On Call… with Dr. Mary Thomas

HPV Vaccine: A Pediatricians Argument to Vaccinate Your Daughters AND Sons !

Although millions of dollars and man-hours have proven again and again that our vaccines are safe, many parents are still afraid.  Each day that I am in my office I find myself making pleas to parents to vaccinate their children with routine vaccines recommended by the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP) and that are also required by New Jersey schools.  Imagine, then, how challenged I feel when faced with the task of vaccinating young girls, and even young boys with a vaccine that has garnered as much controversy as the HPV vaccine. 

 As a pediatrician, and a mom of three young kids I feel that one of my most important purposes in life is to protect children from illness and disease.  My vaccines are my most powerful tool in doing so.  I might even argue that the HPV vaccine is the sharpest tool in my belt because it is the only one that can protect our children from something that we all fear may sneak up on us – cancer. 

If this article has caught your attention you must have wondered about the HPV vaccine once or twice.  What is it and why is it so important?  HPV (Human Papilloma Virus) is a sexually transmitted virus that infects more that half of sexually active people at one time or another.  Usually it is a benign wart that may even be asymptomatic and will in many cases resolve without treatment.  However, in the US, 15,000 women will develop cervical cancer from that virus; and of those 15,000 women, 4,000 will die. 

Those statistics are very frightening, but for the first time in history, we can change them.  The HPV vaccine prevents most cervical cancer if the vaccine is received before first sexual contact.  This is why the optimal time to vaccinate is at age 11 or 12.  This is also the time when the body is primed to create the best immunity.

The schedule is simple.  The first dose is given and then the second will follow 1 to 2 months later.  A third dose is indicated 6 months after the first dose was received.  It seems easy, but we need to do better.  At present, only 32 percent of girls receive all three vaccines and only 1% of boys.

Yes, boys.  I guess you are thinking “Why should I vaccinate my son, who does NOT have a cervix?”  It is a good question.  On October 26^th the CDC recommended the vaccine for all males ages 11 to 12.  For them it can prevent both genital warts and anal cancer.  There is also evidence that it may prevent some types of head and neck cancer transmitted through oral sex by men who have sex with men.  Don’t write me off at this point, this is not just an STD that affects homosexuals.  At some point we all hope that our sons will find the perfect girl and marry.  This vaccine protects her and helps prevent your son from caring for a wife with a cancer that can be potentially fatal. 

These are things that are hard to think about as parents.  They are even harder to talk about with our children.  A recent study in pediatrics showed that daughters of women who have talked to their mothers about the risks of unprotected sex and the benefits of vaccination were more likely to elect for the vaccine.  Talk to your kids.  Protect them before sexual contact.  You may be saving their life! 

On Call with Dr. Basil Bruno

This month Pedimedica asks Dr. Bruno for his insight and recommendations on how to ease your child’s back to school anxiety.

How to Overcome School Anxiety

Going to school offers a wide range of emotions for parents as well as children. Whether it's dread or excitement, fear or euphoria, all of these feelings can be bottled up inside our kids. Remember that any one symptom of distress does not cement a child's fate or mean that their school year will be a failure. All kids, at some point in their academic career, will struggle, so try hard not to view their setbacks or anxiety as a permanent threat to their school career. Every year that your child goes through school will be filled with highs and lows, good moments and devastating ones. The emotions your child experiences before the start of school can also lead to a general sense of anxiety-a feeling most children won't be able to articulate.
As parents, we have to realize that our children rarely will open up to us if they are experiencing any problems or anxiety, whether at home or at school.  This can be due to embarrassment, fears of being punished, or retribution from siblings or classmates.   And sometimes they just can’t figure out what is bothering them, a common sign of anxiety. Sometimes there are signs that we can pick up on that may help us decide if there is a problem.  Significant changes in behavior sleep patterns, homework or grade patterns, and friendships may be signs that your child is experiencing school issues or anxiety. As parents, it’s our instinct to want to jump right in to protect and help our children.  Although it’s fine to initially address the situation with your child, it’s important to not be overbearing and to back off if you are met with resistance.  It might be helpful to talk to your pediatrician if this occurs.

It's important to remember that when placed in any new situation, all children (and parents, too) are going to need to take time to adjust. Realize that your child will require a period of time to figure out their comfort zone and what's required for them to fit in to their new environment. Fortunately, there are steps you can take as a parent to make the prospect less daunting-the key is to prepare your child both emotionally and physically so that they can have the best start possible this school year.

Proactive parents can help their kids overcome school anxiety. Dr. Bruno lists several tips for parents to employ:

• Identify and address anxieties you have about your struggling child.
• Set a time and place to discuss the issue when your child is most relaxed.
• Start the discussion with hopeful empathy.
• Help your child remember past successes.
• Form a plan.
• Familiarize your child with the school.
• Talk to your pediatrician if you notice any significant changes in behavior.

For Learn more about Pedimedica Hackensack Office, Please visit, www.pedimedica.com

On Call with Dr. Lona Yegen, Pedimedica, Closter Office

Understanding ADD and ADHD and their treatment options from a medical and behavioral approach.

Q.What is ADD and ADHD?
A. Attention Deficit (Hyperactivity) Disorder is a condition in which the child has the following symptoms that may or not be accompanied by hyperactivity:
1. Difficulty in paying attention and focusing.
2. Difficulty with impulsivity.
3. A lack of organizational skills.

Q.How do we diagnose ADD?
A.This is a clinical diagnosis.  It is usually diagnosed after a child enters school and because he/she is having difficulties there.  A child should have a complete physical exam with a Pediatrician to confirm that there are no medical problems that could be causing these symptoms including testing a child's vision and hearing.  There should be an evaluation by the child's' teachers and parents using guidelines to evaluate behavior. The child may be evaluated by a Neurologist, developmental Pediatrician, or a Psychiatrist to make certain the child fits the categories for ADD/ADHD and make sure there are no other concerns e.g. learning disabilities.

Q.How do we treat ADD/ADHD?
A.The medical therapies fall into three categories:
1. Stimulant medication e.g. Ritalin, Concerta, Focalin, Daytrana
2. Non stimulant medication e.g. Straterra
3. Anti-depressants e.g. Wellbutrin
Stimulant medications are the most commonly used medications.  There are side effects to all three classes of medication.  For example, stimulant medications can suppress appetite and growth and can cause difficulty with falling asleep. Therefore, they must be used with supervision by a medical professional to make sure they are well tolerated. The medical therapies will be managed by your pediatrician, neurologist, or psychologist so let us talks about behavioral therapies.

Behavioral therapies are multiple.
1. In managing behaviors there are technologies to improve memory and focus.  For example, while riding in a car, tell the child you are going to play a game.  You are going to name three things and you are going to ask the child to name them later. So, at the beginning of the ride, name three items, e.g. ice cream, bicycle, mountain and at the end of the ride, ask the child to list them.  If the child can name three things consistently, then go to five things.  There is also a board game called Memory which works on the same skills.

2. We also want to teach the child organizational skills.  Organizational skills can start at the beginning of the day.  Ask the child to list “what do I need for the day in school?” and make a check list of all items and assemble books, assignments, clothes e.g. gym clothes, lunch so that he/she is ready for the day.  If the morning is too hectic this can be done at night.  Organizational skills should be done throughout the day.  Give the child a notepad so he/she can write down assignments and a check list for all books so the child is prepared when he/she gets home.  Organizational skill should continue after school.Teach the child to make a schedule for what homework and chores need to be done that day and allot specific times for each subject and task with scheduled breaks for sports, play dates, and hobbies like music lessons.

3. School strategies include placing the child with ADD/ADHD in the front of the class so it is easier to focus on the teacher.  Also, the teacher and child can have a special signal that they choose to remind the child to stay on task.  For example, the teacher can raise her right thumb up as a sign so the child needs to look and listen to her.  No one else will know this special signal.

4. Homework should be done in a quiet place without distractions.

5. Goal setting should be clear and concise.  When a goal or assignment is completed there should be verbal rewards or approval with extra time for a pleasurable activity.

6. There are Psychologists and social skills courses for children who need help with their behavior or relationships.

Q.When should we use medication?

A.Consider the following indicators:

• When all the behavioral and psychological therapies are not working.
• When the child's school performance is below expectations due to his/her inability to concentrate on set skills.
• When the child is not able to control impulsive behaviors leading to relationship problems or when the child is disruptive to others in class.
• When there are concerns that poor academic performance is leading to low self esteem.

Q.When should we not use medication?

A.Consider the following indicators:

• The child is doing well academically in school.
• The child's behavior is not disruptive in class.
• The child's peer and family relationships are good.
• When the parents are concerned about long term use of medication.

On Call with Dr. Kolsky

It’s summer and we all love to be outside and enjoy the great outdoors, but take precaution with your children’s delicate skin.

Infants through teens must be careful when it comes to sun exposure. Dr. Kolsky has researched and posted an extremely informative article from Healthykids.org on this topic and has even included a sun burn instruction sheet that you should print out and keep handy during the lazy, hazy days of summer. Also, remember to check back on this site next week to hear Dr. Suldane’s radio show on this very relevant topic!

So as you slather in the suntan lotion make sure to read these important guidelines:

“We all need some sun exposure; it's our primary source of vitamin D, which helps us absorb calciufor stronger, healthier bones. But it doesn't take much time in the sun for most people to get the vitamin D they need, and repeated unprotected exposure to the sun's ultraviolet rays can cause skin damage, eye damage, immune system suppression, and skin cancer. Even people in their twenties can develop skin cancer.

Most kids rack up between 50% and 80% of their lifetime sun exposure before age 18, so it's important that parents teach their children how to enjoy fun in the sun safely. With the right precautions, you can greatly reduce your child's chance of developing skin cancer.

Facts About Sun Exposure

The sun radiates light to the earth, and part of that light consists of invisible ultraviolet (UV) rays. When these rays reach the skin, they cause tanning, burning, and other skin damage.

Sunlight contains three types of ultraviolet rays: UVA, UVB, and UVC.

1.    UVA rays cause skin aging and wrinkling and contribute to skin cancer, such as melanoma. Because UVA rays pass effortlessly through the ozone layer (the protective layer of atmosphere, or shield, surrounding the earth), they make up the majority of our sun exposure. Beware of tanning beds because they use UVA rays as well as UVB rays. A UVA tan does not help protect the skin from further sun damage; it merely produces color and a false sense of protection from the sun.

2.    UVB rays are also dangerous, causing sunburns, cataracts (clouding of the eye lens), and effects on the immune system. They also contribute to skin cancer. Melanoma, the most dangerous form of skin cancer, is thought to be associated with severe UVB sunburns that occur before the age of 20. Most UVB rays are absorbed by the ozone layer, but enough of these rays pass through to cause serious damage.

3.    UVC rays are the most dangerous, but fortunately, these rays are blocked by the ozone layer and don't reach the earth.

Melanin: The Body's First Line of Defense

UV rays react with a chemical called melanin that's found in skin. Melanin is the first defense against the sun because it absorbs dangerous UV rays before they do serious skin damage. Melanin is found in different concentrations and colors, resulting in different skin colors. The lighter someone's natural skin color, the less melanin it has to absorb UV rays and protect itself. The darker a person's natural skin color, the more melanin it has to protect itself. (But both dark- and light-skinned kids need protection from UV rays because any tanning or burning causes skin damage.)

Also, anyone with a fair complexion — lighter skin and eye color — is more likely to have freckles because there's less melanin in the skin. Although freckles are harmless, being outside in the sun may help cause them or make them darker.

As the melanin increases in response to sun exposure, the skin tans. But even that "healthy" tan may be a sign of sun damage. The risk of damage increases with the amount and intensity of exposure. Those who are chronically exposed to the sun, such as farmers, boaters, and sunbathers, are at much greater risk. A sunburn develops when the amount of UV exposure is greater than what can be protected against by the skin's melanin.

Unprotected sun exposure is even more dangerous for kids with:  

• moles on their skin (or whose parents have a tendency to develop moles)
• very fair skin and hair
• a family history of skin cancer, including melanoma

You should be especially careful about sun protection if your child has one or more of these high-risk characteristics.

Also, not all sunlight is "equal" in UV concentration. The intensity of the sun's rays depends upon the time of year, as well as the altitude and latitude of your location. UV rays are strongest during summer. Remember that the timing of this season varies by location; if you travel to a foreign country during its summer season, you'll need to pack the strongest sun protection you can find.

Extra protection is also required near the equator, where the sun is strongest, and at high altitudes, where the air and cloud cover are thinner, allowing more damaging UV rays to get through the atmosphere. Even during winter months, if your family goes skiing in the mountains, be sure to apply plenty of sunscreen; UV rays reflect off both snow and water, increasing the probability of sunburn What's important is to protect your family from exposure to UVA and UVB, the rays that cause skin damage.

With the right precautions, kids can safely play in the sun. Here are the most effective strategies:

Avoid the Strongest Rays of the Day

First, seek shade when the sun is at its highest overhead and therefore strongest (usually 10 a.m. until 4 p.m. in the northern hemisphere). If kids must be in the sun between these hours, be sure to apply and reapply protective sunscreen — even if they're just playing in the backyard. Most sun damage occurs as a result of incidental exposure during day-to-day activities, not at the beach.

Even on cloudy, cool, or overcast days, UV rays travel through the clouds and reflect off sand, water, and even concrete. Clouds and pollution don't filter out UV rays, and they can give a false sense of protection. This "invisible sun" can cause unexpected sunburn and skin damage. Often, kids are unaware that they're developing a sunburn on cooler or windy days because the temperature or breeze keeps skin feeling cool on the surface.

Make sure your kids don't use tanning beds at any time, even to "prepare" for a trip to a warm climate. Both UVA and UVA/UVB tanning beds produce sunburn. And there is an increase in the risk of melanoma in people who have used tanning beds before the age of 35.

Cover Up

One of the best ways to protect your family from the sun is to cover up and shield skin from UV rays. Ensure that clothes will screen out harmful UV rays by placing your hand inside the garments and making sure you can't see it through them.
Because infants have thinner skin and underdeveloped melanin, their skin burns more easily than that of older kids. But sunscreen should not be applied to babies under 6 months of age, so they absolutely must be kept out of the sun whenever possible. If your infant must be in the sun, dress him or her in clothing that covers the body, including hats with wide brims to shadow the face. Use an umbrella to create shade.

Even older kids need to escape the sun. For all-day outdoor affairs, bring along a wide umbrella or a pop-up tent to play in. If it's not too hot outside and won't make kids even more uncomfortable, have them wear light long-sleeved shirts and/or long pants. Before heading to the beach or park, call ahead to find out if certain areas offer rentals of umbrellas, tents, and other sun-protective gear.

With the right precautions, kids can safely play in the sun. Here are the most effective strategies:

Avoid the Strongest Rays of the Day

First, seek shade when the sun is at its highest overhead and therefore strongest (usually 10 a.m. until 4 p.m. in the northern hemisphere). If kids must be in the sun between these hours, be sure to apply and reapply protective sunscreen — even if they're just playing in the backyard. Most sun damage occurs as a result of incidental exposure during day-to-day activities, not at the beach.

Even on cloudy, cool, or overcast days, UV rays travel through the clouds and reflect off sand, water, and even concrete. Clouds and pollution don't filter out UV rays, and they can give a false sense of protection. This "invisible sun" can cause unexpected sunburn and skin damage. Often, kids are unaware that they're developing a sunburn on cooler or windy days because the temperature or breeze keeps skin feeling cool on the surface.

Make sure your kids don't use tanning beds at any time, even to "prepare" for a trip to a warm climate. Both UVA and UVA/UVB tanning beds produce sunburn. And there is an increase in the risk of melanoma in people who have used tanning beds before the age of 35.

Use Protective Eyewear for Kids

Sun exposure damages the eyes as well as the skin. Even 1 day in the sun can result in a burned cornea (the outermost, clear membrane layer of the eye). Cumulative exposure can lead to cataracts (clouding of the eye lens, which leads to blurred vision) later in life. The best way to protect eyes is to wear sunglasses.

Not all sunglasses provide the same level of ultraviolet protection; darkened plastic or glass lenses without special UV filters just trick the eyes into a false sense of safety. Purchase sunglasses with labels ensuring that they provide 100% UV protection.

But not all kids enjoy wearing sunglasses, especially the first few times. To encourage them to wear them, let kids select a style they like — many manufacturers make fun, multicolored frames or ones embossed with cartoon characters. And don't forget that kids want to be like grown-ups. If you wear sunglasses regularly, your kids may be willing to follow your example. Providing sunglasses early in childhood will encourage the habit of wearing them in the future.

Double-Check Medications

Some medications increase the skin's sensitivity to UV rays. As a result, even kids with skin that tends not to burn easily can develop a severe sunburn in just minutes when taking certain medications. Fair-skinned kids, of course, are even more vulnerable.

Ask your doctor or pharmacist if any prescription (especially antibiotics and acne medications) and over-the-counter medications your child is taking can increase sun sensitivity. If so, always take extra sun precautions. The best protection is simply covering up or staying indoors; even sunscreen can't always protect skin from sun sensitivity caused by medications.

If Your Child Gets a Sunburn

A sunburn can sneak up on kids, especially after a long day at the beach or park. Often, they seem fine during the day but then gradually develop an "after-burn" later that evening that can be painful and hot and even make them feel sick.

When kids get sunburned, they usually experience pain and a sensation of heat — symptoms that tend to become more severe several hours after sun exposure. Some also develop chills. Because the sun has dried their skin, it can become itchy and tight. Sunburned skin begins to peel about a week after the sunburn. Encourage your child not to scratch or peel off loose skin because skin underneath the sunburn is vulnerable to infection.

If your child does get a sunburn, these tips may help:

• Have your child take a cool (not cold) bath, or gently apply cool, wet compresses to the skin to help alleviate pain and heat.
• To ease discomfort, apply pure aloe vera gel (available in most pharmacies) to any sunburned areas.
• Give your child an anti-inflammatory medication like ibuprofen or use acetaminophen to lessen the pain and itching. (Do not, however, give aspirin to children or teens.) Over-the-counter diphenhydramine may also help reduce itching and swelling.
• Apply topical moisturizing cream to rehydrate the skin and treat itching. For the more seriously sunburned areas, apply a thin layer of 1% hydrocortisone cream to help with pain. (Do not use petroleum-based products, because they prevent excess heat and sweat from escaping. Also, avoid first-aid products that contain benzocaine, which may cause skin irritation or allergy.)

If the sunburn is severe and blisters develop, call your doctor. Until you can see your doctor, tell your child not to scratch, pop, or squeeze the blisters, which can become easily infected and can result in scarring. Keep your child in the shade until the sunburn is healed. Any additional sun exposure will only increase the severity of the burn and increase pain.

Be Sun Safe Yourself
Don't forget: Be a good role model by consistently wearing sunscreen with SPF 30 or greater, using sunglasses, and limiting your time in the sun. These preventive behaviors not only reduce your risk of sun damage, but teach your kids good sun sense.

Reviewed by: Kate M. Cronan, MD

Date reviewed: August 2010

PEDIMEDICA in Honduras as part of a Humanitarian Medical Brigade.

During April, Members of Pedimedica once again travelled to Honduras as part of a humanitarian medical brigade. For Clare DeBlasio RN, it was her 9th trip, for Dr. Kolsky his 7th, and for medical assistant Carmen Mercado her 3rd.

Always a very rewarding trip, this particular brigade treated over 3000 patients, including more than 1600 pediatric patients.

The pediatric problems treated include a pot pourri of common and some complex medical issues, including, but not limited to, asthma, parasitic infections, skin infections, hepatitis, other respiratory ailments, etc.

On these brigades we are able to recognize previously undiagnosed medical conditions, and refer these patients for further treatment.

Treating these patients is always a pleasure, as they are in such need of medical care. They receive very little care, other than what is provided by the rare medical teams that visit these remote villages. Most of these people have never seen a physician, other than those we provide.

We look forward to our return next year.

On-Call with Dr. Rosenberg…Find out the facts on HPV

HPV will affect an estimated 75% to 80% of males and females in their lifetime. For most, HPV clears on its own. But, for others, certain HPV diseases—such as cervical, vaginal, and vulvar cancers and genital warts—can develop. There is no way to predict who will or won't clear the virus. As a parent of a pre-teen, you need to know the facts.

What is HPV?

Genital human papillomavirus is the most common sexually transmitted virus in the United States.  There are more than 40 HPV types that can infect the genital areas of males and females. These HPV types can also infect the mouth and throat. Most people who become infected with HPV do not even know they have it.  HPV is spread mostly through sexual contact.

How do I know if I have HPV?  What are the signs?
Most HPV infections do not cause any signs and 90% go away spontaneously within two years. More than half of sexually active males and females are infected with HPV at some times in their lives. 

What happens to the 10% that contract the virus that do not resolve on their own?

Certain types of HPV can cause genital warts in males and females. Rarely, these types can also cause warts in the throat or upper respiratory tract.  Other HPV types can cause cervical cancer. These types can also cause other, less common but serious cancers, including cancers of the vulva, vagina, penis, anus, and head and neck (tongue, tonsils and throat). 
The types of HPV that can cause genital warts are not the same as the types that can cause cancer. There is no way to know which people who get HPV will go on to develop cancer or other health problems.

How does one get HPV?

HPV is passed on by genital contact, most often during intercourse (vaginal as well as anal). HPV may also be passed on during oral sex and genital-to-genital contact. HPV can be passed on between straight and same-sex partners—even when the infected partner has no signs or symptoms.
One can have HPV even if years have gone by since he or she had sexual contact with an infected person. Most infected people do not realize they are infected or that they are passing the virus to their partner. It is also possible to get more than one type of HPV.
Very rarely, a pregnant woman with genital HPV can pass HPV to her baby during delivery. In these cases, the child can develop warts in their respiratory tract.


How does one prevent HPV?

Vaccines can prevent both men and women from some of the most common types of HPV.  The vaccines are administered in a three dose series over a matter of months.Gardasil is recommended from ages 9 to 26 years of age.  The first dose is given, the second is two months later and the third is six months from the first.  It protects against two types of HPV that can cause genital warts and two types that can cause cervical cancer.  Cervarix is another type of HPV vaccine that is given in a series of three shots at dose one, one month from the first and six months from the first.  Cervarix protects against two types of HPV that can cause cervical cancer.Only Gardasil is currently available for boys between the ages of 9 to 26 years, for the revention of genital warts.  It is FDA approved, but not yet recommended by the American Academy of Pediatrics as part of the routine immunization schedule for males.It is important to complete the entire vaccine series to get the optimal protection. The vaccines are most effective when given before a person's first sexual contact, when he or she could be exposed to HPV.For those who choose to be sexually active, condoms are important to lower against the risk of HPV.  To insure optimal protection, they should be used with every sex act from beginning to end.   HPV is so virulent that it can affect areas that are not covered by a condom, and therefore even condoms are not 100% protective.  Thus, abstinence is the best way to prevent against HPV and all sexually transmitted diseases.  

Why is HPV vaccine given to such a young age group?

It is important for girls to get HPV vaccine before their first sexual contact--prior to being exposed to the disease.  For this crowd, the vaccines can prevent almost 100% of the types of HPV targeted by the vaccines.  If a woman is already infected with a type of HPV, the vaccine will not provide protection against that type.  

What are the risks from the HPV vaccine?

The HPV vaccine is an inactivated (not live) vaccine protecting against HPV.  It does not give the HPV virus.  Protection from the HPV vaccine is expected to be long lasting.
The most common side effects after the vaccine is administered are very mild:  soreness, redness and swelling at the injection site.  It can also cause mild to moderate fever and itching at the site, nausea and dizziness.  These side effects have been known to dissipate quickly.
While serious events, including death and Guillain-Barre syndrome, have been reported among women who had recently received HPV vaccine, CDC follow-up on these reports found that the events had not occurred more frequently among vaccines recipients than among the general population, and no pattern was detected that would indicate an association with the vaccine.

Who should not receive the HPV vaccine?

Anyone who has had a life-threatening allergic reaction to yeast, to any other component of the HPV vaccine, or a previous dose of the HPV vaccine should not get the vaccine.

How does one treat HPV?

There is no treatment for HPV, but the conditions it causes can be treated.  Genital warts can be treated by health care professionals and cervical cancer can be contained if diagnosed and treated early; with annual Pap smears and regular visits to the gynecologist.  The best
treatment is prevention. 

For more information on HPV, go to www.cdc.gov/std/hpv 

On Call with Dr. Dora Suldan, MD

Breastfeeding, the most natural way to nurture your baby, can pose challenges for first timers!

Dr. Dora Suldan, Pedimedica’s “parent resource” for breast feeding families and mother of three, can coach you through the ins and outs and get you over any bumps along the way.

As a resident in pediatric training, before having kids of my own, I had an idea that I would breastfeed my kids, because it would be the healthier choice for them. I didn't realize, until my first child was born, however, that breastfeeding her would become so important to me on a personal level. Intellectually, I can talk about the fact that breastfed babies are better protected from infection, may have better fat metabolism, and therefore, healthier cholesterol levels in later life, have decreased risk of chronic conditions such as diabetes, celiac disease, allergies and some cancers, or even do better in school. There have been studies showing that breastfeeding for at least two years over a woman's lifetime, can lower her own breast cancer risk as well. There are no guarantees, however. My own twins, never tasted formula and were home with a nanny, but still got their first ear infections at 5 months. Nevertheless, the benefits of breastfeeding are well known and documented in numerous studies, and since we want what's best for our kids, we choose to breastfeed.

One problem, I find, is that people have expectations for their breastfeeding experience that may be unrealistic. It's natural, right? So it must be easy! Nothing could be further from the truth. It hurts the first two weeks, even if the baby latches on properly. The first month or so, you are exhausted from a baby that wakes frequently (breastfed or not) and there doesn't usually seem to be enough of a schedule to let you catch up. Oh, and the advice to sleep when your newborn does, isn't particularly helpful, if you are home alone with a toddler too. When is mom supposed to eat, get dressed, take a shower, feel like her own person again? Just wait. If you get to the two month mark, and latch, supply, and growth issues have been resolved, when you catch that adorable milky smile as the baby finishes a feed, you'll never want to stop. OK so I exaggerate the part about never stopping, but I think you know what I mean.

Lets address some troubleshooting issues with the nursing experience. It starts before the baby is born. Reading about breastfeeding helps. I would recommend reading several books. If you do that, you will realize that each may have a slightly different point of view. That knowledge alone, is helpful when the baby is born, and you start to hear different advice from various sources: doctors, nurses, relatives, and friends. Not everything is dogma, and if you hear different bits of advice, you won't panic that you are not doing things exactly so.

My experience as a pediatrician is that most babies that receive formula in the hospital tend to wean earlier than their parents may have intended. Often it is an issue of supply. Normal nursing involves feeding TEN times a day. Too often, I see a mom that nurses 3 or 4 times, then gives formula, because, “There isn't enough milk.” The way your body knows to produce the milk, is through release of oxytocin in the brain, alerting the breast milk glands to produce more milk and to later release it through the milk ducts. The breast has receptors that are stimulated when the baby feeds. Thus, when the baby nurses more often, more milk will be produced. If the baby is offered formula, he or she doesn't feed as often on the breast, and you miss the opportunity to stimulate the supply. Unless you are going to pump at the same time that you give a bottle, your body won't know that there is a baby that needs more milk. Why sit hooked up to a pump, when you can have your adorable infant in your arms instead?

Some moms have been advised to pump to see how much milk they have. I don't recommend this in most cases. Pumping and only seeing a few drops of colostrum would tend to discourage most people. Also, a baby that latches well can more efficiently get milk out of mom than even the best of pumps. The colostrum that arrives initially is lower in volume than the milk that arrives later, but it is packed with all the nutrients the baby needs. As long as the baby has at least 1 wet (urine) diaper the first day, increasing by one a day, and at least one bowel movement daily, your newborn will get enough milk. Babies are born with excess water weight. They can lose up to ten percent of their birth weight in the first few days, but generally gain it back by two weeks of age. Rest assured, that your doctor will monitor the weight gain and feel free to discuss your concern at those frequent newborn visits.

Finally, remember that you will produce enough as long as you feed frequently. Thus, a mother of twins can produce enough to exclusively nurse the twins, because the body gets double the stimulation when she nurses twins. It is helpful to switch sides. With a single baby, nurse longer on one side, then “top off” on the other. Next feeding will start on that second side. With twins, you might want to feed each twin per side then switch for next feeding. Don't be scared to ask for help. A lactation consultant can help by working with you if there is a supply or latch problem. Sometimes a little intervention early on can make a huge difference in the overall experience and ability to nurse for a longer time period.

So what's Dad's role in all of this? Remember, Mom just gave birth and her body needs to recover from not just the childbirth itself (abdominal surgery in case of a cesarean delivery), but the 9 month gestation as well. Now she is also producing milk for your baby. Fathers are instrumental in the breastfeeding process. Avoid company that will not actually help you. If someone will come over to cook a meal, fold laundry, and you are not uncomfortable nursing in their presence, welcome them with open arms. If, however, Mom will feel pressured to entertain the guests while they hold the baby, and she thereby misses opportunities to feed, that will be counterproductive. Dads can run interference with the friends and relatives. Fathers can also pick up the slack on things Moms may otherwise feel obligated to do. If pumping is necessary, Dad can give the bottle, and/or change diapers while Mom pumps. That way there is some chance to “rest” during this hectic time. Mom nurtures the baby with her milk; dad nurtures the whole family with his help in the process.

As for the older siblings, breastfeeding the newborn provides important learning opportunities. We want our older kids to eat healthy, and we model this by showing that Mom and Dad are doing everything possible to make sure the new baby gets the healthiest nutrition as well. Even toddlers can be enlisted to help “their” baby by bringing a burp cloth, sitting with Mom or otherwise “helping,” by alerting you if the baby spits up. Having sibling involvement can improve their relationship with the baby. Just as, “It takes a village to raise a child,” it takes a family to nurture a newborn.

For More information about Dr. Suldan, Please go to http://www.pedimedica.com/pedimedica_teaneck/teaneck_doctors.html