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Pediatrics/Re: Infection & baby weight

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Question
Dear Doctor,

My daughter is 7 mths old and weighs 6.7 kgs. Her was born on 09-08-12 prematurely at 34 weeks with wt. of 1.48 kgs. She is very active and has achieved all milestones till now. Her wt at 5 ½ mths was 6.4 kgs

About 20 days back she suffered from stomach infection (routine stool examination done) as a result of which her bottom would turn red and painful upon her passing the poop. She had no problem at the time of passing her stool, but would cry when she was being cleaned and also when the skin would come in contact with her urine. Her infection was treated by giving oral medicines and applying ointment – nizral & sofradex-F for a course of 5 days. Her doctor said that it is food or water infection.

Based on her doctor’s consultation, apart from breastmilk we starting giving her wheat cerelac (consistency between semi-solid & liquid form) 1 spoon a day, gradually increasing to twice a day soon after she turned 5 months as I had to resume office shortly and she was not happily taking milk (NAN 1). She was digesting the same. When she turned 6 mths, we gradually started giving her other foods, introducing one item after a gap of 4-5 days and now her schedule is as under:
Morning- Formula milk (switched from Nan 2 to Simalac Advance 2 as advised by her doctor)
Mid morning- 2 spoons of Ragi Malt or Sattva cooked in water and then mixed with milk (buffalo or formula) – semi-solid consistency
Afternoon – Rice and Moong dal khichdi – with little ghee and jaggery – semi solid to liquid consistency
Mid-evening – Banana milkshake
Late evening – Breast milk
Night - Wheat cerelac 2 spoons
Milk for rest of the time whenever she is hungry.
We also have tried giving her little mashed potatoes, melon juice or mix vegetable juice with dal water.
She does not like anything that is in liquid form, be it milk or plain water. Her milk consumption is also very less around 100 – 150 ml a day  
Recently, last 2 days back, her bottom again become red & painful and we applied sofradex F cream for 2 days and it has healed.
1.   Is her weight Ok. Her weight in the last 1 ½ months has not increased much. What could be the reason? Her doctor said it is normal and nothing to worry.
2.   What could be reason that her bottom turns red – is the infection not gone or is it because of hot weather or her taking less water?
3.   Is her food intake ok or what additional things can be given to her
4.   Can we clean her tongue because it becomes white as she takes food. Her doctor has advised not to clean the tongue as it can cause meningitis

Thanking you in advance for the reply.

Answer
Hi Gururaj,

Here are the answers:

1. Her weight gain is excellent. Babies normally triple their birth weight by 9 months of age. Because of good care that your baby has got, she is more than 4 times the birth weight at 7 months!! There should be no worry on this count...

2. Common reasons for rashes are use of diapers. Diapers should be avoided and should be repeatedly checked for small amount of motion that babies pass often and is sometimes missed. Cleaning should be with wet cotton, not with any cloth or wipes.

4. Your pediatrician is right: Tongue should not be cleaned.

3. Home cooked food is better than Cerelac in the longer run. Following write up is what I suggest everyone as far as complementary feeding is concerned:



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.

For preparing cereals like suji-kheer etc, you can use small amount of toned milk. However, make sure that the final consistency is paste-like and not liquid (see below for details).

2. Whatever is given has to be semi solid (thick paste consistency), rich in fat (ghee/ 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). Liquids like daal paani, fruit juices, soups etc. fill baby's stomach easily but do not provide enough calories. Instead, baby should be given thick dal (with added ghee/butter), mashed fruits and vegetable puree.

3.Commercial infant formulae like “Cerelac” provide only one advantage: 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. Still, if one wishes to use infant formula, it comes in various stages, as you know: stage-1, 2, 3 and 4. You have to stat from stage-1 and gradually move to stage 4 over several months. In stage 1, usually there are 2 variants: Rice and Wheat-Apple. One needs to start from Rice and then move to Wheat-Apple.

4. The food items which are usually started are: Moong-dhuli Dal with added ghee (NOT daal paani), Moong-dhuli daal  and rice gruel (khichri) with added ghee, suji-halwa (sweet or saline) 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, roti( mashed) can also be started. Move to paratha in next few days. add vegetables in paratha/ rice gruel/ suji. Jaggery (Gur) can often be used in place of sugar, as it is rich in iron.

5. Amount and mode of administration: Breast feeding is continued as before. In between two feeds, small amount (1/2 to 1 spoon only) of above food items are offered. gradually amount is increased as the baby's acceptance improves. As baby's solid diet increases, the interval between breast feeds automatically increases.

6. All babies require iron supplement from 6 months to 12 months of age. Please consult your doctor regarding the brand and dose according to weight (Your baby being preterm must be on iron supplements from early infancy)


Best wishes,
Dr. Puneet Kumar,
Kumar Child Clinic, Dwarka,
New Delhi, India

www.KumarChildClinic.com

+91-9818356846

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Dr. Puneet Kumar

Expertise

I would be happy to answer general queries on prevention and treatment of ailments in newborn, infant, toddler, child or an adolescent. Needless to say, it will not be possible to answer any query requiring specific diagnosis of a particular subject.

Experience

I have worked in various capacities (medical officer, resident, senior resident, consultant) in public as well as private sector in Pediatrics and Neonatology. Today, I have over 15 years of experience in the field.

Organizations
Currently, I am running my own clinic (Kumar Child Clinic) in Dwarka, New Delhi and am attached to Lifeline Hospital, Dwarka as consultant pediatrics and neonatology. I am also developing my clinic website into a comprehensive child health/ parenting website (http://www.kumarchildclinic.com)

Publications
(a) Chapter "National Immunization Schedule" in Frontiers of Social Pediatrics, Jaypee Publishers: 2nd edition, 2016. (b) Article, "All about Pertussis vaccines" in special issue of Indian Journal of Practical Pediatrics, July-Sept 2015 (c) Three chapters (DTP vaccines, Pneumococcal vaccines and Poliovirus vaccines) in "Textbook of Pediatrics for Post-graduates" First edition: 2015. (c) Chapter: "Alternative delivery methods of vaccines" in IAP textbook of Vaccines, First edition, 2014 (published by IAP/ Jaypee Brothers) (d) Special Article: "50 years of Immunization in India: Progress and Future" in January 2013 issue of Indian Pediatrics (e) Four chapters in "FAQ: Book on Vaccines and Immunization Practices" First edition, 2011 AND 2nd edition, 2015 published by Jaypee Brothers. (f) Three articles in special issue of Journal of Pediatric Sciences on “Controversies and Challenges in Pediatric Vaccination Today" in Sept, 2010. Co-edited the series also. http://www.pediatricsciences.com/issue/view/1050000010 (f) Regular column, “How do I treat” in Pediascene (www.pediascene.com) (g) Review article, “Role of Anti-Poliovirus Agents in Polio eradication and beyond” in Polio Pulse, April, 2008. (h) Chapter on “Acute Infectious Diarrhea” in Textbook of Infectious Diseases in Children. (An IAP Publication), 2007. 2nd edition in 2011. (i) Book-Review (IAP Pediatric Drug Formulary, 2004) in Pediascene, March 2005 (http://www.pediascene.com/page.php?cid=6&catid=9&id=132 ) (j) Case-report on Osteopetrosis. Jharkhand Journal of Pediatrics, Dec-2002.

Education/Credentials
After MBBS, I have done DNB residency in Pediatrics.

Awards and Honors
Winner of IAP practising pediatrician's quiz in 2001.

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