Caring for Your Baby and Young Child: Birth to Age 5 by Steven P. Shelov (Editor), Steven P. Shelov, Richard Trubo, Robert E. Hannemann (Editor)

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1

Preparing for a New Baby



Pregnancy is a time of anticipation, excitement, preparation, and, for many new parents, uncertainty. You dream of a baby who will be strong, healthy, and bright--and you make plans to provide her with everything she needs to grow and thrive. You probably also have fears and questions, especially if this is your first child, or if there have been problems with this or a previous pregnancy. What if something goes wrong during the course of your pregnancy, or what if labor and delivery are difficult? What if being a parent isn't everything you've always dreamed it would be? These are perfectly normal feelings and fears to have. Fortunately, most of these worries are needless. The nine months of pregnancy will give you time to have your questions answered, calm your fears, and prepare yourself for the realities of parenthood.

Some of these preparations should begin when you first learn you're pregnant. The best way to help your baby develop is to take good care of yourself, since medical attention and good nutrition will directly benefit your baby's health. Getting plenty of rest and exercising moderately will help you feel better and ease the physical stresses of pregnancy. Talk to your physician about prenatal vitamins, and avoid smoking and alcohol.

As pregnancy progresses, you're confronted with a long list of related decisions, from planning for the delivery to decorating the nursery. You probably have made many of these decisions already. Perhaps you've postponed some others because your baby doesn't yet seem "real" to you. However, the more actively you prepare for your baby's arrival, the more real that childwill seem, and the faster your pregnancy will appear to pass.

Eventually it may seem as if your entire life revolves around this baby-to-be. This increasing preoccupation is perfectly normal and healthy and actually may help prepare you emotionally for the challenge of parenthood. After all, you'll be making decisions about your child for the next two decades--at least! Now is a perfect time to start.

Here are some guidelines to help you with the most important of these preparations.



GIVING YOUR BABY A HEALTHY START



Virtually everything you consume or inhale while pregnant will be passed through to the fetus. This process begins as soon as you conceive. In fact, the embryo is most vulnerable during the first two months, when the major body parts (arms, legs, hands, feet, liver, heart, genitalia, eyes, and brain) are just starting to form. Chemical substances such as those in cigarettes, alcohol, illegal drugs, and certain medications can interfere with the developmental process and with later development, and some can even cause congenital abnormalities.

Take smoking, for instance. If you smoke cigarettes during pregnancy, your baby's birthweight may be significantly decreased. Even inhaling smoke from the cigarettes of others (passive smoking) can affect your baby. Stay away from smoking areas and ask smokers not to light up around you. If you smoked before you got pregnant and still do, this is the time to stop--not just until you give birth, but forever. Children who grow up in a home where a parent smokes have more ear infections and more respiratory problems during infancy and early childhood. They get more sore throats, they cough and wheeze more and have a harder time getting over colds, and they are more prone to hoarseness. They also have been shown to be more likely to smoke themselves when they grow up.

There's just as much concern about alcohol consumption. Alcohol intake during pregnancy increases the risk for a condition called fetal alcohol syndrome (FAS), which is responsible for birth defects and below-average intelligence. A baby with fetal alcohol syndrome may have heart defects, malformed limbs (e.g., club foot), a curved spine, a small head, abnormal facial characteristics, small body size, and low birth weight. Fetal alcohol syndrome is also the leading cause of mental retardation in newborns. Alcohol consumption during pregnancy increases the likelihood of a miscarriage or preterm delivery, as well.



Where We Stand



Drinking alcohol during pregnancy is one of the leading preventable causes of birth defects, mental retardation, and other developmental disorders in newborns. There is no known safe amount of alcohol consumption during pregnancy. For that reason, the American Academy of Pediatrics recommends that women who are pregnant, or who are planning to become pregnant, abstain from drinking alcoholic beverages of any kind.



Although no one has determined exactly how much alcohol is too much for a pregnant woman, there is evidence that the more you drink, the greater the risk to the fetus. It is safest not to drink any alcoholic beverages during pregnancy.

You also should avoid all medications and supplements except those your physician has specifically recommended for use during pregnancy. This includes not only prescription drugs that you may have already been taking, but also nonprescription or over-the-counter products such as aspirin, cold medications, and antihistamines. Even vitamins can be dangerous if taken in high doses. (For example, excessive amounts of vitamin A have been known to cause congenital (existing from birth) abnormalities.) Consult with your physician before taking drugs or supplements of any kind during pregnancy, even those labeled "natural."

Your caffeine intake also should be limited while you are pregnant. While no adverse effects from minimal caffeine intake (one cup of caffeinated coffee per day) have yet been proven, recent studies suggest that consuming large amounts of caffeine during pregnancy might affect fetal growth. Caffeine also tends to keep adults awake and make them irritable, which can only make things less comfortable and restful for you.

Another cause of congenital abnormalities is illness during pregnancy. You should take precautions against these dangerous diseases:

German measles (rubella) can cause mental retardation, heart abnormalities, cataracts, and deafness. Fortunately, this illness now can be prevented by immunization, although you must not get immunized against rubella during pregnancy.

The majority of adult women are immune to German measles because they had the disease during childhood or already have been immunized against it. If you're not sure whether you're immune, ask your obstetrician to order a blood test for you. In the unlikely event that the test shows you're not immune, you must do your best to avoid sick children, especially during the first three months of your pregnancy. It is then recommended that you receive this immunization after giving birth to prevent this same concern in the future.



Where We Stand



The Academy message is clear--don't smoke when pregnant. Many studies now show that if a woman smokes during pregnancy, her child's birth weight and growth during the first year of life may be reduced. The range of indisputable effects runs from depressed breathing movements during fetal life to cancer, respiratory disorders, and heart disease in later years.

If you smoke, quit. If you can't quit, don't smoke around children (especially indoors or in the car). Children of parents who smoke have more respiratory infections, bronchitis, pneumonia, and reduced pulmonary function than children of nonsmokers. The Academy supports legislation that would prohibit smoking in public places frequented by children. The Academy also supports a ban on tobacco advertising, harsher warning labels on cigarette packages, and an increase in the cigarette excise tax. For more information, visit www.aap.org.



Chickenpox is particularly dangerous if contracted shortly before delivery. If you have not already had chickenpox, avoid anyone with the disease or anyone recently exposed to the disease. You also should receive the preventive vaccine when you are not pregnant.

Toxoplasmosis is primarily a danger for cat owners. This illness is caused by a parasitic infection common in cats, but it also is found in uncooked meat and fish. The infected animal excretes a form of the parasite in its stools, and people who come in contact with infected stools could become infected themselves.

If you own a cat, have it checked for toxoplasmosis before you become pregnant or as early as possible in your pregnancy. You can reduce the chances that your cat will contract toxoplasmosis by feeding it only commercially prepared cat food, which is processed in a way that destroys the parasites. Also, to decrease your own chances of being infected, have someone who is not pregnant clean the litter box daily. (The toxoplasmosis parasites cannot infect humans until forty-eight hours after the cat excretes them.) If you do clean the litter box or handle cat litter, make sure to wash your hands thoroughly afterward. As previously mentioned, toxoplasmosis also is found in uncooked meat and fish, so avoid eating uncooked or partially cooked meat or fish such as sushi, and practice good hand-washing techniques after handling uncooked meat products.



GETTING THE BEST PRENATAL CARE



Throughout your pregnancy, you should work closely with your obstetrician to make sure that you stay as healthy as possible. Regular doctor's visits up until the birth of your baby can significantly improve your likelihood of having a healthy newborn. During each doctor's visit, you will be weighed, your blood pressure will be checked, and the size of your uterus will be estimated to evaluate the size of your growing fetus.

Here are some areas that deserve attention during your pregnancy.



Nutrition



Follow your obstetrician's advice regarding your use of prenatal vitamins. As mentioned, you should only take vitamins in the doses recommended by your doctor. Perhaps more than any other single vitamin, make sure you have an adequate intake (generally, 400 micrograms a day) of folic acid, a B vitamin that can reduce the risk of certain birth defects, such as spina bifida. Your obstetrician may recommend a daily prenatal vitamin pill, which includes not only folic acid and other vitamins, but also iron, calcium, and other minerals. Make sure your doctor knows about any other supplements you may be taking, including herbal remedies.



Eating for Two



When it comes to your diet, do some planning to ensure that you're consuming balanced meals. Make sure that they contain protein, carbohydrates, fats, vitamins, and minerals. This is no time for fad or low-calorie dieting. In fact, as a general rule, you need to consume about 300 more calories per day than you did before you became pregnant. You need these extra calories and nutrients so your baby can grow normally.



Exercise



Physical activity is just as important when you're pregnant as at any other time of life. Discuss a fitness program (including any video fitness tapes you may be interested in) with your doctor. Particularly if you haven't been exercising regularly, she may suggest a moderate walking or swimming regimen. Don't overdo it. Take it particularly slowly during the first few workouts--even just five to ten minutes a day is beneficial and a good place to start. Drink plenty of water while working out, and avoid activity with jumping or jarring movements.



Tests During Pregnancy



Even when your pregnancy is progressing normally, your obstetrician may recommend some of the following tests.

An ultrasound exam is one of the most common tests given to pregnant women. It monitors your fetus's growth and the well-being of his internal organs by taking sonograms (images made from sound waves) of him.

A nonstress test monitors the fetus's heart rate. In this test, a belt is positioned around your abdomen to measure the fetus's heart rate.

A contraction stress test is another means of checking the fetus's heart rate, but this time it is measured and recorded in response to mild contractions of the uterus that are induced during the test.

Other tests may be recommended, depending on your own physical health and personal and family history. For example, particularly for women with a family history of genetic problems or for those who are age thirty-five or older, your obstetrician may advise tests that can detect genetic disorders. The most common genetic tests are amniocentesis and chorionic villus sampling.



CHOOSING A PEDIATRICIAN



Every pediatrician is committed to helping parents raise healthy children with the greatest possible ease, comfort, pleasure, and success. However, different pediatricians have different approaches, so you may want to interview several before selecting the one who best suits your family's particular preferences and needs. Conduct these visits before the baby arrives, so the pediatrician you choose can give your newborn her very first exam.

Here are some considerations to help you make your choice.



Training of Pediatricians



Pediatricians are graduates of four-year medical schools with three additional years of residency training solely in pediatrics. Under supervised conditions, the pediatrician-in-training acquires the knowledge and skills necessary to treat a broad range of conditions, from the mildest childhood illnesses to the most serious diseases.

With the completion of residency training, the pediatrician is eligible to take a written examination given by the American Board of Pediatrics. Once she passes this examination, a certificate is issued, which you probably will see hanging on the pediatrician's office wall. If you see the initials "FAAP" after a pediatrician's name, it means he has passed his board exam and is now a Full Fellow of the American Academy of Pediatrics. Only board-certified pediatricians can add the designation "FAAP" after their name, which means they have reached the highest status of membership in this professional organization.

Following their residency, some pediatricians elect an additional one to three years of training in a subspecialty, such as neonatology (the care of sick and premature newborns) or pediatric cardiology (the diagnosis and treatment of heart problems in children). These pediatric subspecialists generally are called on to consult with general pediatricians when a patient develops uncommon or special problems. If a subspecialist is ever needed to treat your child, your regular pediatrician will help you find the right one for your child's problem.



How to Find a Pediatrician



The best place to start looking for a pediatrician is by asking other parents you know and trust. They are likely to know you, your style, and your needs. You also should consider asking your obstetrician for advice. She will know local pediatricians who are competent and respected within the medical community. If you're new to the community, you may decide to contact a nearby hospital, medical school, or county medical society for a list of local pediatricians. If you are a member of a managed care plan, you probably will be required to choose a pediatrician from among their approved network of doctors. (For more information about managed care, see "Managed Care Plans: Getting Good Care for Your Child" on pages XX-XX).

Once you have the names of several pediatricians you wish to consider, start by contacting and arranging a personal interview with each of them during the final months of your pregnancy. Many pediatricians are happy to fit such preliminary interviews into their busy schedules. Before meeting with the pediatrician, his office staff should be able to answer some of your more basic questions:

Is the pediatrician accepting new patients with my insurance or managed care plan?

What are the office hours?

What is the best time to call with routine questions?

How does the office handle billing and insurance claims? Is payment due at the time of the visit?

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Choosing a Pediatrician

Every pediatrician is committed to helping parents raise healthy children with the greatest possible ease, comfort, pleasure, and success. However, different pediatricians have different approaches, so you may want to interview several pediatricians before selecting the one who best suits your family's particular preferences and needs. Conduct these visits before the baby arrives, so the pediatrician you choose can give your newborn her very first exam.

Here are some considerations to help you make your choice:

The Training of Pediatricians

Pediatricians are graduates of four-year medical schools with three additional years of residency training solely in pediatrics. Under supervised conditions, the pediatrician-in-training acquires the knowledge and skills necessary to treat a broad range of conditions, from the mildest childhood illnesses to the most serious diseases.

With the completion of residency training, the pediatrician is eligible to take a written examination given by the American Board of Pediatrics. If he or she passes this examination, a certificate is issued, which you will probably see on the pediatrician's office wall. If you see the initials FAAP after a pediatrician's name, it means he or she is a Fellow (member) of the American Academy of Pediatrics. Only Board-certified pediatricians can become members of this professional organization.

Following their residency, some pediatricians elect an additional one to three years of training in a subspecialty, such as neonatology (the care of sick and premature newborns) or pediatric cardiology (the diagnosis and treatment of heart problems in children). These pediatric subspecialists are generally called upon to consult with general pediatricians when a patient develops uncommon or special problems. If a subspecialist is ever needed to treat your child, your regular pediatrician will help you find the right one for your child's problem.

How to Find a Pediatrician for Your Baby

A good place to start looking for a pediatrician is by asking your obstetrician for referrals. He or she will know local pediatricians who are competent and respected within the medical community. Other parents also can recommend pediatricians who have successfully treated their children.

Once you have the names of several pediatricians you wish to consider, arrange a personal interview with each of them during the final months of your pregnancy. Most pediatricians routinely grant such preliminary interviews. Both parents should attend these meetings if possible, to be sure you both agree with the pediatrician's policies and philosophy about child rearing. Don't be afraid or embarrassed to ask any questions. Here are a few suggestions to get you started:

How soon after birth will the pediatrician see your baby?

Most hospitals ask for the name of your pediatrician when you're admitted to deliver your baby. The delivery nurse will then call that pediatrician or his associate on call as soon as your baby is born. If you had any complications during either pregnancy or the delivery, your baby should be examined at birth. Otherwise, the examination can take place anytime during the first twenty-four hours of life. Ask the pediatrician if you can be present during that initial examination. This will give you an opportunity to learn more about your baby and get answers to any questions you may have.

When will your baby's next exams take place?

Pediatricians routinely examine newborns and talk with parents before the babies are discharged from the hospital. This lets the doctor identify any problems that may have arisen and also gives you a chance to ask questions that have occurred to you during your hospital stay, before you take the baby home. Your pediatrician will also let you know when to schedule the first office visit for your baby (as early as one day after discharge), and how he or she may be reached if a medical problem develops before then.

When is the doctor available by phone?

Many pediatricians have a specific call-in period each day when you can phone with questions. If members of the office staff routinely answer these calls, you should find out what their training is. Also ask your pediatrician for guidelines to help you determine which questions can be resolved with a phone call and which require an office visit.

What hospital does the doctor prefer to use?

Ask the pediatrician where to go if your child becomes seriously ill or is injured. If the hospital is a teaching hospital with interns and residents, find out who would actually care for your child if he was admitted.

What happens if there is an emergency?

Find out if the pediatrician takes her own emergency calls at night. If not, how are such calls handled? Also, ask if the pediatrician sees patients in the office after regular hours or if you must instead take your child to an emergency room. When possible, it's often easier and more efficient to see the doctor in her office, because hospitals frequently require lengthy paperwork and extended waits before your child receives attention. On the other hand, serious medical problems are usually better handled at the hospital, where staff and medical equipment are always available.

Who "covers" the practice when your pediatrician is unavailable?

If your physician is in a group practice, it's wise to meet the other doctors, since they may treat your child in your pediatrician's absence. If your pediatrician practices alone, he probably will have an arrangement for coverage with other doctors in the community. Usually your pediatrician's answering service will automatically refer you to the doctor on call, but it's still a good idea to ask for the names and phone numbers of all the doctors who take these calls--just in case you have trouble getting through to your own physician.

If your child is seen by another doctor at night or on the weekend, you should check in by phone with your own pediatrician the next morning (or on Monday). Your doctor will probably already know what has taken place, but this phone call will give you a chance to bring him up to date and reassure yourself that everything is being handled as he would recommend.

How often will the pediatrician see your baby for checkups and immunizations?

The American Academy of Pediatrics recommends checkups by one month, and at two, four, six, nine, twelve, fifteen, eighteen, and twenty-four months, and annually after that. If the doctor routinely schedules examinations more or less frequently than this, discuss the difference with her.

What are the costs of care?

Your pediatrician should have a standard fee structure for hospital and office visits as well as after-hours visits and home visits (if he makes them). Find out if the charges for routine visits include immunizations. If not, ask how much they will cost. Also, if you are covered by a managed-care system (HMO, etc.), check whether the pediatrician is on the panel of physicians.

After these interviews, you need to ask yourself if you are comfortable with the pediatrician's philosophy, policies, and practice. You must feel that you can trust him or her and that your questions will be answered and your concerns handled compassionately. You should also feel comfortable with the staff and the general atmosphere of the office.

Once your baby arrives, the most important "test" of the pediatrician you have selected is how he or she cares for your child and responds to your concerns. If you are unhappy with any aspect of the treatment you and your child are receiving, you should talk to the pediatrician directly about the problem. If the response does not address your concerns properly, or the problem simply cannot be resolved, don't hesitate to change physicians.

Excerpted from CARING FOR YOUR BABY AND YOUNG CHILD: BIRTH TO AGE 5, edited by Steven Patrick Shelov, M.D., and Robert E. Hannemann, M.D. Copyright © 1998 by the American Academy of Pediatrics. Excerpted by permission of Bantam Books, a division of the Bantam Doubleday Dell Publishing Group, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.