25 May 1998

1. Cereal to Help Infants Sleep?
2. The Baby Who Won't Eat - A Parent's Advice
3. My Son Sweats and Smells All the Time
4. Teenage Boy Embarrassed by Urine Problem
5. Screaming Baby
6. Infant Feeding, Pacifiers
7. Rare Disease Which Makes Sun Exposure Dangerous
8. Is It Worth the Effort to Become a Pediatrician?
9. Disclaimer

• Read Questions & Answers in Another Column

Cereal to Help Infants Sleep?

-Sincerely yours,
A

Dear A: I cannot be sure what is disturbing your baby's sleep, but since he generally goes right back to sleep after you cover him, there is no reason to believe it is due to hunger. Since formula and breast milk are complete foods, there is no nutritional advantage to introducing cereal early. Since most babies do not have the appropriate degree of head and swallowing control for spoon feeding before 4 months the American Academy of Pediatrics advises against starting spoon feeding before 4 months. Your infant's response to spoon feeding is adequate evidence that he isn't ready for it, therefore I would discontinue it.

Your response of doing the minimal intervention that gets your baby back to sleep appears to be the right response for now. There is no way to guarantee that he won't wake during the night. As he gets older, it will help to put him into the crib awake so he can learn to put himself to sleep.

Sincerely,
Dr. Warren

While I feel the pain and fear this couple must be going through, I had to laugh when I read their question. I'm going through the same thing with my 11.5 month old. The article sounded as if I had written it myself. My baby is the happiest baby I've ever known. Unfortunately (or maybe not), she would rather play, explore and sing (yes sing!) than eat.

She weighs only 18 lbs., 4 oz. and is only 29.75 inches long. My husband and I have been beside ourselves. However, things are finally looking better (her appetite started to decline at about 4 months). Recently she has begun to consume more calories via table food and juice and is finally gaining some weight. She weighed 16.5 pounds for about a month. If it's o.k. with the doctor, I'd like to offer some tips:
Hopefully, as your baby gets more teeth, his interest in eating will increase.

• 1. Offer a variety of foods, especially nutritious table food (this may mean wasting a lot of food and spending a lot of money, but it's worth it) It may also mean that he takes less formula (use a vitamin supplement if you're about that). Get the formula in by offering it after the solids (he’ll be thirsty) or after a play session.
• 2. Mix his favorite fruit or vegetable baby food in his formula (buy some nipples with large holes).
• 3. Use a sippy cup whenever possible. Feeding will take longer, but he may like the novelty of it and take in more.
• 4. Add a small of half and half to his formula (2 oz. of half&half and 6 oz. of formula is what we use).
• 5. Take him to places where he can see other people eating and enjoying food (picnics, restaurants, family gatherings, etc.) Our child seems to eat more when we are relaxed and other people around her are also eating.
• 6. Try not to push (I know it's hard). This will only make matters worse.
• 7. Finally, when someone comments "Ohhh, he's sooo small", simply say "yes, he is but thank goodness he's happy, healthy and smart. Every ounce of him makes up the small miracle that he is."

Your child and your family are in our prayers.

-Kathy

Dear Kathy: Thank you for your interest and your desire to help other readers with your experience. Mr. and Mrs. H wrote to me 4 months ago, so their 4 month old would now be 8 months old, and if they are still having a problem they might find some of your suggestions useful as may others who have had similar problems.

In publishing your letter for others to see, I feel obliged to put my two cents into the discussion. Your suggestion about putting food into the bottle may have served as an excellent solution for your difficult situation, but I wouldn't want my readers to think I endorse putting food into the bottle as a general practice. At the time that spoon feeding is first introduced, between 4 and 6 months, most babies should be getting the bulk of their nutrition from formula or nursing. Offering food in a bottle may alter the nutritional balance in an undesirable manner by decreasing the infant's formula consumption significantly. In addition, those children who don't acquire spoon feeding skills during the first 9 months may be more difficult to switch from liquid to solid nutrition later on.

The decision to add half and half or any other source of additional fat to the baby's formula should be undertaken on the advice of a physician after a review of the baby's growth and the nutritional content of his current diet. The addition of fat can increase the caloric content and may be useful in infants who are not gaining weight adequately.

Once again, thank you for writing and sharing. Many parents will appreciate your words of advice and encouragement when they read them on the Web.

Sincerely,
Dr. Warren

-Thank you,
KG

Dear KG: The strongest non-prescription antiperspirant on the market is Mitchum. If your son hasn't tried it he should. In the event that it doesn't control the sweating, you might consult a dermatologist about a medication called Drysol. Antiperspirants and deodorants are not the same thing. An antiperspirant controls the sweating which causes the odor.

If your son sweats a lot, he may need to use something on his body as well as his underarms. The best thing to start with would be powder applied to the neck, torso, and crotch. These areas may contribute to the odor in an active, sweaty young man.

Sincerely,
Dr. Warren

-Danny

Dear Danny: Having some urine leak out into your pants after you finish urinating and put your penis back into your pants is not a part of puberty, but there may be some simple, nonmedical reasons for it and every man experiences what you're experiencing on occasion.

One of the things that happens in puberty is that your penis gets larger and hangs down. As a result, when you urinate, the underside of your penis may be resting against your fly. If this happens, once your bladder is empty, there will be no more urinary stream to push the last few drops of urine out of your urethra (the tube through which urine flows in your penis), and the pressure of your pants against the urethra (which is on the underside of the penis) may prevent the last few drops of urine from coming out. To avoid this leaking out into your pants, before you put your penis away, you should lift it up off your fly and milk any urine still in it out by running your finger along the urethra (the underside of the penis) from your body toward the tip of your penis. Just shaking your penis may not be sufficient to empty it.

If you are not circumcised, you will want to be sure that your foreskin is not tight. If the foreskin balloons out when you urinate, the foreskin is too tight. You can milk the urine out of it before you put your penis back in your pants, but if that is the problem, a tight foreskin does require medical attention. As a general rule, the foreskin grows along with the penis so that if it wasn't tight before puberty, it shouldn't be tight after puberty. Even most boys who can't pull their foreskins back don't have a tight enough foreskin to interfere with urine flow.

A urethral web is a web of tissue that goes across part of the urethra, sort of like a shelf. It doesn't obstruct the urethra completely, but once the bladder is empty, some urine could remain on top of the web and leak out afterwards. Webs and diverticulae (outpouchings) of the urethra that might cause dribbling after voiding are congenital (you're born with them) and are unlikely to first cause symptoms in adolescence.

My advice is to try what I suggested to see if that solves your problem. Don't let embarrassment in public restrooms such as in school make you rush to put your penis back into your pants before you've made sure there is no urine left in your urethra. If that doesn't solve the problem for you, even though it's embarrassing and frightening to go to the doctor, you must tell your parents and have them bring you to your pediatrician.

Sincerely,
Dr. Warren

I'm looking forward your response.

Regards,
-LY

Dear LY: If your 5 month old screams a lot because he enjoys using his voice and is happy while he is screaming, that is perfectly normal. If he is screaming as if he is uncomfortable and doesn't respond to comforting, then he needs to be evaluated by his pediatrician..

At 5 months some infants still may wake occasionally at night, but he should not be up multiple times during the night or need to be fed during the night. You might benefit from reading my article, "Helping Your Child to Sleep Through the Night". If you have any questions after you read it, get back to me with your specific questions.

Sincerely,
Dr. Warren

Question 1: My baby's pediatrician told me don't give baby anything else other than breast milk or formula until he's six month. My mother gave me vegetable soup already even when I was 3 month old. Could you tell me if I should do what our pediatrician said. Also, is there any time schedule you can tell me when I can give my baby what kind of food?

Question 2: Some people said that pacifiers are not good for baby. They said the baby is not smart if he or she likes pacifiers because they're satisfied with the fake nipple. Is this true?

I'm so happy that I found your web site with a pediatrician like you. It's not very convenient to call our pediatrician any time for advice.

Thank you for your help.

Regards,
-LY

Dear LY: The American Academy of Pediatrics recommends not offering any food besides formula or human milk until at least 4 months or preferably 6 months. Human milk or formula are the best things for a baby to be nourished with. After 4 months, infants are ready to start some spoon feeding. We generally start with cereal and fruit, then introduce vegetables, meats, yogurt, and cottage cheese. There is no rush to get through these different foods. Any time you introduce a new food you should give it to the baby for 3 days before introducing something else new in order to be sure the baby tolerates it.

By 9 months many babies are ready for some table food. Others may gag on tiny particles of food. The introduction of table food doesn't depend on how many teeth the baby has. It depends on when the baby's swallowing mechanism is mature enough to handle food particles without gagging. Table food can be introduced with small pieces of soft food that the baby can pick up and put in his mouth. Banana cut into small pieces is a good example. Soft fruit, well cooked vegetables, pasta, and cheese may follow.

These recommendations are based on what we know about babies' nutritional needs and development. 23 years ago, when my oldest was an infant, his pediatrician had us start spoon feeding at 1 month of age. I'm certain it did no harm, but we wouldn't recommend it today. There is some slight increased risk when foods are introduced early of allergic reaction

For more information on infant feeding read my article, "Feeding Your Infant".

Infants have a sucking need that goes beyond their need to eat. An infant who has been fed may still want to suck. Infants are soothed by sucking. If an infant wants to suck, but doesn't want to eat, he is smart to suck on a pacifier. A hungry infant will not suck on a pacifier long. The sucking may comfort him briefly, but he will become angry and cry out if his hunger isn't satisfied. Pacifiers are not harmful, but if parents offer them to their infants every time they cry, the babies will become dependent on having a pacifier long beyond the age that they have a need to suck. If you don't want your child to be dependent on a pacifier, you would be wise to see if your baby can be soothed without one before you offer it.

Sincerely,
Dr. Warren

-JP

Dear JP: I believe the illness to which you are referring is Porphyria. It is a genetic inborn error of metabolism which interferes with the metabolism of heme which is part of hemoglobin and other important molecules in the body. The particular genetic defect will determine which part of the metabolic pathway malfunctions and which types of porphyrins build up in the body to cause symptoms. The porphyrins cause photosensitization, i.e., the skin reacts to sun exposure. The reaction includes rash and pain. Porphyria also causes symptoms in internal organs which can cause abdominal pain and psychiatric symptoms.

I have given you the short version of the explanation which I suspect will suffice. If you need more information on porphyria and can't find it, get back to me.

Sincerely,
Dr. Warren

-Sara

Dear Sara: The first two years of medical school are a chore. They are not as intellectually stimulating as college and there's a ton of new material to stuff into your brain. But everyone who's there is in the same boat, so you make friends and you study together, and you survive. The second half of medical school is what you're waiting for. You apply what you've learned to people, patients, clinical situations. You would be amazed how poorly book learning prepares you for the real thing. It's an exciting and scary challenge.

Is it worth it? It depends what you want out of life. There are easier ways to earn a living. Being a physician isn't about money, and it's become harder to earn a handsome income with managed care. It's challenging, hard work, but it's rewarding. As to whether or not medical school is worth it: What do you give up? It takes 4 years to complete medical school, but you don't stop enjoying life while you're doing it even though there's less leisure time. Few experiences can rival college for the broad range of exciting and intellectually stimulating activities, and that includes medical school; however, if you don't go to medical school after college, you have to go to some kind of graduate school or get a job.

All jobs have their good points and the stuff that aggravates you. The best thing about being a pediatrician is the patients. I love the kids from babies straight through teens. Of course, to be a good pediatrician, you have to enjoy helping parents too, since that's a large part of what you do.

The worst thing about being a pediatrician is middle of the night calls and missing family occasions when kids are sick on holidays or weekends. Another thing that's unpleasant about being a pediatrician is worrying about a patient that's really sick.

I would become a pediatrician if I had to choose again, and so, obviously, I would do all the things I had to do to become one including 4 years of college, 4 years of medical school, and 3 years of residency (which is on the job training).

Sincerely,
Dr. Warren

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