Congratulations on the newest member of your family! We are pleased that you have selected us to care for your new arrival and we look forward to working with you as your pediatricians. This booklet will serve as a quick guide to some common child care issues. There are many books on child care. Two that we recommend are Barton Schmitt’s Your Child’s Health and Steven Shelov’s Caring For Your Child: Birth to Age Five, from the American Academy of Pediatrics. This booklet is not an exhaustive reference, so do not hesitate to reference these other sources if any questions arise. Our phone nurse is also available Monday through Friday during business hours. The doctors are available for emergencies twenty-four hours a day.

About Our Office

We are open Monday through Thursday 8am to 5pm and Friday 8am to 4:30pm with evening hours Tuesday and Thursday until 7pm as needed. If you call during regular office hours, our receptionist will direct you to our phone nurse or the appropriate person at our appointment desk.

If you call in for medical advice, please be sure to have ready:
1) pen and paper
2) your child’s age and weight
3) child’s temperature, if you suspect fever
4) phone number for your child’s pharmacy

Calls received outside of business hours (that is, emergencies) will be forwarded to the doctor on call. We do not batch or screen calls so most calls are answered immediately. However, if you need to leave a message and your call is not returned within 20 minutes, please call us back. Occasionally, our pagers may malfunction. As always, use your judgment if you need more urgent assistance by calling 911 or going to Children’s Urgent Care or Emergency Department.

Physician Profiles and Website

Cornerstone Pediatrics has six physicians on staff: Dr. Greg Eberhart, Dr. Craig Chalfie, Dr. Lori Ellis, Dr. Kim Khosla, Dr. Karen Starrett, and Dr. Ann Burke. You can access detailed profiles of our physicians, as well as other helpful links and information, on our website at www.cornerstonepediatrics.info.

Insurance Coverage

If your baby will have insurance coverage, it is very important to remember to contact your insurance company and let them know to add your baby onto your insurance plan. Most insurance companies require this to be done within the first 30 days following the birth of your child, but some may require earlier notification. It is also helpful to find out what kind of benefits your child will have for well child visits, immunizations, and visits due to illness, so that you will know what you can expect your insurance to cover.

Feeding Your Baby

Newborn Feeding Options

One of the most personal decisions to be made for your new baby is the selection of a feeding program. We recommend breast feeding as the best alternative for most babies. However, we support your choice if you decide to use formula for your baby. We also recommend feeding on demand for your baby in the newborn period. Babies regulate their intake very adequately and balance feeding and sleeping needs. However, every family is different and sometimes a schedule will work better for you, the baby and other members in the household. We encourage you to try different approaches to determine what works best for you.

Breast feeding, while not for everyone, may provide you with great satisfaction and will provide your baby with excellent nutrition and added protection from disease. In the first two weeks, a breast fed baby should feed 8-12 times in a 24 hour period. When breast feeding, mothers should remember to drink plenty of fluids and to maintain good nutritional habits. Before taking any medication, consult your own doctor. Pumping breast milk may be started at any time and may provide you will some added flexibility. Breast milk may be stored refrigerated for 4 days or frozen up to four months in a standard freezer. Once thawed, it should be used within 24 hours.

Commercial formulas come in several varieties, but there are some general categories. Cow’s milk based formulas with iron are our first choice. Iron is critical for normal brain and blood development, so we recommend regular and NOT LOW IRON FORMULAS. Soy milk based formulas also provide adequate nutrition and provide a good alternative for children who cannot tolerate certain milk proteins. Formula changes should be based on discussion between you and one of our staff.

Babies may be fed formula at room temperature. Some babies will also tolerate formula right out of the refrigerator. If you would like to warm formula, do so by running warm tap water over the outside of the bottle. Other methods, including microwave heating, may decrease nutritive value of the formula by changing component proteins. Additionally, microwave heating may form “hot pockets” in the milk. These pockets are areas of extremely hot milk which occur due to uneven exposure to microwave radiation.

Starting Solids

The introduction of solids into your baby’s diet will be discussed at their well child checks. In general, exclusive breast feeding or formula is recommended until the age of 6 months. Rice cereal may be begun, on a spoon, between the ages of 4-6 months and baby food after 6 months. It is best to avoid meat until the age of 9 months, eggs and honey until 1 year, and nuts, including peanut butter, and shellfish until the age of 2.

Problems in the Newborn Period

Crying and Colic

Many babies become fussy or “colicky” at about two weeks of life. Some developmental pediatricians believe that fussing and crying at this age actually represents the first developmental milestone for babies. It is their first opportunity to interact with the environment and represents the first time that one of their actions (crying) can bring about another action (being held). This does not represent the baby manipulating the parents, but does mean that crying is not always associated with needing to be fed, changed or anything else in particular. Every child is different, but fussing is generally most pronounced between 6pm and midnight. (Just in time for many parents to get home from a hard day at work!)

So, what should you do if you have a baby who cries frequently? First, be a good observer. Is there anything that may be hurting? Is your baby indeed hungry or acting ill or uncomfortable because of a temperature, dirty diaper, or other cause. Second, does holding help or make no difference? If your baby fusses regardless of what you do, it may be that there is nothing you can do. Some babies will cry for long periods of time. You may, after checking to make sure everything else is normal, just need to let your baby fuss. This is easier said than done, and we are happy to discuss concerns you may have about crying periods. Things that remind your baby of being inside mom such as rhythmic sounds (dryer, vacuum cleaner), rhythmic motions (swing, car or stroller rides), and being swaddled may help.

Normal Bowel Habits and Constipation

One of the most frustrating events in a newborn’s life can be passing of stool. Because babies have bowel movements lying on their backs and because they do not have fully developed abdominal muscles, they may cry and turn red in the face in order to force the stool out. While this is distressing to watch, it is a quite normal pattern as long as stool is passed and there is no change in appetite.

Normal stools are usually seedy or mustard-like in consistency for breastfed babies and are more formed in formula-fed infants. Frequency may vary from several times daily to once every 3-4 days.

When the lack of bowel movements causes poor feeding, extreme discomfort, or hard stools, intervention may be needed for constipation. This may involve dietary supplements or other maneuvers for relief. Please call us if you have questions regarding constipation and its treatment.

Eye Drainage

Mucus drainage from the eye is a frequent occurrence during the newborn period. In newborns, tears are produced on the outside corner of the eye, move across the surface of the eye and drain through the nose through the nasolacrimal duct in the inner corner of the eye. Because babies are so much smaller than adults this duct may be quite tiny. Skin cells, nasal mucus and other cellular debris may quickly clog this duct and provoke persistently draining eyes. Massaging the inner corner of the eye and wiping out mucus gently with a wash cloth may be sufficient to unclog the duct. This condition usually spontaneously resolves by 6-12 months of age. If redness is present on the whites of the eye, notify your doctor.

Temperature Taking

A normal temperature in a newborn under 2 months of age is somewhat different than a normal temperature in an older child. A temperature varying from 98.6 by more than 2 degrees above or below (i.e. 96.6 to 100.4) may be a sign of infection in a child under 8 weeks of age and should be promptly evaluated. We recommend checking temperatures in newborns rectally with a thermometer when your child feels warm, acts ill, feeds poorly, or show signs of respiratory problems. The American Academy of Pediatrics recommends using a digital thermometer when taking an infant’s temperature. Infrared thermometers (Thermoscan and other brands) are not recommended for taking a newborn’s temperature. They may be inaccurate by several degrees in a newborn’s narrow ear canal. Since babies respond quickly to environmental temperature, temperatures should not be taken shortly after you baby has been tightly bundled or exposed to cold.

Emergency Preparedness

So, what constitutes an emergency in your new infant?

Call us immediately if your child under 2 months of age has:

1) A rectal temperature greater than or equal to 100.4 F (38 C) or less than 96.8 F (36 C)
2) A sudden decline in the length or amount of feeding, lasting over two consecutive feedings (4-6 hours)
3) Persistent crying lasting over one hour without interruption

Jaundice

Jaundice refers to the yellow or orange hue some newborns acquire during the first week of life. Babies are born with high red blood cell levels in order to use the limited amount of oxygen available in the uterus. After their arrival in the relatively oxygen-rich world, those red blood cells are broken down. Because babies also have relatively immature livers (where red blood cells are disposed of), there can be an accumulation of bilirubin, a yellow compound found in red cells.

From time to time, newborns may require therapy with lights to prevent extremely high levels. Usually, normal feeding regimens and hydration will allow for adequate excretion of bilirubin in stool and urine. If your newborn shows yellow appearance on the eyes, face or upper trunk only, the bilirubin level is not dangerously high. If there is jaundice, or yellow color, on the abdomen or below or if there is poor feeding, you show call us to discuss what to do next. Normally, jaundice hits its peak on day four or five of life.

Spitting Up

Most babies will spit up a certain amount, and the important distinction to be made is between spitting which is normal and vomiting which may be the sign of illness or something more serious. As long as it conforms to the following pattern, it is likely normal.

Normal spitting generally should:

1) occur between 5 and 45 minutes after feeding
2) involve less than half the feeding
3) not contain blood or green material (bile)
4) not be projectile or shooting from the mouth (though it may come out both the mouth and nose)
5) not be associated with a lot of irritability

To minimize spitting, you may need to try different regimens for feeding. Varying frequency of burping may be helpful in reducing spitting up. Different positions, for example elevation of the head and upper trunk, may also be helpful.

The most important consideration in evaluation of spitting up is growth. The general rule of thumb is that sustained growth means that spitting is not impairing your newborn’s health.

Problems Concerning Infants (older than 2 months) and Toddlers

Fever

Fever is a natural and healthy response to infection, either viral or bacterial. It is part of the body’s defense against infection. It is important to keep several things in mind when thinking about fever.
1) The height of the fever is not always an indication of the severity of the illness. Children tend to respond to any infection with higher temperatures than adults.
2) The temperature will normally fluctuate during the course of the illness, and tends to be highest in the late afternoon or night. It does not mean your child is getting better or worse.
3) The child’s symptoms are much more important than the height of the fever. A child with a fever who is cheerful and playful does not warrant great concern.

Call the office if:

1) the temperature is 100.4 in a child less than 2 months of age
2) the temperature is above 104 in a child 1 year of age or older
3) the temperature is not responding to a fever reducer
4) the fever has lasted longer than 3-5 days
5) your child is extremely irritable or lethargic

Treatment of fever:

The main goal of treatment is to make your child more comfortable.
1) Give the correct dosage of fever reducer (Tylenol if < 6 months, Motrin or Tylenol if > 6 months). If you are unsure of proper dosing, please call our office and we will be happy to assist you in determining the proper dosage for your child.
2) Encourage fluids.
3) Do not expect to lower the temperature to normal. If the temperature comes down a couple of degrees and your child appears more comfortable, be satisfied. If it doesn’t respond to these measures, call our office for advice.

Vomiting, Diarrhea, and Dehydration

Children with diarrhea will have frequent loose or watery stools. Diarrhea is most often caused by a virus. Children may not show any other symptoms, but there may be vomiting, fever, or fussiness. If the vomiting or diarrhea are severe, or occur together, and the child is not able to take enough liquids, a child may lose too much body water and become dehydrated. In severe dehydration, the eyes look sunken, the skin looses its tone, the mouth is dry and urination stops. This situation might require hospitalization for fluid administration through an IV.

General Rules:

1) Do not give any over-the-counter diarrhea or vomiting medications to your child unless instructed to do so.
2) If your infant is breastfed, continue to nurse.
3) If there is no vomiting, you may continue to give a regular diet with additional fluids.
4) Monitor you child’s urine output closely.
5) When vomiting occurs, you may offer your child small amounts of a clear liquid (Pedialyte for infants, Pedialyte, Infalyte, half-strength Gatorade, flat Sprite in older children) every few minutes. Offering large amounts all at once often distends the stomach and results in further vomiting.
6) Gradually increase the amount of clear liquid offered and increase the time between offering the liquids until your child is drinking as much as he wants.

Call our office if:

1) Your child is becoming less alert or less responsive.
2) He refuses liquids.
3) There is blood in his diarrhea or blood or dark green in his vomitus.
4) He shows signs of dehydration such as less urination or a dry mouth.
5) He has severe stomach pains or excessive crying.

Cough

Many coughs are due to drainage from a cold. Usually, it is a dry, hacky cough that can last 2-3 weeks, but at times it may be a loose productive cough. The purpose of the cough is to clear the lungs and prevent pneumonia, and, therefore, should not be suppressed unless your child is very uncomfortable.

Treatment:

1) Encourage fluids which will loosen the mucous and therefore make it easier to cough up.
2) A cool mist vaporizer will moisten the air and soothe the cough.
3) Elevate the head of the bed so that the nasal secretions drain without always triggering a cough.
4) Since the purpose of the cough is to bring up mucous that is present, we normally do not recommend a cough suppressant. If your child is uncomfortable, or the cough is keeping him awake, there are several over-the-counter medications you can try that contain dextromethorphan. Under 2 years of age, we recommend only suctioning the nose with nasal saline drops.

Call the office for:

1) Difficulty breathing, including breathing fast, belly breathing, sucking in at the ribs
2) Chest pain