaches you’ve learned, you’ll soon have your baby in a steady, settled routine.
• Keep any suggested strategies in writing. Reading them will remind you of what you need to do. When things aren’t working, you can double-check to see whether you’re following the strategies correctly.
• Try to organize back-up for when you start new strategies. Find out who you can contact for help or emotional support. Most early parenting centers, for example, provide a telephone number for follow-up concerns. They have staff who can answer your questions.
• Talk with your partner, if you have one, and make sure you agree on the plan. If you don’t agree, this can put more stress on your family. It also means that the plan is less likely to work.

Although medicine isn’t the best solution to sleep problems, it can help in some extreme cases.

Tips for children to sleep better

How to sleep better for children:

1. Set up a bedtime routine. A regular bedtime routine starting around the same time each night encourages good sleep patterns. A routine of bath, story and bed can help younger children feel ready for sleep. For older children, the routine might include a quiet chat with you about the day then some time alone relaxing before lights out.
2. Relax before bedtime. Encourage your child to relax before bedtime. Older children might like to wind down by reading a book, listening to gentle music or practising breathing for relaxation. If your child takes longer than 30 minutes to fall asleep, he might need a longer wind-down time before turning the lights out to go to sleep.
3. Keep regular sleep and wake times. Keep your child’s bedtimes and wake-up times within 1-2 hours of each other each day. This helps to keep your child’s body clock in a regular pattern. It’s a good idea for weekends and holidays, as well as school days.
4. Keep older children’s naps early and short. Most children stop napping at 3-5 years of age. If your child over five years is still napping during the day, try to keep the nap to no longer than 20 minutes and no later than early afternoon. Longer and later naps can make it harder for children to get to sleep at night.
5. Make sure your child feels safe at night. If your child feels scared about going to bed or being in the dark, you can praise and reward her whenever she’s brave. Avoiding scary TV shows, movies and computer games can help too. Some children with bedtime fears feel better when they have a night light.
6. Check noise and light in your child’s bedroom. A quiet, dimly lit space is important for good sleep. Check whether your child’s bedroom is too light or noisy for sleep. Blue light from televisions, computer screens, phones and tablets might suppress melatonin levels and delay sleepiness. It probably helps to turn these off at least one hour before bedtime and to keep screens out of your child’s room at night.
7. Avoid the clock. If your child is checking the time often, encourage him to move his clock or watch to a spot where he can’t see it.
8. Eat the right amount at the right time. Make sure your child has a satisfying evening meal at a reasonable time. Feeling hungry or too full before bed can make your child more alert or uncomfortable. This can make it harder for her to get to sleep. In the morning, a healthy breakfast helps to kick-start your child’s body clock at the right time.
9. Get plenty of natural light in the day. Encourage your child to get as much natural light as possible during the day, especially in the morning. Bright light suppresses melatonin. This helps your child feel awake and alert during the day and sleepy towards bedtime.
10. Avoid caffeine. Caffeine is in energy drinks, coffee, tea, chocolate and cola. Encourage your child to avoid these things in the late afternoon and evening, and don’t offer them to him at this time.

It’s always a good idea to praise your child when you notice she’s trying to make changes to sleep patterns or is trying out a new routine.

When worries affect your child’s sleep

If your child has worries and anxieties that stop him from relaxing at bedtime, there are a couple of things you can do.

If there’s a quick and easy answer to your child’s problem, you can deal with it straight away. For example, ‘Yes, you can have Emma over to play on the weekend even though Grandma is staying with us’.

But if the problem needs more time, it’s probably best to acknowledge your child’s feelings and gently plan to sort things out in the morning. For example, ‘I understand that you’re worried about whether you can swim 50 m at the swimming carnival next week. Let’s talk about it in the morning and work out what to do’.

Omphalitis

Omphalitis is an bacterial infection of the umbilical cord stump, the umbilicus and/or surrounding tissues, occurring primarily in the neonatal period ¹⁾. Omphalitis typically presents as a superficial cellulitis that can spread to involve the entire abdominal wall and may progress to necrotizing fasciitis, myonecrosis, or systemic disease ²⁾. Omphalitis is a true medical emergency that can rapidly progress to systemic infection and death, with an estimated mortality rate between 7% and 15% ³⁾. Early recognition and treatment are essential to prevent the morbidity and mortality associated with omphalitis.

The umbilical cord is the lifeline between the baby and mother during pregnancy and is cut after birth. The umbilical cord stump then gradually dries and typically falls off within 5 to 15 days. Both skin and enteric bacteria may colonize the devitalized tissue of the stump and lead to infection. Omphalitis is, therefore, a polymicrobial infection and the most common pathogens are Staphylococcus aureus, Streptococcus pyogenes, and gram-negative bacteria such as Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis ⁴⁾. If maternal infection with chorioamnionitis is suspected, anaerobic bacteria such as Bacteroides fragilis, Clostridium perfringens, and Clostridium tetani can also contribute to infection ⁵⁾.

Omphalitis is uncommon outside of the neonatal period. Symptoms typically begin at an average age of 3 days. Omphalitis is a rare disease in developed countries, with an incidence of 0.7%. However, in developing countries, the incidence of neonates delivered at hospitals can approach 8%, and if born at home, the incidence can be as high as 22% ⁶⁾. Risk factors for the development of omphalitis include the following: low birth weight, prolonged rupture of membranes, maternal infection, umbilical catheterization, nonsterile delivery, maternal infection, prolonged labor, home birth, and improper cord care. Cultural application of cow dung is also associated with higher rates of omphalitis. In addition, immune system abnormalities such as defects in leukocyte adhesion, neutrophil or natural killer lymphocyte function, and interferon production have been associated with an increased risk of omphalitis ⁷⁾.

Omphalitis in newborn staging

Staging of neonatal omphalitis is as follows ⁸⁾:

• Grade 1: Funisitis with purulent umbilical discharge that may be malodorous
• Grade 2: Funisitis with purulent umbilical discharge that may be malodorous with periumbilical abdominal wall cellulitis
• Grade 3: Funisitis with purulent umbilical discharge that may be malodorous, the presence of periumbilical abdominal wall cellulitis, and systemic involvement, including sepsis, shock, disseminated intravascular coagulation, multiple organ dysfunction
• Grade 4: Funisitis with purulent umbilical discharge that may be malodorous; the presence of periumbilical abdominal wall cellulitis, ecchymosis, crepitus, bullae; with evidence of involvement of superficial and deep fascia and associated muscle; and with systemic involvement, including sepsis, shock, disseminated intravascular coagulation, multiple organ dysfunction

Omphalitis causes

Immediately after birth, the umbilicus becomes colonized with many different types of bacteria. Gram-positive cocci are present within hours, followed shortly by the presence of many enteric microorganisms. The devitalized tissues of the umbilical stump promote rapid growth of these bacteria, and the thrombosed blood vessels allow entry into the bloodstream, potentially leading to systemic infection.

Associated risk factors for omphalitis of newborn include the following:

• Low birth weight (< 2500 g)
• Prior umbilical catheterization
• Septic delivery (as suggested by premature rupture of membranes, nonsterile delivery, or maternal infection)
• Prolonged rupture of membranes

Omphalitis occasionally manifests from an underlying immunologic disorder. Leukocyte adhesion deficiency is most prominent among the immunodeficiency syndromes ⁹⁾. Numerous infants with acute or chronic omphalitis have been diagnosed with leukocyte adhesion deficiency, a rare immunologic disorder with an autosomal recessive pattern of inheritance. These infants typically present with the following:

• Leukocytosis
• Delayed separation of the umbilical cord, with or without omphalitis
• Recurrent infections

Omphalitis may also be the initial manifestation of neutrophil disorders in the neonate, including neonatal alloimmune neutropenia and congenital neutropenia ¹⁰⁾. Affected infants may present with other cutaneous infections, pneumonia, sepsis, and meningitis.

Neonatal alloimmune neutropenia is a disease analogous to Rh-hemolytic disease and results from maternal sensitization to fetal neutrophils bearing antigens that differ from the mother’s ¹¹⁾. Maternal immunoglobulin G antibodies cross the placenta and result in an immune-mediated neutropenia that can be severe and last for several weeks to 6 months ¹²⁾.

The congenital neutropenias are a disease group of heterogeneous disorders that range from intermittent to persistent manifestations of varying severity ¹³⁾.

Because omphalitis complicated by sepsis can also be associated with neutropenia, the underlying immune-mediated neutrophil destruction may not be immediately appreciated in affected newborns.

Rarely, an anatomic abnormality such as a patent urachus, a patent omphalomesenteric duct, or a urachal cyst may be present ¹⁴⁾.

Omphalitis prevention

Prevention of omphalitis requires both aseptic techniques during delivery services and proper cord care. The umbilical cord should be cut with a sterile blade or scissors. In the hospital setting where aseptic care is routine, and the risk of omphalitis is low, dry cord care is recommended. In developing countries with a higher risk of omphalitis, chlorhexidine as a topical agent has been shown to reduce the risk of omphalitis inexpensively. In a meta-analysis of studies conducted in community settings of developing countries, the use of chlorhexidine reduced all-cause mortality and the risk of omphalitis when compared to dry cord care ¹⁵⁾. Inappropriate cord care has also been shown to increase the risk of umbilical infection. Cultural application of cow dung or bentonite clay to the umbilical stump has resulted in neonatal tetanus ¹⁶⁾.

Omphalitis symptoms

Omphalitis is primarily a disease of the neonate and is characterized by tenderness, erythema, and induration of the umbilicus and surrounding tissues. Early on, patients may only have superficial cellulitis but, if untreated, this can progress to involve the entire abdominal wall. Patients may also have purulent drainage or be bleeding from the umbilical cord stump. Foul-smelling drainage should raise the suspicion of anaerobic infection. Systemic symptoms such as lethargy, poor feeding, fever, and irritability suggest sepsis and portend a worse prognosis. If there is a rapid progression of abdominal wall erythema or gas in the surrounding tissues, necrotizing fasciitis should be considered, and acute surgical consultation is needed ¹⁷⁾.

Local disease

Physical signs of omphalitis vary with the extent of the disease. Signs of localized infection include the following:

• Purulent or malodorous discharge from the umbilical stump
• Periumbilical erythema (Recently, algorithms that attempt to standardize the clinical diagnosis of omphalitis have been developed, emphasizing extent of periumbilical erythema and absence or presence of pus.)
• Edema
• Tenderness

Extensive local disease with extension

The following signs indicate more extensive local disease, such as necrotizing fasciitis or myonecrosis, which are typically found in a periumbilical location but may spread across the abdominal wall, onto the flanks and back, and into the scrotum. These signs may also suggest infection by both aerobic and anaerobic organisms and include the following:

• Ecchymoses, violaceous discoloration
• Bullae
• Peau d’orange appearance
• Crepitus
• Petechiae
• Progression of cellulitis despite antimicrobial therapy

Systemic disease

Signs of sepsis or other systemic disease are nonspecific and include disturbances of thermoregulation or evidence of dysfunction of multiple organ systems. Examples include the following:

• Disturbances of thermoregulation: Fever (temperature > 100.4 °F [>38°C]), hypothermia (temperature < 96.8 °F [< 36°C]), or temperature instability
• Cardiovascular disturbances: Tachycardia (pulse >180 beats per minute [bpm]), hypotension (systolic blood pressure < 60 mm Hg in full-term infants), or delayed capillary refill (< 2-3 seconds)
• Respiratory disturbances: Apnea, tachypnea (respirations >60/min), grunting, flaring of the alae nasi, intercostal or subcostal retractions, or hypoxemia
• Gastrointestinal tract disturbances: Rigid or distended abdomen or absent bowel sounds
• Cutaneous abnormalities: Jaundice, petechiae, or cyanosis
• Neurologic abnormalities: Irritability, lethargy, weak sucking, hypotonia, or hypertonia.

Omphalitis complications

Early recognition and treatment of omphalitis are essential to prevent the serious complications of omphalitis. Sepsis is the most common complication and can progress to septic shock and death. Other rare complications include peritonitis, intestinal gangrene, small bowel evisceration, liver abscess, septic umbilical arteritis, and portal vein thrombosis. Although uncommon, necrotizing fasciitis can occur and should be suspected if there is a rapid progression of infection and signs of systemic toxicity. It should also be suspected if there is no clinical improvement with intravenous antibiotics in 24 to 48 hours. Mortality rates as high as 60% to 85% have been reported in patients with omphalitis complicated by necrotizing fasciitis ¹⁸⁾. If suspected, in addition to broad-spectrum antibiotics, prompt surgical consultation for debridement of the umbilical structures and the involved abdominal wall is essential.

Omphalitis diagnosis

Laboratory evaluation with complete blood count and culture should be obtained for all patients with suspected omphalitis. In addition, cultures of any purulent material from the umbilical stump should be sent prior to initiation of antibiotics if possible. If the patient has systemic symptoms, a full neonatal septic workup including chest radiograph, urinalysis, urine culture, and cerebrospinal fluid culture should be obtained.

Omphalitis treatment

Broad spectrum parenteral antibiotics are required to treat omphalitis. Antibiotic coverage should be directed against both gram-positive and gram-negative organisms. Initial empiric treatment with antistaphylococcal penicillin and aminoglycoside is recommended. If there is a high prevalence of methicillin-resistant Staphylococcus aureus, vancomycin should be administered while awaiting culture results. If there is suspicion for maternal chorioamnionitis or the patient has foul-smelling discharge from the stump, clindamycin or metronidazole is indicated to cover for anaerobes ¹⁹⁾. The duration of antibiotic therapy depends on the patient’s clinical response and any complications that may develop during hospital admission. For uncomplicated cases of omphalitis, the recommended course of parenteral therapy is ten days, followed by a switch to oral therapy depending on culture results.

Omphalitis prognosis

The prognosis for infants with omphalitis varies.

Outcome is usually favorable in infants with uncomplicated omphalitis associated with cellulitis of the anterior abdominal wall. In a study by Sawin and colleagues, no deaths occurred among 32 infants with omphalitis in the absence of necrotizing fasciitis and myonecrosis ²⁰⁾. The mortality rate among all infants with omphalitis, including those who develop complications, is estimated at 7%-15%. The mortality rate is significantly higher (38%-87%) after the development of necrotizing fasciitis or myonecrosis. Suggested risk factors for poor prognosis include male sex, prematurity or being small for gestational age, and septic delivery (including unplanned home delivery); however, data are limited and conclusions cannot be drawn regarding the role of these factors in the mortality rate.

Kids sore throat

Sore throat also called pharyngitis, is common at any age and can be caused by many things, from viral infections (most often, the common cold or flu), or mononucleosis (mono) to seasonal allergies and gastroesophageal reflux (GER). Sore throats can also be caused by a strep throat infection (bacterial infection), although this is rare in children younger than 2 years old.

Sore throat signs and symptoms:

• painful throat
• fever
• swollen glands in the neck
• bad breath
• scratchiness in the throat
• redness in the back of the mouth

As with most common illnesses, preventing a sore throat or tonsillitis starts with regular hand washing. Kids also can avoid sore throats by:

• not sharing food utensils and glasses with others and wash them in hot, soapy water or a dishwasher after each use.
• don’t share food, drinks, napkins, or towels
• avoiding contact with people who have sore throats or cold symptoms
• sneeze or cough into a shirtsleeve, not your hands.

Here are some ways kids can relieve sore throat pain:

• sip warm liquids
• drink plenty of water
• eat cool or soft foods
• eat cold or frozen liquids (such as ice pops) – but do not give young children anything small and hard to suck because of the risk of choking
• gargle with saltwater
• suck on hard candy or throat lozenges (for kids age 4 or older)
• take ibuprofen or acetaminophen (paracetamol) as needed
• rest

Sore throat causes

Viruses are the most common cause of sore throat in all age groups. Experts estimate that group A strep, the most common bacterial cause, causes 20% to 30% of sore throat episodes in children. In comparison, experts estimate it causes approximately 5% to 15% of sore throat infections in adults.

Many sore throats are due to:

• Strep throat, which is a contagious bacterial infection of the throat and tonsils (the fleshy clusters of tissue on both sides of the back of the throat). It also can cause headache and fever.
• Tonsillitis, which is usually not serious but can lead to complications, like breathing or swallowing trouble. Most cases are caused by either a virus (such as a common cold virus or Epstein Barr virus, the virus that causes mono) or strep bacteria.

Conditions that can cause a sore throat:

• Laryngitis
• Tonsillitis
• Strep throat (a bacterial throat infection)
• Glandular fever

What is Strep throat?

Strep throat is an infection caused by a type of bacteria (Streptococcus pyogenes also called group A Streptococcus or group A strep). Strep bacteria cause almost a third of all sore throats. However, not all sore throats are strep throats. Often, kids have a sore throat because of a virus , which will usually clear up without medical treatment.

Strep throat usually needs treatment with antibiotics. With the proper medical care — and plenty of rest and fluids — most kids get back to school and play within a few days.

Strep throat signs and symptoms

Symptoms of strep throat include:

• sore throat
• fever
• red and swollen tonsils
• painful or swollen neck glands

Kids who do have strep throat might get other symptoms within about 3 days, such as:

• red and white patches in the throat
• trouble swallowing
• a headache
• lower stomach pain
• general discomfort, uneasiness, or ill feeling
• loss of appetite
• nausea
• rash

Is strep throat contagious?

Strep throat is very contagious. Anybody can get it, but most cases are in school-age kids and teens. Infections are common during the school year when big groups of kids and teens are in close quarters.

To prevent spreading strep throat to others in your home:

• Keep your child’s eating utensils, dishes, and drinking glasses separate and wash them in hot, soapy water after each use.
• Make sure your child doesn’t share food, drinks, napkins, handkerchiefs, or towels with other family members.
• Teach your child to cover all sneezes or coughs. If a tissue isn’t handy, kids should sneeze or cough into a shirtsleeve, not their hands.
• Remind everyone to wash their hands well and often.
• Give your child a new toothbrush after the antibiotic treatment starts and he or she is no longer contagious.

How do people get strep throat?

The group A strep bacteria (Streptococcus pyogenes) that cause strep throat tend to hang out in the nose and throat and spread through direct person-to-person transmission. So normal activities like sneezing, coughing, or shaking hands can easily spread an infection from one person to another. Typically transmission occurs through saliva or nasal secretions from an infected person.

Kids with untreated strep throat are more likely to spread the infection when their symptoms are most severe, but can still infect others for up to 3 weeks. People with group A strep pharyngitis are much more likely to transmit the bacteria to others than asymptomatic pharyngeal carriers. Crowded conditions — such as those in schools, daycare centers, or military training facilities — facilitate transmission. Although rare, spread of group A strep infections may also occur via food. Foodborne outbreaks of pharyngitis have occurred due to improper food handling. Fomites, such as household items like plates or toys, are very unlikely to spread these bacteria.

Humans are the primary reservoir for group A strep. There is no evidence to indicate that pets can transmit the bacteria to humans.

That’s why it’s so important to teach kids the importance of hand washing. Good hygiene can lessen their chances of getting contagious diseases like strep throat.

Risk factors for strep throat

Group A strep pharyngitis can occur in people of all ages. It is most common among children 5 through 15 years of age. It is rare in children younger than 3 years of age.

The most common risk factor is close contact with another person with group A strep pharyngitis. Adults at increased risk for group A strep pharyngitis include:

• Parents of school-aged children
• Adults who are often in contact with children

Crowding, such as found in schools, military barracks, and daycare centers, increases the risk of disease spread.

Strep throat complications

Rarely, suppurative and nonsuppurative complications can occur after group A strep sore throat. Suppurative complications result from the spread of group A strep from the pharynx to adjacent structures. They can include:

• Peritonsillar abscess
• Retropharyngeal abscess
• Cervical lymphadenitis
• Mastoiditis

Other focal infections or sepsis are even less common.

Acute rheumatic fever is a nonsuppurative sequelae of group A strep sore throat. Post-streptococcal glomerulonephritis is a nonsuppurative complication of group A strep sore throat or skin infections. These complications occur after the original infection resolves and involve sites distant to the initial group A strep infection site. They are thought to be the result of the immune response and not of direct group A strep infection.

How is Strep throat diagnosed?

If your child has a sore throat and other strep throat symptoms, see your doctor. Your doctor will use either a rapid antigen detection test (RADT) or throat culture to confirm group A strep pharyngitis. Throat culture is the gold standard diagnostic test. Your doctor will likely do a rapid strep test in the office, using a cotton swab to take a sample of the fluids at the back of the throat. The test only takes about 5 minutes.

If it’s positive, your child has strep throat. If it’s negative, the doctor will send a sample to a lab for a throat culture. The results are usually available within a few days.

Your doctor should confirm group A strep pharyngitis in children older than 3 years of age to appropriately guide treatment decisions. Giving antibiotics to children with confirmed group A strep pharyngitis can reduce their risk of developing complication such as acute rheumatic fever. Testing for group A strep pharyngitis is not routinely indicated for:

• Children younger than 3 years of age
• Adults

Acute rheumatic fever is very rare in those age groups.

Your doctor can use a positive rapid strep test as confirmation of group A strep pharyngitis in children. However, clinicians should follow up a negative RADT in a child with symptoms of sore throat with a throat culture. Clinicians should have a mechanism to contact the family and initiate antibiotics if the back-up throat culture is positive.

How is Strep throat treated?

Doctors usually prescribe about 10 days of antibiotic medicine to treat strep throat. Within about 24 hours after starting on antibiotics, your child probably won’t have a fever and won’t be contagious. By the second or third day, other symptoms should start to go away.

Penicillin or amoxicillin is the antibiotic of choice to treat group A strep sore throat. There has never been a report of a clinical isolate of group A strep that is resistant to penicillin. However, resistance to azithromycin and clarithromycin is common in some communities. For patients with a penicillin allergy, recommended regimens include narrow-spectrum cephalosporins (cephalexin, cefadroxil), clindamycin, azithromycin, and clarithromycin.

Even when kids feel better, they should take the antibiotics as prescribed. This is the best way to kill the harmful bacteria. Otherwise, bacteria can remain in the throat and symptoms can return. Completing all the antibiotics also prevents other health problems that a strep infection can cause, such as rheumatic fever (which can cause heart damage), scarlet fever, blood infections, or kidney disease.

When left untreated, the symptoms of group A strep sore throat are usually self-limited. However, acute rheumatic fever and suppurative complications (e.g., peritonsillar abscess, mastoiditis) are more likely to occur after an untreated infection. Patients, regardless of age, who have a positive rapid strep test or throat culture need antibiotics. Clinicians should not treat viral sore throat with antibiotics.

Table 1. Antibiotic regimens recommended for Group A Streptococcal pharyngitis

Drug, Route	Dose or Dosage	Duration or Quantity
For individuals without penicillin allergy
Penicillin V, oral	Children: 250 mg twice daily or 3 times daily; adolescents and adults: 250 mg 4 times daily or 500 mg twice daily	10 days
Amoxicillin, oral	50 mg/kg once daily (max = 1000 mg); alternate: 25 mg/kg (max = 500 mg) twice daily	10 days
Benzathine penicillin G, intramuscular	<27 kg: 600 000 U; ≥27 kg: 1 200 000 U	1 dose
For individuals with penicillin allergy
Cephalexin,a oral	20 mg/kg/dose twice daily (max = 500 mg/dose)	10 days
Cefadroxil,a oral	30 mg/kg once daily (max = 1 g)	10 days
Clindamycin, oral	7 mg/kg/dose 3 times daily (max = 300 mg/dose)	10 days
Azithromycin,b oral	12 mg/kg once (max = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days	5 days
Clarithromycinb, oral	7.5 mg/kg/dose twice daily (max = 250 mg/dose)	10 days

Footnotes:

^a Avoid in individuals with immediate type hypersensitivity to penicillin.
^b Resistance of group A strep to these agents is well-known and varies geographically and temporally.

Abbreviation: Max, maximum.

[Source ¹⁾ ]

How can I help my child feel better?

Home care can help your child feel better while battling strep throat. Give plenty of liquids to prevent dehydration, such as water or ginger ale, especially if he or she has had a fever. Avoid orange juice, grapefruit juice, lemonade, or other acidic beverages, which can irritate a sore throat. Warm liquids like soups, sweetened tea, or hot chocolate can be soothing.

Talk to your doctor about when your child can return to normal activities. Most kids can go back to school when they’ve taken antibiotics for at least 24 hours and no longer have a fever.

Sore throat remedies for kids

Treatment for a sore throat will depend on what’s causing it. Treating an underlying condition (like gastroesophageal reflux or allergies) can bring relief, as can home care (like gargling with saltwater, running a cool mist humidifier at night, and avoiding irritants like smoke).

Strep throat requires medical treatment with antibiotics, which will improve symptoms quickly. Untreated strep throat can lead to complications like rheumatic fever (which can cause permanent heart damage), a peritonsillar abscess, scarlet fever, or kidney disease.

Treatment for tonsillitis depends on whether it is caused by a virus or by bacteria. Doctors usually will test for strep bacteria with a rapid strep test or a throat culture. Tonsillitis caused by a virus will go away on its own. If it’s caused by strep bacteria, the doctor probably will prescribe an antibiotic. If so, it’s important to take all of the antibiotic for as long as prescribed to help prevent complications.

People with tonsillitis or strep throat can return to activities 24 hours after beginning antibiotic treatment if there’s no fever and they’re feeling better. If someone is still feeling weak, tired, or achy, staying home for another day or two is recommended.

What are Epstein pearls

Epstein pearls are small, firm, white, keratin-filled cysts located on the mid-palatal raphe at the junction of the hard and soft palates ¹⁾. Some authors use the terms Epstein pearls, Bohn nodules, and dental lamina cysts interchangeably. However, Epstein pearls have been labeled as epithelial debris of the tooth follicle, gingival glands of Serres, and as abortive enamel organs on the Palatine area. On the other hand, Bohn’s nodules are those found along the buccal and lingual aspects of the dental ridges.

Epstein pearls are observed in nearly 60% to 85% of newborn infants. Among the different racial groups, Japanese newborns are most commonly affected (up to 92%), followed by Caucasians and African-Americans ²⁾. No gender predilection has been observed through the years ³⁾.

In one study, Epstein pearls were more common in infants born to multigravida mothers, also with those with higher birth weight. One study done in Turkey found that Epstein’s pearls were less frequent in post-term babies in comparison with pre-term and term ones. A greater rate seen in term babies was reported. ⁴⁾.

Epstein pearls are a clinical diagnosis. No laboratory or imagining is needed.

Epstein pearls are small, opaque whitish-yellow lesions adjacent to the mid palatine raphe with no mucous glands in it. Epstein pearls are firm in consistency, size range from less than a millimeter to several millimeters in diameter. Size does not progress over time. Epstein pearls can be palpated during sucking by the examiner.

• Epstein pearls can be seen in cluster groups of 2 to 6 cysts, although they can present as an isolated lesion. Their distribution varied from mouth to mouth, barely being identical even in twins.
• Occasionally these cysts show communication with the mucosal surface.
• Cleft children appear to have cysts in the identical distribution pattern as non-cleft children except for those with a cleft palate which are located at the margins of the palatal shelves instead of the midline.
• Parents of newborn infants sometimes worriedly visit a dental surgeon or pediatrician, complaining of the presence of these abnormal structures in the mouth of their infants.
• The clinician should explain that Epstein pearls are benign and asymptomatic, with no interference with feedings or tooth eruption.
• Epstein pearls resemble the equivalent of milia (white papules produced by retention of sebum and keratin in the hair follicles), which are frequently seen on the faces of neonates.

Figure 1. Epstein pearls on hard palate

What causes Epstein pearls?

Near the end of the 8 weeks in utero, the palate begins its development. Each maxillary process generates a lateral palatine process within the mouth. These processes are horizontal and shelf like, growing from the lateral aspect of the mouth toward the midline and downward. Between the 10 to the 11 weeks in utero, the lateral palatine processes meet and fuse with each side and with the much smaller premaxillary process and the nasal septum; palatal fusions normally are completed by the end of the 4 months of gestation.

In this stage, there is a theory that states that epithelium entrapped between the palatal shelves and the nasal process formed cysts called Epstein pearls. Another theory expressed that these cysts may come from epithelial remnants that have arisen from the formation of the minor salivary glands of the palate.

Epstein pearls treatment

No treatment or removal is required ⁵⁾. Most of these cysts involute or spontaneously rupture eliminating their keratin contents into the oral cavity within the first few weeks to months of postnatal life. Epstein pearls are hardly ever seen after three months of age. However, it has been suggested that part of the cystic epithelium may remain inactive even in the adult gingiva.

Epstein pearls differential diagnosis

After a lesion is found in the oral cavity, it is important to formulate a differential diagnosis since this will help lead any additional evaluation of the condition and managing the patient.

Some of the differential diagnosis for Epstein pearls include:

• Bohn nodules which are mucous gland cysts, frequently located on the buccal or lingual aspects of the alveolar ridges and rarely on the palate. Histologically consist of mucous glands and ducts. They are numerous, grayish white and firm in consistency.
• Dental lamina cyst (gingival cyst of newborn) are remnants of dental lamina epithelium found on the crest of the alveolar mucosa. Dental lamina cyst is a benign oral mucosal lesion of transient nature. Dental lamina cysts (gingival cysts) are yellow-white cystic lesion over the alveolar crest that arises from epithelial remnants of the degenerating dental lamina. Dental lamina cysts (gingival cysts) may be greater in size, more transparent, solitary lesion and fluctuant. Dental lamina cysts (gingival cysts) are usually multiple but do not increase in size. Since the lesions are self-limiting and spontaneously shed a few weeks or months after birth no treatment is required. Clinical diagnoses of these conditions are important in order to avoid unnecessary therapeutic procedure and provide suitable information to parents about the nature of the lesion. In addition, it may be incorrectly diagnosed as natal teeth if present in mandibular anterior region.
• Natal and Neonatal teeth are rare and usually located in the lower incisors region. Humans are usually born edentulous (without teeth), but tooth eruption may occur before birth (natal teeth) or within the first month of life (neonatal teeth) at a rate of 1:2,000 to 1:3,000 live births (Figure 4) ⁶⁾. Central mandibular incisors are most likely to prematurely erupt; these are usually primary dentition and not extra teeth ⁷⁾, so they should not be extracted without cause. Management is usually observation, although extraction may be considered if teeth are mobile and present an aspiration risk, interfere with breastfeeding or cause Riga-Fede ulceration ⁸⁾. Natal teeth are most commonly an isolated finding but can be associated with genetic syndromes of chondroectodermal dysplasia (Ellis-van Creveld syndrome), oculomandibulofacial syndrome (Hallermann-Streiff syndrome) ⁹⁾ and recognized syndromes including Rubinstein-Taybi, Hallerman-Streiff, Ellis-van Creveld, Pierre-Robin, pachyonychia congenita, short rib-polydactyly type 2, steatocystoma multiplex, cyclopia, Pallister-Hall, and many others ¹⁰⁾. Therefore if the patient has any other dysmorphic features, genetic evaluation is indicated.
• Congenital epulis is pedunculated, soft nodule from 1 mm to several cms in diameter located on gingival margin.
  A congenital ranula is a translucent, firm papule or nodule found on the anterior floor of mouth, lateral to lingual frenulum.
• Alveolar lymphangioma is bluish fluid-filled lesions on the alveolar ridges. No seen in the palate. Predominant in black neonates. These lesions can be isolated or multiples.

Bohn nodules

Bohn’s nodules are keratin cysts derived from remnants of odontogenic epithelium over the dental lamina or may be remnants of minor salivary glands. They occur on the alveolar ridge, more commonly on the maxillary than mandibular.

Bohn’s nodules usually rupture spontaneously and disappear within a few weeks to a few months. Counseling of the family members regarding its benign and self-limiting nature is all that is required in the management.

Figure 2. Bohn’s nodules

Footnote: A full term newborn boy, weighing 3 kg, born out of an uncomplicated pregnancy, was brought to us for evaluation of a few small, white and round bumps on the gingival surface. Examination of the oral cavity showed multiple, firm, pearly-white papules measuring 2 to 4 mm in diameter, grouped over the vestibular aspect of the alveolar ridge of the maxillary arch (Figure 2). Two similar lesions were seen on the mandibular area. These lesions were asymptomatic, non-tender, and fixed to the mucosa. Oral mucosa was otherwise normal. A few milia were noted on his chin. Detailed systemic examination was normal. No specific therapy was prescribed. Within a couple of months, most of the lesions subsided spontaneously. Based on the clinical features and the natural course of the disease, a diagnosis of Bohn’s nodule was made.

[Source ¹¹⁾ ]

Figure 3. Dental lamina cyst (gingival cyst)

Footnote: A 14-day-old male newborn infant presented with nodular papules in the deciduous lower central incisor region. No treatment of any kind was
done, except for parental counseling and reassurance. It is important to note that management of all oral inclusion cysts (dental lamina cysts, Epstein pearls and Bohn’s nodules) remains the same, as all these have a self-limiting nature and require no treatment.

[Source ¹²⁾ ]

Figure 4. Natal tooth

[Source ¹³⁾ ]

Dehydration in kids

Dehydration might happen if your child has lots of diarrhea and vomiting, doesn’t drink enough liquids, exercises a lot or sweats a lot. You should see your doctor if you’re concerned your child is dehydrated. Dehydration can be treated by increasing your child’s fluids. In severe cases, your child might need to go to hospital to get more fluids.

Dehydration can happen slowly or quickly, depending on how the fluid is lost and the age of the child. Younger children and babies are more likely to become dehydrated. This is because their bodies are smaller and they have smaller fluid reserves. Older children and teens can more easily handle minor fluid imbalances.​

Gastroenteritis is the most common cause of dehydration. This is because it can make your child lose a lot of body fluids quickly. Any illness with persistent diarrhea, vomiting or reduced fluid intake can result in dehydration.

Lots of sweating can also result in dehydration, particularly in babies in very hot weather, or in adolescent children who are doing vigorous activity.

It’s important to know the early signs of dehydration and to respond quickly if your child has them. The goal in treating dehydration is to replace fluids and restore body fluids to normal levels.

Kids who are mildly dehydrated from lots of activity will probably be thirsty and should drink as much as they want. Plain water is the best option. They should rest in a cool, shaded spot until the lost fluid has been replaced.

Rehydration

Kids with mild to moderate dehydration due to diarrhea from an illness (like gastroenteritis) should have their lost fluids replaced. This is known as rehydration. It’s done by giving a special liquid called an oral rehydration solution (ORS, a solution that restores lost fluids and minerals) over the course of 3 to 4 hours. Minerals in the body, such as sodium, potassium and chloride, help to keep a healthy fluid balance.

ORS (oral rehydration solution) is available in many grocery stores and drugstores without a prescription. It has the right combination of sugar and salts that dehydrated kids need.

Start the rehydration process by giving your child 1 or 2 teaspoons (5 or 10 milliliters) of an ORS every few minutes. You can use a spoon or an oral syringe. This may not seem like enough fluids to rehydrate your child, but these small amounts can add up to more than a cup (237 milliliters) an hour. If your child does well, you can gradually give bigger sips a little less often.

Even kids who are vomiting can usually be rehydrated this way because the small frequent sips get absorbed in between the vomiting episodes.

A breastfed infant should continue to be nursed, even during rehydration, unless vomiting repeatedly. Give the ORS in between feedings. Stop giving formula to a formula-fed baby during rehydration, and restart as soon as your baby can keep fluids down and isn’t showing signs of dehydration.

Do not give a dehydrated child water, soda, ginger ale, tea, fruit juice, gelatin desserts, or chicken broth. These don’t have the right mix of sugar and salts and can make diarrhea worse. Older kids who are dehydrated can have sports drinks, but oral rehydration solution is best for young children and infants.

When your child is rehydrated, you can serve a normal diet, including breast milk, formula, or milk.

Some dehydrated kids do not improve when given an ORS, especially if they have explosive diarrhea (very frequent BMs that are forceful and very loud) or are vomiting often. When fluid losses can’t be replaced for these or other reasons, a child might need to get intravenous (IV) fluids in the hospital.

If you’re treating your child for dehydration at home and feel that there’s no improvement or that the dehydration is getting worse, call your doctor right away or take your child to the nearest emergency room (ER).

Dehydration in kids key points:

• Babies and younger children are at greater risk of dehydration.
• Early, appropriate treatment can prevent dehydration.
• Children with mild dehydration can be managed at home.
• Children with moderate to severe dehydration should be seen by a doctor.

Causes of dehydration in kids

Dehydration happens when more fluid leaves the body than enters it. This can happen when a child does not drink enough fluid or when they lose more body fluid than normal. When a child is sick, fluid is lost through vomiting, diarrhea and fever. The imbalance of losing fluid without replacing it results in dehydration.

The most common causes of dehydration are:

• poor fluid intake during an illness
• fluid losses from diarrhea and/or vomiting.

Healthy children can vomit or have loose stools once in a while without becoming dehydrated. When a child is sick, dehydration can happen quickly and be very dangerous, especially for babies and young children. If children are vomiting, have diarrhea and are not able to drink, they can lose fluids quickly and become very sick.

Dehydration in kids prevention

Making sure kids get plenty of fluids when they’re sick or physically active can help protect them from getting dehydrated. The best way to avoid significant dehydration is to see your doctor if your child has an illness that’s causing her to lose lots of fluid or stop drinking.

On hot days or when your child is exercising, he needs to stay hydrated. Make sure there’s plenty of water handy so your child can drink if he’s thirsty. You might need to remind some children to have regular drink breaks.

How to keep your child hydrated can depend. For example, a child with a sore throat may become dehydrated because drinking or eating is too painful. Easing the pain with acetaminophen or ibuprofen may help, and cold drinks or popsicles can soothe a burning throat while also giving fluids.

Not all fevers need to be treated, but if your child is uncomfortable and not getting enough fluids, you can give acetaminophen or ibuprofen to help control the fever.

It’s important that kids drink often during hot weather. Those who play sports or are very physically active should drink extra fluids beforehand, and then take regular drink breaks (about every 20 minutes) during the activity. Ideally, sports practices and competitions should be held in the early morning or late afternoon to avoid the hottest part of the day.

Thirst is not a good early sign of dehydration. By the time they feel thirsty, kids might already be dehydrated. That’s why they should start drinking before they feel thirsty and have more fluids even after thirst is quenched.

Dehydration and gastroenteritis

Kids with mild gastroenteritis also called the “stomach flu”, who aren’t dehydrated should still drink extra fluids to replace those lost from vomiting and diarrhea. Most kids can safely eat their regular diet while they’re sick.

Infants with mild gastroenteritis who aren’t dehydrated should continue getting breast milk or regular-strength formula. Older kids may continue to drink full-strength milk and other fluids.

Foods that are usually well tolerated by kids with gastroenteritis who aren’t dehydrated include: complex carbohydrates (such as rice, wheat, potatoes, bread, and cereals), lean meats, yogurt, fruits, and vegetables. Avoid fatty foods or foods high in sugars (including juices and soft drinks).

If your child is vomiting and isn’t dehydrated, give fluids often, but in small amounts.

Signs and symptoms of dehydration in kids

If your child has a fever, diarrhea, or vomiting, or is sweating a lot on a hot day or during intense physical activity, watch for signs of dehydration. These include:

• a dry or sticky mouth
• few or no tears when crying
• eyes that look sunken
• in babies, the soft spot (fontanelle) on top of the head looks sunken
• peeing less or fewer wet diapers than usual
• dry, cool skin
• irritability
• drowsiness or dizziness

Mild to moderate dehydration:

• a dry tongue
• few or no tears when crying
• fussiness in an infant
• no wet diapers for 6 hours in an infant
• no urination (peeing) for 8 hours in children

Severe dehydration:

• very dry mouth (looks “sticky” inside)
• dry or wrinkly skin (especially on the belly and upper arms and legs)
• inactivity or decreased alertness and excessive sleepiness
• sunken eyes
• sunken soft spot on top of an infant’s head
• no peeing for 8 or more hours in an infant
• no peeing for 10 or more hours in a child
• deep, rapid breathing
• fast or weakened pulse

Dehydration diagnosis

The Clinical Dehydration Scale is used by health-care professionals to determine the severity of dehydration. Parents and caregivers can use it at as well. Using this scale can help to guide you as to whether your child is getting better, staying the same or getting worse. A doctor may use more findings to assess dehydration, but this scale is a good place to start. If you have any concerns, see a doctor to get your child checked.

The chart assigns points for certain signs or symptoms you observe in your child. The higher the point total, the worse the dehydration.

To calculate your child’s dehydration status:

• mark down your child’s symptoms
• for each symptom, find the point value in the chart
• add up the points to get a score for your child’s level of dehydration.

For example, if your child has dry mucous membranes* (2 points), decreased tears (1 point), and a sweaty appearance (2 points), the total point value is 5 points. A score of 5 points means your child has moderate to severe dehydration.

Table 1. Clinical Dehydration Scale

	0	1	2
General appearance	Normal	Thirsty, restless, or lethargic but irritable when touched	Drowsy, limp, cold, sweaty
Eyes	Normal	Slightly sunken	Very sunken
Mucous membranes*	Moist	Sticky	Dry
Tears	Present	Decreased	Absent

Footnotes: *Mucous membranes include the moist lining of the mouth and the eyes.

• Score of 0 = no dehydration
• Score of 1 to 4 = some dehydration
• Score of 5 to 8 = moderate to severe dehydration

Dehydration in kids treatment

The treatment of dehydration is based on how dehydrated your child is. You can treat mild cases of dehydration by giving your child more fluid. Over-the-counter medications to treat vomiting and diarrhea are not recommended for children.

One option is oral rehydration fluid like Gastrolyte®, Hydralyte™, Pedialyte® or Repalyte®. You can buy these fluids over the counter from a pharmacy.

Other options include water, diluted lemonade, cordial or fruit juice. If you’re using a sugary drink, it’s important to dilute it – use one part of lemonade, cordial or juice to four parts of water.

Your child might not be keen to drink. You can try to get her drinking more by giving her drinks via a syringe or spoon, or letting her suck icy poles. You can get Hydralyte™ icy poles from pharmacies.

If your child is vomiting, it’s usually better to offer small amounts, but frequently. For example, give your child a few mouthfuls every 15 minutes.

If you have a breastfed baby older than six months, keep breastfeeding but feed more often. You can give your child extra oral rehydration fluid between feeds.

If your baby is older than six months and is bottle fed, give him oral rehydration fluid for the first 24 hours only and then reintroduce full-strength formula in smaller, more frequent feeds. You can still offer extra oral rehydration fluids between feeds.

In more severe cases, your child might need to go to hospital to catch up on fluid loss.

In many cases, the safest and quickest way to do this is by via a small tube that goes into your child’s nose and then into his stomach. The rehydrating fluids go through this tube. Less often, your child will be given fluids intravenously (directly into the vein).

Moderate to severe dehydration (score of 5 to 8 on the Clinical Dehydration Scale)

Take your child to see a doctor or go to the nearest hospital for assessment and treatment right away.

Home remedy

Mild dehydration (score of 1 to 4 on the Clinical Dehydration Scale) often can be treated at home. If your child has diarrhea but no vomiting, continue feeding a normal diet. If your child is vomiting, stop milk products and solid foods, and:

• Give infants an oral electrolyte solution (a solution that restores lost fluids and minerals), about 1 tablespoon every 15–20 minutes. Oral rehydration solutions (ORS) such as Pedialyte, Gastrolyte, Enfalyte or other brands contain a properly balanced amount of water, sugars and salts to help the body absorb the fluid. Giving your child water on its own is not enough because water lacks sugars and salts, which are needed to treat dehydration.
• Give children over 1 year old sips of clear fluids such as an oral electrolyte solution (ORS) to replace the water and salts your child has lost, ice chips, clear broth, or ice pops. Give 5 to 10 mL (1 to 2 teaspoons) every 5 minutes. Slowly increase this amount to reach the amount your child will tolerate. If your baby is breastfeeding, continue to breastfeed. If your baby refuses to breastfeed, see a doctor immediately.

No dehydration (score of 0 on the Clinical Dehydration Scale)

Continue to offer your child fluids and an age-appropriate diet. If your child has vomiting or diarrhea, give diluted apple juice, their preferred drink or oral rehydration solution for each diarrhea or vomiting episode. Give 60 – 120 mL (1/4 to ½ a cup) for toddlers and 120 mL (1/2 a cup) for older kids. Continue to offer your child small frequent feedings.

Treatment after rehydration

Once your child is better hydrated, the next step is to work toward getting them back to what they normally eat. This can usually happen about four to six hours after the last episode of vomiting. Offer your child the usual foods and drinks they enjoy.

You do not need to give your child a restrictive diet such as BRAT (bananas, rice, apple sauce, toast). However, avoid offering your child foods that have a high sugar content, fried or high-fat foods, and spicy foods until they have recovered. These foods can be more difficult to digest.

Do not dilute your child’s formula or milk with water, oral rehydration solution or any other fluid.

If your child has ongoing diarrhea or vomiting, give diluted apple juice, your child’s preferred drink or oral rehydration solution for each stool or vomiting episode. Give 60 – 120 mL (1/4 to 1/2 a cup) for toddlers and 120 mL (1/2 a cup) kids. You can also offer them the usual foods and drinks they enjoy. Even if there is diarrhea, it is usually better to continue offering nutritious foods your child’s body needs to recover and to heal.