Q. 1. Should my baby be vaccinated against the meningococcal vaccine?
Q. 2 Should my child be given Flu vaccine?
Q. 3 Which vaccines are compulsory & which are optional?
Q. 4 Why is there so much variation in vaccination charts of different Clinics/ Hospitals?
Q. 5 Should I go for DTwP or DTaP?
A. Answer to all such queries can be summarized in one sentence, "One should follow the standard guidelines of the country where the child usually stays". In India, the guidelines are formulated and regularly updated by the Indian Academy of Pediatrics (IAP). Diversions from the standard recommendations can be made in some exceptional cases, not a routine. For example, currently, IAP does not recommend the Meningococcal vaccine routinely in children. IAP recommends Influenza (Flu) vaccine routinely in 6 months to 5 years age group. Meningococcal vaccine and Influenza vaccine above 5 years of age is recommended only in high-risk children (Even the term "high risk children" is well defined). Similarly, if some hospital/ clinic in India is recommending Pneumococcal vaccine at 18, 22 and 26 weeks rather than standard recommendation of 6, 10 and 14 weeks), it is unfortunate.
IAP guidelines of 2013, 2014 and 2016 clearly stated that DTaP should NOT be used, especially for first 3 doses at 6, 10 and 14 weeks. Only DTwP should be used. Guidelines were updated in December 2018 that stated that although DTaP may be used, but DtwP is definitely superior in effectiveness. Latest update (January 2021) continues to endorse this.
Here is the the latest standard immunization chart (updated in january 2021) recommended by the Indian Academy of Pediatrics (IAP) that needs to be followed by all:
Q.5 My child has hurt himself. Does he need "tetanus injection"?
A. Tetanus toxoid is one of the components of routine vaccination that is given at 6, 10, 14 weeks (DTP vaccine), 16-18 months (DTwP/ DTaP), 5 years (DTwP/ DTaP), 10 years (TdaP) of age. If the child has received these vaccines as per his/ her age, he/ she does not need a tetanus toxoid ("tetanus injection" or "tetanus shot") after injury. The child also would not need human Tetanus immunoglobulin (TIG) injection.
If, however, your child has missed any of these or any of these is due, please consult your doctor immediately for appropriate vaccination. It is better to take the recommended vaccine (DTP/ TdaP/ Td depending upon child's age) rather than plain tetanus toxoid ("TT"), as it would help prevent diphtheria and whooping cough also in addition to tetanus. For larger, deeper or contaminated woulds, child would also need human Tetanus immunoglobulin (TIG) in addition to tetanus vaccine
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Vaccination issues
Q. 1. Doctor, my baby is healthy with good weight and born without any complications. Still, the hospital has advised some blood tests (newborn screening) and hearing test. Is it OK? We have never heard about these in our time.
A. Yes, many of these tests have been increasingly been done in India in last few years, although they have been the norm in developed countries for a long time. The aim is to rule out some issues soon after birth before the symptoms develop. Although these issues are not very common, but it is worthwhile to detect these early since it has been seen that by the time symptoms develop some irreparable damage is already done. Most common of these issues is hypothyroidism ("thyroid problem"). although this thyroid issue can begin at any age, sometimes it is present right from birth (congenital hypothyroidism). Unlike in older children/ adults affected with hypothyroidism where lethargy, weight gain, hoarse voice, dry skin are prominent symptoms, it affects brain development adversely when it is present from birth. This effect on brain development is irreversible. Detecting it soon after birth enables starting treatment right away and mental retardation is prevented. Similarly, detecting hearing problems soon after birth helps to start treatment at the right time before it affects brain development (especially speech and language development). There are some rare metabolic disorders that can be ruled out soon after birth and recent advances help to do the panel of tests with just one drop of blood!
Q. 2. My baby is just one day old and my breastmilk flow is not adequate yet. Which milk should I give to my baby?
A. Baby should be given only breastmilk. In the first 2 days after delivery, the breastmilk is normally very less since the baby's needs are minimal. All babies have an excess of water in their body at the time of birth and have to lose weight: all babies lose up to 10% of body weight in the first 3 days of life. Hence, a small amount of yellowish milk (called colostrum) that comes is sufficient for the baby. What's more, this colostrum is very rich in antibodies and many anti-infection factors...it is the strongest "immune booster" known: it is like vaccinating the baby against many infections. Not offering this to the baby means losing a golden opportunity forever! No other milk should be offered to the baby (not even once) as it would "overfeed the baby" and no other milk has those antibodies. Skin to skin contact of mother and baby promotes not only breastmilk flow, but it also helps in the long-term emotional bonding between the two.
Q. 3. Doc, my baby was crying whole night. I think she has some colic/ pain abdomen. He also strains and passes a lot of gas. What medicine should I give to help my little baby? Should I restrict anything in my diet?
A. It should be understood that babies have reverse "day-awake cycle". They are more active at night and sleep more during the day. This is because before the birth baby has been in dark 24*7. In the womb, the baby was in fluid (amniotic fluid) and keeps getting rocked as the mother moves about and does her daily activities...and the baby keeps sleeping. At night when the mother goes off to bed and everything becomes "silent", the baby wakes up and starts moving (remember the "baby kicks" were more at night?). The same pattern follows after birth: baby sleeps during day time and wakes up at night. So, if one holds the baby, the baby becomes a bit calmed, but resists being laid on bed (cries). This is normal. Had this excessive cry due to any "problem", where does this "problem" go during daytime and baby sleeps better...only to return every night?. So, what is the solution? There is no choice but to go by the baby's requirements and adjust one's schedule as per the baby. Mother should take rest during the daytime when the baby goes off to sleep (usually after sponging/ bath) and be prepared for less sleep at night. The only thing to be taken care of is to keep the room dimly lit even if the baby is active at night and keep the room well-lit even if the baby is sleeping during the daytime. If one keeps this difference between day and night, the baby adjusts to this within 1-1.5 months and starts sleeping at night by then. If, however, the room is well lit even at night, the baby remains in light 24*7 and this "reverse day awake cycle" persists longer.
Q. 4. When should I start bathing the baby? Can I apply soap? What about oil massage and other skin products?
A. In the first few days of life, just sponging with water is sufficient, taking care to keep the umbilical cord stump ("naal") dry. After the cord dries and falls down, wait for 2 more days till the base (umbilicus/ navel) is completely dry. After that, the baby can be given proper bath. Baby soap (unperfumed, uncoloured mild soap) can also be used. For soap and any other skin product, first application should be careful. Any skin product should not be applied on the whole body. It should be "tested" by applying it on a small area of baby's leg. Only when it is clear that it is not causing any rash/ reaction, can a skin product may be applied on the whole body from the next day. Oil application should be avoided for a month, as the skin is sensitive and chances of reaction/ rashes is more. Oil massage can be started after 1 month of age (after "testing" as described above). Oil massage should always be followed by bath with soap and water so as to remove the excess oil. Oil massage should be skipped on the days when the bath is being skipped. On the other hand, Baby lotion/ moisturizer is best applied just after the bath. Application Talcum should be avoided at any age.
Q. 5. My baby passes stools very frequently and with lot of gas. Should I worry?
Q. 6. My baby has not passed stool for 5 days.What should I do?
Q. 7. My baby "twists and turns" a lot. Is he having a problem?
A. All these are usually normal patterns in a newborn baby. If baby is active, feeding well, passing urine regularly, no medicines are usually required. In case of persisting concern or sudden change in pattern, it is worthwhile to get the baby examined to be doubly sure.
Q. 8. My baby keeps making noises while in sleep. Is there congestion in chest?
A. Baby's nose is very small and often gets blocked, especially at night when the temperature drops. If baby is sleeping well and making some sounds, this can be ignored. If you feel baby is having difficulty in sleeping or feeding due to nasal block then "saline nasal drops" can be instilled (3- 4 drops or 1 piff of spray in each nostril) to help the baby. In case of persisting concern, get the baby examined.
Issues regarding diet/ nutrition
Q. 1. Is Cow's milk good for babies?
A. The composition of animal milk is according to animal's need...not human. That is why breastfeeding is best for your baby.
Fat content is important for brain development. Hence, humans need high fat concentration in first 2 years of life when brain is developing. Animals need less fat.
Animals walk (and in fact run) from day 1 of life. Humans take more than one year to do so. Hence, animal milk has excessive protein that is OK for a cow but is "overload" on baby's immature kidney. The quality/ type of protein requirement is also different for human and a cow. In earlier days, many people used to dilute animal milk with water to reduce this protein concentration in milk. However, if milk is diluted, fat (that is already less) and many other nutrients (like iron) is further reduced: Hence, we can't get appropriate composition by diluting milk.
For better absorption of calcium from human intestine, we need calcium and phosphorus in 2:1 ratio. In animal milk, the ratio is 1:2. Moreover, anim and has excessive calcium as they walk from day 1 of life. Excessive calcium and reverse ratio can cause constipation and iron deficiency anemia (since calcium interferes with iron absorption)
These are only 3 examples: there are scores of differences in composition between human and animal milk: That is why, while human milk (breastmilk) is "24-karat gold" for your baby while cow or any other animal milk is just brass: Your baby deserves the best!!
In very limited situations where breastfeeding is not possible, infant milk formula is given to babies. However, it is to be remembered that even formula milk can't match the quality of breastmilk: It is like "14-karat gold": while it is much much better than brass (animal milk), it is still inferior to breastmilk ("24-karat gold")
Q. 2. Doctor, there are so many types of infant milk formulae available these days in the market. Which one to use?
A. First of all, it is to be noted that despite phenomenal amount of research and scientific and technological advancements, no infant milk formula anywhere in the world has matched breastmilk digestibility, effectiveness in terms of prevention of infections and allergies, IQ of babies, etc. Breastmilk continues to be "24-karat gold" for babies. Hence every effort should be made to give only breastmilk.
There is a popular myth that baby should be given bottle milk once or twice a day so that baby is "used to it". Why would you like your baby to get used to "bad habit"? Your baby deserves the best!! One must think 100 times and consult your doctor before giving infant milk formula to your baby even once!!
In limited situations where formula milk is required, choice is as per age of baby and affordability. Age: For all brands that are available in market, there is "Stage-1" formula for baby upto 6 months of age. For babies above 6 months of age, there are some brands that have "Stage-2" formula from 6 months of age to 24 months of age, while some brands have "Stage-2" formula from 6 months of age to 12 months of age. These brands have "Stage-3" and "Stage 4" formulae for babies from 12+ to 18 months and 18+ to 24 months of age. So, you have to select as mentioned on the pack of respective brand. "Basic" vs "Premium/ Advanced" or "Ultra-premium" variants: All brands of infant milk formulae have 2-3 variants. Even "basic" variant is much much better than cow or any other animal milk and must always be preferred over animal milk. The more advanced variants of infant milk formulae are definitely better than basic ones in their composition: They are closer (but do not match!!) to breastmilk composition. These should be preferred if affordability is not an issue.
Q. 3. Doctor, My baby is now 6 months old. What should be her diet now?
A. Following are the general guidelines on infant feeding in addition to milk (complementary feeding):
1. There is no doubt that breast milk is the best for a baby and one should not switch to any other milk. Complementary feeding is started, while continuing breastfeeding as before. Breastfeeding should preferably be continued till 2 years or even longer, as recommended by WHO/ UNICEF/ IAP. New research continues to endorse this. It improves lifelong health and intellectual outcome.
Babies who are on formula-milk should change to stage-2 formula and should still be breastfed as much as possible. Babies on formula milk need extra water, more so during any illness.
Animal milk (Cow milk/ Buffalo milk, “Mother Dairy”/ “Amul”/ “DMS” milk etc.) should strictly not be given to young babies to drink. However, for preparing cereals like suji-kheer, dalia etc., you can use small amount of animal milk. However, make sure that the final consistency is paste-like and not liquid (something that doesn’t drip if the spoon is tilted). Curd, cheese, etc made of animal milk can also be given.
2. Whatever is given has to be semi-solid (thick paste consistency), rich in fat (ghee/ butter/ oil) and very little added sugar and salt and almost no spices. The idea is to give condensed food: small in volume (as baby's stomach capacity is small) but high in calories (since baby has to grow fast). Roughly, 10-20 grams of extra butter/ ghee/ oil should be added to baby’s diet daily. Liquids like daal paani, fruit juices, tea/ coffee, thin soups etc. fill baby's stomach easily but do not provide enough calories. Instead, baby should be given thick “daal” (legumes/ lentils) with added ghee/butter, mashed fruits and vegetable puree. Also, processed/ tinned/ packed foods should be avoided. Never give biscuits, chips, noodles and other junk foods to your little one.
3. The food items which are usually started are: Moong-dhuli Dal with added ghee (NOT daal paani), khichari (rice gruel) with added ghee, suji-halwa (sweet or salty) rich in ghee, mashed banana, other fruits in mashed form (mango, papaya, melon, water-melon: practically any fruit without seeds in mashed form (NOT juices). After a few days, paratha (Indian bread) (mashed) can also be started. Add vegetables in paratha/ rice gruel/ suji. Gradually add other dal also. Jaggery (Gur) can often be used in place of sugar, as it is rich in iron. You can also add powdered dry fruits to anything that is being given to the baby: It adds to nutrition. Sprouts are also very nutritious.
4. Try to give non-vegetarian items (egg, fish, chicken, etc.) daily, or as often as possible, if culturally acceptable. If not, then give cheese, soya (“Nutrella” granules), etc. daily, or as often as possible.
5. Amount and mode of administration: Breast feeding is continued as before. In between two feeds, small amount of above food items is offered. Let the amount be decided by baby only. Some babies take only ½-1 spoon; but some babies accept ½ bowl right from day-1. Gradually amount is increased as the baby's acceptance increases. As baby's solid diet increases, the interval between breastfeeds automatically increases.
6. Consistency/ texture of food offered is also very important. Initially, mashed food is started. The food is mashed with hand or spoon, so that there is some “unevenness”: this helps your little one to learn chewing. Never use mixer-grinder (“mixie”) to make the food offered. With such uniform consistency, baby will have severe problems in future related to chewing of food. Gradually, the texture of foods is further increased. For example, initially, mashed banana is offered. By 7-8 months, baby should be given semi-formed banana and by 9-10 month: baby should be able to take small pieces of banana as such. At the same time, too hard food items like dry fruits, raw carrots, etc. should also be avoided as they can cause choking.
6. One of the advantages of Commercial infant formulae like “Cerelac” is that they are easy and quick to prepare. They are ideal when baby suddenly demands food or during travel etc. Otherwise home-cooked food is much better: it has no preservatives, and baby does not need transition from "infant food" to home food at a later age and is used to all that you eat from a very early age. Even during travel one can use home-cooked foods or reconstituted home made cereal mixtures/ fruits. Still, if one wishes to use “infant cereal”, it comes in various stages, as you know: stage-1, 2, 3 and 4. You have to start from stage-1 and gradually move to stage 4 over several months.
7. Continue iron and vitamin D supplements as advised.
8. All this was about what all infant can be fed. How food is given is also important. “Responsive feeding” (giving food in “response” to baby’s indications/ cues of hunger) is the best way, rather trying to “control” the amount and timing of feeding. It has been shown to improve not only baby’s food intake, but also emotional bonding and brain development in the long run. Ask about details of “responsive feeding” from your doctor on your next visit.
Q. 4. My baby is now 1 year old. Can I give Animal milk to him?
A. The composition of animal milk is according to animal's need...not human. That is why continuing breast feeding is best for your baby. If you have been giving formula milk (infant milk formula) to your baby, it should be continued since its composition is according to baby's need. While some brands have stage-3 milk for babies above one year of age, in some other brands, stage-2 is to recommended till 2 years of age. Please check the brand you are using to choose appropriate "stage" of formula milk to be given. However, formula milk (any brand) is much much better than giving animal milk to your baby. If breast milk is like "24-karat gold", then animal milk is like "brass" for a young baby. Formula milk is like "14-karat gold" that is still better than "brass"!!
However, please note that you can continue giving milk products like curd, cheese and even milk cereal (like kheer, dalia, etc.) that is prepared in animal milk. It is just that milk as a drink is avoided in young ones till two years of age. Another important point to be noted here is that at this age (above 1 year), baby should be more on solid, family- diet (with extra fat) and amount of milk should go on decreasing as the child grows.
Please note that formula milk is also made from animal milk only..but it's composition is altered according to human need. For example, extra protein is removed, type of protein is also altered and extra fat is added....
If you wish to know more about differences in animal milk vs human milk or formula, please see Q. 1 above.
Q. 4. Doctor, then when can I give animal milk to my child?
A. Animal milk should ideally be started when child is above 2 years of age. Toned milk should be given and amount of milk and milk products should not exceed 500mL in 24 hours for a child between 2 years of age and teen age. Teenagers require upto 1 L/ day during growth spurt.
Newborn issues
Q. 1. My 3 year old son frequently suffers from cough and cold. Does he have low immunity? Does he require any tests?
A. Every child in 2-6 years of age group suffers from frequent cough/ cold. These children, especially in lower side of this age group can have 6-8 episodes of cough/ cold every year. The frequency of these episodes is even more during change of season and when the toddler starts going to day-care (creche)/ play school/ school, since there are a number of children (all in this vulnerable age-group) in a room that facilitates spread of infection. These episodes appear similar, but in fact there are numerous viruses that can cause similar symptoms. Hence, technically these infections are not "same" but by different viruses. Recovery can be fast with some viruses, while prolonged course (occasionally even upto 3 months) with others. It does not indicate "low immunity". IN fact, it is immunity only that helps the kids recover. The frequency of these episodes decreases somewhat at ~ 5-6 years of age (when the child has unfortunately already suffered from most of these viruses).
Medicines are not always needed, especially in milder cases. In more severe episodes, medicines are given to provide relief from symptoms but do not shorten the course of illness. Parents must know that most of these episodes of cough/ cold are viral infections and antibiotics have no role in viral infections. Antibiotics are prescribed only when bacterial infection is suspected. Lab tests are rarely required.
Q. 2. My 2-year old daughter throws a tantrum every now and then. How to handle?
A. When your lovable, adorable cutie pie throws his first tantrum, the usual reaction is, “He is getting spoilt!!” However, that is not true. Temper tantrum signifies that the toddler has finally discovered a sense of his own individuality, and is asserting that. It is an immature way of expressing anger and is normal in the toddler age-group. No matter how calm and gentle a parent you are, your child will probably throw some tantrums. They generally begin around age 12-18 months, get worse between 2 and 3 years and then decrease rapidly until age 4, after which they should be seldom seen.
First, one must understand what causes temper tantrums?
As a young child learns more and becomes more independent, he wants to do more than he can physically and emotionally manage. Moreover, at this age he may not have the vocabulary to adequately express his feelings. Thus, although he is old enough to assert his individuality, he is too young to express his frustration/strong emotions in socially acceptable way. This manifests as a temper tantrum. Being tired, hungry, or sick can make tantrums worse or more frequent.
Can we prevent temper tantrums?
Yes, preventing situations which can precipitate temper tantrum can help.
Avoid over-exertion
Don’t expect more from your child that he can handle. For example, don’t expect your toddler to “cooperate” with you while you are waiting in a long queue. Try visiting bank/departmental store during lean hours. If that is not possible, then don’t forget to carry his favorite toys/ snacks to keep him busy.
Avoid over-reacting
Toddlers are very inquisitive and learn by exploring surroundings. Thus, things like spilling glass of water, throwing a spoon on the floor are just his ways of gathering information. If you over-react (e.g., shout at him/lose your temper), you are creating a perfect setting for temper tantrum. Basically, you have to imagine yourself to be in his shoes and try to understand his point of view. Be patient and help him learn.
Minimize use of “no!”
Toddlers pick up everything from their environment. Those who hear “no” often tend to say it a lot! Some toddlers simply get frustrated by hearing “no” all the time from the adults around him. As far as possible, try to make positive statements and be surprised to see positive change in your baby. For example, “Yes, let me finish folding the clothes and then we'll go out” is better than “No! We can’t go out now”. It is equally important to allow reasonable requests, ignore some “minor” misbehavior and let him explore this fantastic world!
Prepare in advance
If you know you are going for a long drive or visiting relatives, it helps if you are prepared and know what to expect. Carry snacks if you feel your toddler might get hungry, let his nap beforehand if he has had a tiring day, carry crayons and a colouring book or a book to keep him occupied. If you go shopping it may be best to avoid, if possible, the toy-shop and things that you know may trigger off a tantrum. If he accompanies you to a departmental store, let him select a couple of things that he may want.
Positive reinforcement
It is basic human nature that we respond better to appreciation and encouragement than corrective diktats. That’s true for your little one also. Thus, rather than simply reacting to your toddler’s misbehavior, appreciate his good behaviour and see the difference. Your baby prizes your approval above all else. Kiss him when he is behaving well. Never forget to say, “Very Good!!” when he has done something good, for example, putting his toys back into basket. This will build his confidence and encourage him to keep up the acts of good behaviour.
Q.3 My kid is 5 years old. He still wets bed at night. What to do?
A. Bedwetting at night (medical term, “nocturnal enuresis”) is fairly common, especially in boys. In fact, it is considered as “normal” till 5-6 years of age. Even after 6 years of age, it needs treatment only because it becomes a social issue. It is known to run in families; it is more common in children where there is family-history of the same problem.
It should be clearly understood that it is a problem that always gets resolved sooner or later. However, it is also a fact that there is no "quick fix" solution to this and one needs to have loads of patience and approach the problem gently and systematically.
The first step in treatment is of course, restriction of fluids after 7 pm. Avoid any drinks with caffeine (e.g., cola drinks). The child is asked to urinate before going to bed. Older children who don’t like “being told” about it every day may respond favourably to a sign at their bedside or on the bathroom mirror. Ask the child to promise to himself and/ or pray before going to bed that he would wake up from bed for passing urine. It is to be done daily irrespective of results. It is preferable to wake him up at mid might again and make him pass urine. Avoid using diapers. Although diapers make the child (and parents!) comfortable, they interfere with motivation for getting up at night. However, they can be used selectively for camping or overnights at other people's homes.
The child should be encouraged to drink a lot during the morning and early afternoon. The more the child drinks, the more urine child will produce, and more urine leads to larger bladder. Thus, it helps in increasing bladder capacity.
These children do not like being wet. They feel quite guilty and embarrassed about this problem. They need support and encouragement, not blame or punishment. Siblings should not be allowed to tease bed-wetters. Home needs to be a safe haven for the child. Punishment or pressure will delay a cure and cause secondary emotional problems. In fact, sometimes bedwetting is a channel to relieve anxiety/frustration/anger by the child. Thus, any reprimands, punishments, name-calling etc. for bedwetting certainly become impediments to success: Bedwetting worsens. Verbally and non-verbally (your body language) must suggest that you are "with" him for this problem and you do not "accuse" him for this: as it is definitely not in his control.
“Positive reinforcement” does wonders in these children: By positive reinforcement, I mean rewards for being dry at night. You must maintain a written diary/ calendar and mark the days he was dry. Keep realistic "targets" for him and pre-decide appropriate rewards for achieving the targets. For example, if he wets almost every day, he must be rewarded even for single dry night in a week (reward like an outing or extra play time, etc); if he wets 3-4 times a week, the reward should be for 3 consecutive dry nights. Gradually he would move up the ladder.
When your child wakes with wet sheets, have your child help you change the sheets. Explain that this isn't punishment, but it is a part of the process. It may even help your child feel better knowing that he or she helped out. It should not look like a punishment to the child.
In case the child is not improving with above steps or is already more than 7 years of age, consult your doctor for further treatment.
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