What is normal, what is not?

What is normal, what is not? Parenting is a mammoth task, and brings with it a lot of uncertainty as to what is actually within the norm, and what may need more urgent attention. I shall therefore attempt to sketch a picture of what is considered normal, with initial focus on the first few months of life, which are particularly panic-provoking! This includes a few words on the dreaded “C-word”…Colic. I shall then go through system by system what may go wrong and when to seek help. As a paediatric allergist, I have a particular interest in allergy prevention strategies, hence shall attempt to dispel a few myths and iron out some truths about what we can do to reduce allergies in the offspring.

1. What is normal in the first few months?

The first few months of parenthood are particularly tough as you take full responsibility for a precious but needy little baby, and have to function on minimal sleep. My advice: accept all the help you can, don’t set your expectations too high, and don’t expect your baby to fit into a mould! This is “survival time” for all- the enjoyment of parenthood will come! For the first 3-4 months babies’ brains and tummies are still very immature. This time has been dubbed the “fourth trimester.” The baby is not yet able to manipulate you hence it is not really possible to “spoil” a baby during this time. However, routines can be established from an early age and it is useful to try have a baby in some kind of a routine of sleep, feeding and play by 12 weeks or so if possible. The predictability of a routine helps you as well as other caregivers as well as your baby. Remember to be flexible and especially adaptable at times of travel, sickness and immunisations when the routine may be disturbed for a while. The first few months are vital for establishing a bond with your baby and a relationship of trust- the baby needs to know that “warmth and food and cuddles will come my way when I need them.” Remember that it is normal for a baby to cry as it is its only way of communicating. Crying increases from an average of about 1 hour a day at birth to 2-3 hours a day at 6 weeks, then slowly decreases again to about 1-2 hours a day at 3 months. Remember this “crying curve” when you are tearing your hair out at 6 weeks post birth! Gripes and Groans in the first few months The immature gut during the first 3-4 months means that most babies have gripes and groans to varying degrees. “Colic” by definition is excessive crying of more than 3 hours a day, more than 3 days a week, typically from 2-3 weeks until 3-4 months of age. Truly colicky babies by definition are thriving and usually have a pattern of an unsettled period, typically (but not always) in the early evening, when they cry inconsolably and may draw their legs up in discomfort. Although the specific cause of colic is rather mysterious, the general feeling is that it may be caused by an immature gut and immature nervous system (oversensitivity). Colic does not cause long term harm or distress to the baby. Simple measures such as winding the baby carefully, holding them upright with gentle pressure on the tummy, movement, driving, “white noise”, wind drops and probiotic drops may be useful. More potent colic mixtures can be sedating hence should be used sparingly only for “crisis” times once or twice a day after discussion with your clinic sister or doctor. Individual colic “medications” do not have a great success rate, and each one may work in only about a third of patients. Therefore, if they do not make a difference after a week or 2, stop them. Time is the great healer for colic, but this is hard to accept when you have a little baba crying 24/7! Some cases of excessive crying and discomfort may be caused by reflux of acid and milk into the throat, lactose intolerance and cow’s milk protein allergy. Please discuss concerns of with your clinic sister and doctor, especially if there is excessive vomiting, constant crying, inadequate weight gain, severe nappy rash, or chestiness. On that note, most babies vomit as they have an immature valve at the top of their stomachs which lets milk go up again. This is normal. Vomiting, in fact, only peaks at 4 months. However, if the vomiting seems excessively painful, the baby back-arches a lot, refuses to lie on the back, and is extremely miserable after feeds or fusses excessively during feeds, reflux “disease” should be considered and discussed with your healthcare practitioner. Stools During the first few days of life the baby passes meconium, which is a black or dark green stool of “marmite” consistency. After a few days, stools change. Breastfeeding stools are normally mustard yellow with white “seeds” of curdled milk. Breastfed babies have a wide variety of stooling habits. In the first few weeks they tend to pass stool after most feeds. After a few weeks they settle into a pattern which is widely variable: from 7-8 stools per day to one stool per week- this is all within normal limits. Babies on predominantly formula feeds should ideally pass stool at least once a day. Babies often groan and strain and become red in the face when they are passing stools- this is normal unless accompanied by painful crying. If you are concerned about constipation- (if stools are infrequent or unusually hard or painful to pass) please consult your doctor. Sleep Sleep is always an issue in families with young kids. We won’t go into detail here as every child and family is so different. Don’t expect miracles before 6 months- the young baby is programmed to require night feeds which can be normal until 8-9 months of age. Thereafter, demanding a milk feed is usually not a nutritional issue but a comfort “prop” to help them fall asleep again. Teaching a child to self soothe is an important tool to impart on your young one and can be done from about 4 months of age. They may need a comforter such as a special blanket, soft toy or dummy (or a combination of these) to help them fall asleep. Babies are generally reasonably easy for the first 10 days or so then may become more difficult as colic and wind sets in. Their sleep requirements are high (about 16 hours a day in total for the first few weeks), gradually settling into a pattern of approximately 3 naps per day by 3 months of age. If possible, some naps should be more than 40 minutes long to provide restoring sleep. At night time they will continue to wake 3-4 hourly for feeds for the first few weeks; by 3 months there is often a longer “stretch” of sleep during the night of 5-6 hours. Remember that the safest sleep position for your baby is on the back. The “back to sleep” campaign in the UK has seen the rate of cot deaths halve over only a few years. If the family is really not coping with the interrupted nights, or if there is a sudden change in sleep pattern, it is worth having the child looked at to make sure there is not a physical ailment disrupting the sleep. The routine and feeding pattern should be examined to make sure the daytime sleep and feed requirements are being met. There are a variety of forms of sleep training available, from controlled checking to gentle gradual separation techniques- please discuss with your clinic sister or doctor before embarking on these. If a child is unwell or going through a stage of separation anxiety, it is not a good time to sleep train. Remember that “this too shall pass” and that most children- even the worst initial sleepers- sleep very well by the age of 5 or 6 years. Feeds Initial feeds should be 3-4 hourly during the day, and on demand at night. Some babies only manage 2 hours in between feeds initially- this should stretch once they are able to drink more at one time. Breastfeeding is ideal for babies for several reasons including cost, convenience, allergy prevention and to boost their immune systems. The clinic sisters have vast experience with breastfeeding, please consult them for advice if you are battling. However, not all mothers manage to breast feeds or have insufficient milk- nothing to feel guilty about. There is a vast choice of formula milks and the approximate volume that a baby needs for the first few months is 150 mL milk per kg per day (divide this volume into the number of feeds per day). For example, a 4 kg baby on formula milk who feeds 3 hourly needs approximately 150 x 4= 600 mL per day; ie approximately 75 mL per feed every 3 hours. (8 feeds per day) Some babies need less milk, some need more- the best way to judge is by their weight gain. For this reason we plot babies’ weights on the growth chart regularly to make sure they are not falling off the growth curve. Babies lose weight during the first few days of life- loss of up to 10% of their birth weight is normal. The baby should regain its birth weight by 2 weeks of age. After that, for the first 3 months or so weight gain should be between 150-350 grams per week. After 3 months it slows down somewhat. Solids can be introduced any time from 4 months (17 weeks) onwards. Throughout the first year of life milk is the most important component of the infant’s diet, and even on 3 solids meals a day, during the first year the infant requires at least 450-600 ml milk per 24 hours. After the age of one, milk can be cut down gradually to 300-500 mL per day- overfeeding with milk after a year of age will interfere with an appetite for solids and may lead to problems such as anaemia. From about 14 months or so many toddlers notoriously go through a fussy eating stage-their growth curve naturally slows down and the world around them is SO much more interesting than food! It is therefore important to try and introduce a great variety of foods to the toddler before the fussy stage begins. Developmental Milestones Every baby develops at a slightly different pace, but generally the sequence of development is similar. Stimulation of a baby’s development will be covered by my colleagues. As soon as the baby starts fussing and seems fed up, stop with the stimulating process so that they can calm down in preparation for the next nap. Below are basic milestones typical at different ages. Remember each child develops at a different pace, and individual babies may be advanced in a certain area e.g, grabbing and mouthing yet a bit slower in other areas e.g. sitting/crawling. If your child is lagging behind significantly please consult the paediatrician: the sooner delays are picked up, the quicker we can intervene to find a diagnosis and treatment. Developmental milestones

Age	Gross Motor Skills	Fine Motor Skills	Hearing and Language Development	Visual Development	Personal/Social
Birth	Very little head control	Hands are closed and grasp reflex present	Startles to loud noises	-Eyes close in response to bright light -Best distance of vision is about 30 cm away -Black and white vision	Cries
6 weeks	Moderate amount of head control	-Can make tight fists -Places hands in mouth	-Responds to sounds by calming, startling or crying -Starts making cooing sounds	May follow slow moving objects through 90 degrees	Begins to smile in response to familiar face or voice
3 months	-Very little head lag -Can lift upper body and head when lying on tummy -Leg kicking and stretching -Standing reflex develops (pushes down on a surface with legs when held up)	-Hands held loosely -Inspects hands and grasps objects that are place within hands -Can bring hands together	-Recognises and responds to parents -Coos and gurgles -Blows bubbles	Follows objects moving up to 180 degrees in the field of vision	-Smiles spontaneously -Develops facial expressions to show basic emotions -Recognises mother’s face and scent
6 months	-Supports head well -Can support upper body with hands when lying on stomach -Sits with support -Can roll over	-Reaches for and grasps objects -Places objects in mouth -Transfers objects from hand to hand	-Responds vocally when spoken to -Uses sounds such as squealing or laughter to express emotions -Uses repetitive monosyllabic sounds like bababa	Can move eyes in all directions	Recognises toys
9 months	-Sits without support -Crawls on stomach and then on hands and knees -Starts to pull body into a standing position	-Can pick up, shake and drop small objects -Grasps food and places in mouth -Holds a bottle Begins to point	Starts imitating sounds		-Stranger anxiety- Knows and trusts a limited number of caregivers -Recognises own name
12 months	-Cruises around furniture -Starts to walk (walking may take up to 18 months) -Begins to throw objects	-Good pincer grip -Holds 2 objects and bangs together -Still mouths a lot	-Speaks 2-3 words -Makes sounds at toys	Picks up tiny things from the ground	-Searches for hidden or fallen toys (0bject permanence) -Waves goodbye, - points -Shakes head
15 months	-Walks steadily -Starts to climb	Stacks 2- 3 blocks	Speaks 3-4 words		-Has temper tantrums when frustrated -Becomes attached to a soft toy or other object
18 months	-Walks steadily. -Runs -throws ball underhand -kicks	-Scribbles -Stacks 3-4 blocks	-Speaks 6-8 words -May have some 2 word phrases		As above -Starts to use fork and spoon -“reads” picture books on his own
24 months	-Runs -Jumps with 2 feet -Walks down stairs one foot at a time	-stacks 6 blocks -scribbles -may still use both left and right hands to draw	-Names at least 6 body parts -Uses 2-3 word sentences -Half of speech understandable -Starts to learn some colours	Adult visual acuity	-Asks “why?” -Begins to show interest in playing with other children but finds it difficult to share. Play is often in parallel -Helps with dressing -Uses fork and spoon
30 months	-Jumps easily -Balances on one foot for a few seconds -Walks down stairs with alternating legs	-Draws vertical line and circle -Pencil grip starts to develop -Handedness becomes evidence	-Able to name some colours and shapes -2-4 word sentences		-Able to recite name -Able to brush teeth with assistance -Washes and dries own hands
36 months	-Hops on one leg -Rides a tricycle	-Copies a circle -Shows definite handedness	-3-4 word sentences -Able to follow 2-3 word commands		-Starts to play with other children -can name a friend -Able to help with dressing

Dr Claudia Gray, Paediatrician and Allergologist, Vincent Pallotti Hospital and Red Cross Children’s Hospital, Cape Town