Baby's oral hygiene

Care for baby gum and teeth

• Informative pamphlet about baby's oral health (from Singapore Natl Healthcare group polyclinics) suggest that we should clean baby's gum daily using a wet muslin cloth or special tooth tissues (available in pharmacy and online shops such as ebay and Amazon). An example is shown below.

Toothtissue for wiping baby's gum. The substrate/"tissue" is not known (could be plant fiber, e.g.bamboo?), the ingredient is as follows: water, aloe vera juice, glycerin/glycerol, hydrated silica, xylitol (sugar alcohol as sweetener), levulinate (pungent "whiskey" flavouring),phytate (as preservative), xantham gum (as thickening),sorbate (as preservative). Refer to http://toothtissues.com/.

• When baby's teeth are out, we should brush them using soft bristle toothbrush. 

• When baby is able to spit, use a small amount fluoride toothpaste on the teeth. Brushing frequency is twice daily.

Bad habit to avoid

• Avoid giving milk or sweetened drunk right before bed.
• Avoid giving pacifier to baby (if possible). If teething, we can give them teething ring to chew on. Prolonged use of pacifier has been associated with misaligned front teeth.
• Don't introduce too many sugary diet to baby, e.g. raisins are high in sugar content too.

When to visit the dentist?
First visit is ideally when baby turns 1 yo (as suggested by the booklet), whereas Natl Dental Centre Singapore (NDCS) suggest between 6 to 12 mo (see "Pediatric dentistry - your child's first visit to the dentist", NDCS).

My notes

• First tooth (start circa 6 mo to 12 mo or more).
• By 3 yo, all primary (or milk) teeth are out.

Challenges

• My girl likes to keep food in her mouth for a longest time before swallowing. She spends almost 1 hour finishing her food. The last mouthful will be a challenge for her to swallow. In order to prevent prolonging food in her mouth, I would ask her to spit out the last mouthful and ask her to rinse her mouth later. This will minimize tooth decay.
• Ordinary children toothbrush is not small enough for most toddlers. Stuffing the toothbrush into our child's mouth often induce her to vomit. I wish there is smaller toothbrush catered for children. Read an article about "choosing the right toothbrush for your child" by Westvalleysmiles. In short, picking the right toothbrush requires soft and proper bristle, dimension of toothbrush that fits in your child's mouth, and easy grip.

Tips

• Salt water gargle. Tooth caries (or decay) is caused by Streptococcus infection (transmission is usually from mother to child, especially when the former's oral hygiene is poor). In order to minimize tooth decay, a salt water gargle has been shown to possess antiseptic property, but it will be a challenge to convince your child to gargle the solution.
• Gargle and swallow sufficient amount of water after each meal. Instead of giving our child flavoured drinks, we encourage her to drink plenty of water.
• Cheese, milk and calcium helps to build strong bones and teeth. Plenty of healthy sun exposure helps to produce vitamin D that helps calcium absorption.

Pediatric dentist registered with Google Maps  

There are several clinics available and from the map, they are scattered in the south and east coast region.

Note that I wanted to add dentists registered in Streetdirectory but the site popped up irritating register your email. To get to business, just click on "Are you lost".

I couldn't get a hit by entering "pediatric dentist/dental/dentistry".
 

ABO incompatibility between mother and child equals jaundice

I am B+ and my wife is A+. Our first child was not screened for her blood group, which was surprising, especially considering that this test is not too expensive and would be informative for parents and children. The hospital told us that such test is only applicable if we asked for it or if the baby is G6PD deficient.

Our first child had jaundice and it took us some time before her bilirubin level was reduced. At that time, we thought that her jaundice must have been a common case among Asians.

Then, when it was our second child, we explicitly asked for his blood group to be determined. Our boy was AB+. Similar to his older sister, our boy had jaundice and it was not manageable for us when we brought him home. As we opted for full breast feeding, my wife's milk supply was initially low (colostrum) and it did not provide sufficient fluid and material for baby to pass enough stool or urine to cleanse his system of bilirubin. We brought our baby out for the morning sun for the purpose of reducing his jaundice, but that effort was insufficient.

A visit to a polyclinic to have our boy tested showed that his bilirubin level was high (at 292 micromol/l). The doctor recommended admission for phototherapy. It took our baby 4 days for his jaundice to subside under the phototherapy!

Our insistence on testing for our baby blood type allowed the pediatrician to suggest that our baby's jaundice could have been due to ABO incompatibility. We wondered, if we didn't insist on the blood test, would the pediatrician have been able to form such diagnosis? If ABO incompatibility is a common problem that contribute to jaundice in baby, why doesn't the hospital provide compulsory blood group test, so that parents' can be informed of next course of action?

Just a thought

Note

• ABO incompatibility in mother and child is due to the traversing of mother's antibody to her baby's circulatory system. In our case, my wife is A+ (which means she has antibody against antigen B). When the antibody gets into baby's circulatory system, it will attack baby's red blood cells that have both antigen A and antigen B on them. This causes increased lysis/destruction of babies red blood cells and hence increase in bilirubin level (intermediate product of the cell turnover).
• Abnormal increase in bilirubin level in babies have been associated with mental retardation. That is why we are compelled to send our son to the hospital for phototherapy when the doctor told us his bilirubin level was high.
• How blue light reduces bilirubin is by solubilizing the chemical in the body so that it can be cleansed from the system via passing of water and motion. See Bilirubin by Wikipedia.

Penicillin administered during labour detriment to baby's gut microflora

For expectant mom who got her water broke for more than 12 hours (whereas CDC recommends > 18 hours!), Singapore General Hospital (SGH) will recommend administering penicillin-type of antibiotic to the mother. My wife was given this without choice.

Our main concern in intrapartum (or during delivery) administration of antibiotic was whether the administered antibiotic will kill mother's good bacteria and deprive the baby these bacteria, especially in natural vaginal delivery. If yes, then it would defeat the purpose of natural birth! It has been known that natural vaginal delivery provides babies with good gut flora and minimize allergy in later development (see subsection on "Acquisition of gut flora in human infants" by Wikipedia), whereas C-sections reduces the diversity of baby's gut flora.

Sometimes, I think hospitals are being too overzealous in their effort to beat infection (or prescription of antibiotics). This effort can be more harmful than helpful, considering that depriving babies of good gut flora weakens their gut health and not to mention, babies abilities to acquire immunity against these bacteria. FYI, we can use gut bacteria because we are immune to them and able to rein in any "rebellious" bacteria by an immune response. To deprive babies of early exposure to gut bacteria will deprive them of this immunity.

If hospitals strive to encourage more "bubble babies" (babies in sterilized condition), then they are not doing any good to patients (or mankind). I was let down that SGH went down-the-road of trying to sterilize mothers' womb by prescribing antibiotics when there was no indication/suggestion that babies were immunocompromised/immunodeficient. Why would SGH want to prevent good "infections". Note that there was no indication that my wife was having any infection (i.e. the vaginal bacteria was at "normal" titer/amount rather than overran by them during infection).

Since when did "infection" (exposure to mild titer of bacteria or microbes) become a bad thing? We are constantly fighting (or balancing) "infection". That is how we grow stronger (rather than weak and dependent on antibiotics).

Fortunately, a study showed that intrapartum administration of antibiotic (specifically penicillin) has minimal effect on microfloral transmission of babies undergone vaginal delivery. Read "effects of intrapartum penicillin prophylaxis on intestinal bacterial colonization in infants".

However, in contrast, another study showed that regardless of antibiotic-type, intrapartum administration of antibiotic due to rupture of membrane (or water broke) caused significant drop in transmission rate of good bacteria (e.g. Lactobacillus) in infants. Note that good bacteria is responsible in preventing the development of allergic diseases later in life, so... it's no wonder that in developed countries, many people are having one or several kind of auto-immune diseases. We are just too darn clean!

Now, my question is that, do we have a choice when it comes to "medical intervention" that do not require our consent? As patients, are we well represented by doctors and the medical team? I mean, did these doctors judged correctly the risk-over-benefit criteria before prescribing treatments to us?

Another example is that during my wife vaginal swap to test for presence of Group B Streptococcus, which seemed to be a contributing factor in infection in newborn babies (or in worst scenario, septicemia or infection in blood), the test tested negative but there was presence of fungi. The doctor gave the good news, and then shocked us to the news that my wife has fungal infection! FYI, our body is constantly covered with Strep and Fungi, and as long as we are healthy and strong, we are not at risk. Also, Strep presence in our body do come-and-go and today's test is negative doesn't mean that it will be negative tomorrow. How the hospital earned from us for this test is funny because it did not help us a bit during expected delivery date (EDD) where by then, Strep tested earlier is nullified by time!

What was alarming was the suggestion by this doctor that she could help my wife administer medication to rid of the Fungi. Oh my goodness, what is wrong with doctors these days? We might as well be living in a bubble from now on, no?

According to CDC Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines from CDC, 2010, one thing that is lacking in this report is the mention of harmful effect of the measures taken to fight Strep on babies (i.e. post-treatment effects). There are always benefit-over-risk and vice versa and giving the right information to patients is always appreciated.

As a parent, what I can hope for now is to allow my kids to be exposed to as much of environmental microbes as possible (naturally), so that their immune system will be an efficient machine that manages host-microbe interactions to their favours.

As for the TV commercials frightening the populace with overblown picture of infections so that more of us will buy their antiseptic cream, spray, soap, mouth rinse etc., these companies are not helping one bit in protecting us from infections. Best protection is to overcome the infection rather than "hiding" from it.

Being too clean has been shown to pose health problems (see Hygiene hypothesis by Wikipedia). However, in practice, it's not possible to be completely clean from microbes, fortunately.

Just a thought.

Anti-itch remedy for polymorphic eruption of pregnancy (aka PUPPP)

Pruritic urticarial papules and plaques of pregnancy (PUPPP) cause is not known, but the effect on patients are unpleasant. Pruritic means itchy and urticarial means nettle-like sensation, whereas papules and plaques are just description of the appearance of the "bumps" or rashes.

Although the cause of PUPPP is not known, it can be speculated to be contributed by abdominal stretch due to baby size. Overly stretching the skin might have exposed tissues (not normally found in circulation) to the immune system and that caused an allergic reaction. There is no medication to stop the rogue immune reaction. However, anti-histamine can be given to reduce the symptoms, e.g. itchiness and eruptions.

Some mothers had to go through the itchiness from 2 weeks to several weeks.

Things that exacerbate the rashes are

• Bathing in hot/warm water
• Seated for too long (heat seemed to increase more rashes)
• Scratching increases severity

Doctor would normally prescribe

• Anti-histamine to relieve itchiness, but it doesn't seem to mask the itchiness completely. However, a mild relieve is better than none.
• Calamine, which is composed of zinc oxide and ferric oxide (see Wikipedia). Its anti-itch property has been debated, and doctors seemed to discourage its use because the solution can dry up the skin and could potentially worsen the recovery. My wife seemed to prefer this solution rather than the steroid based medication as she is worried about the harm of steroid on baby during breast-feeding (although doctors said it's not harmful).
• Steroid based cream for topical (skin) application, e.g. Elomet (R) Mometasone furoate by Merck.

Home based remedies are as follows

• 2.1% (v/v) sodium bicarbonate (or baking soda) in bath water. E,g, 2 ml in 100 ml or 2 cup in 100 cups (or 1 cup in 50 cups [3.125 gallon]) of water.
• Oatmeal bath, and how to prepare the bath is described "How to make an oatmeal bath" (by WikiHow). Taking a dip in oat bath provides the minerals and nutrients needed to rejuvenate the skin, especially one that is "sad".
• Epsom salt (or Magnesium sulfate) bath. The concentration in the bath is not fixed and some just guess the right concentration to use. Although the bath is normally at higher temperature, it is not advisable to take a dip in warm bath especially considering that rashes tend to get worst with higher temperature! Here is an instruction on how to prepare Epsom bath (Scdlifestyle)
• For Chinese, there is a necessity to increase body heat by consuming herbs that will increase body temperature. Although it helps in the postpartum (after delivery) recovery process, there should also be a need to balance it to help alleviate the rashes. A nurse suggested that drinking buttermilk or plain yogurt could help (See buttermilk as cooling drink by MediManage). I am giving my wife coconut drink to cool her body but drink moderately as breast-fed baby might have runny stool if too much of this drink.
• Other suggestions are Aloe Vera gel  and cucumber puree. I wrote down these two because there has not been report of anyone being allergic to these health food.
• There are those suggestions that should be used with care as some might be allergic to the ingredient, e.g. lemon juice might exacerbate the skin condition and banana peels might be harmful to some people. Those interested to experiment (with own risk) can refer to this site, "Home Remedies for Rash" (by HomemadeMedicine).

Tips
To apply calamine solution is quite tricky, we initially used cotton balls to apply the medication on the skin but most of the solution is soaked up to the cotton. I tried to squeeze the solution out and re-apply it on my wife's skin numerous time to avoid wastage. Today, I got a small spray bottle (from Daiso Singapore) to try to apply the solution on her skin by aerosol. I filled a small volume of the calamine to the spray bottle and dispense the aerosol enough to cover her affected skin. It worked, but the aerosol caused the whole room to be smelly. Also, care should be taken to prevent inhaling too much of calamine! For your information, read about zinc poisoning, (MerckManuals) and iron poisoning (CDC).

 

For now, I just hope my wife will recover next week. Seeing her in this state makes me feel helpless...

"Daddy, can you please stop singing", say my girl

The first time I heard her saying, "Daddy, can you stop singing" was when I sang lullaby to her at night (which I've been doing for many nights now). She also said, "please be quiet". 

These two sentences didn't belong to our household. We would never tell her that. FYI, our 2-going-to-3-yo girl loved to sing. 

My wife and I are guessing that she had picked up these sentences from her play school. It could have been from one of the teachers saying that to her when she was singing in class (while not paying attention). 

It was sad knowing that she could pick up these sentences and used them at home. Probably she thought they were uttered for the fun of it. Fortunately, it was not because daddy's singing was bad.

I remembered the time I sent our girl to school when she started crying (pleading that daddy join her in the class), and one of the teachers said to her, "don't cry already", and immediately our girl held back her cry (but not her tears flowing down her cheek nor her muffled gasp for air). I was sad seeing her like that.

How could a teacher deprive a 3 yo from "free expression"? Teacher should encourage children expressing their emotion and thoughts; and try to reason with them if the expression is temporarily (or spatially) unsuitable/unfavorable. An example would be when our girl was in the library, and she said, "it's so quiet here". Then she made several loud shouts to enliven the atmosphere. Instead of calling her to keep quiet, Daddy said to her, "baby, we have to lower our voice here because it's a game. Whoever keep the quietest wins". Our girl then replied, "I lost, I lost!" (making a sad face). 

In a calm voice, I told her she can still win if she can start lowering her voice. That was the first time she whispered that day. She learnt to whisper! 

Of course kids can't keep quiet for long, and as parents, we should accommodate them and hasten our activities in the library so that our children can go back to their normal self of talking loudly and lively. Also, if children aren't paying attention in class, as teachers, we should be creative to engage them. E.g. sounding a funny horn to draw children's attention intermittently OR use a more lively tone to teach them (rather than being monotonous).

All in all, we never try to suppress our girl's feelings nor voice (or thoughts). Sometimes, she would drive us crazy that we are tempted to ask her to "keep quiet". Fortunately, most times we did not do that. Now that she is schooling, I guess she will have to learn the way the world really works and there is no better way that in school where kids are groomed to be adults.

Boy bilirubin level at 292 micromol/l

This morning went to polyclinic to have our boy screen for bilirubin level. It was high at 292. The doctor recommended admission for photo-therapy. 

When we left for home and ready to get re-admitted, we couldn't find the referral letter. The attending doctor didn't give us that. In addition, we were not given the bilirubin test result. Is this how the SOP is?

We decided to forgo re-admission today and decided to revisit the polyclinic tomorrow. 

However,  we received a phone call from SGH later for a routine update on mother and child. We told the nurse about the bilirubin result. She advised us to admit our boy for photo-therapy today. We told her we had no referral letter. After getting back from her superior, she advised us to walk in anyway. 

We were instructed to walk in to SGH Accident & Emergency (A&E). The place was chaotic. There were many patients and the place looked like Black Friday sale but with lethargic looking "shoppers" instead.

Registration was slow but our 4 days old baby was cooperating. Mom's wound was still hurting because of hematoma and stitches. There was no place to sit. There was no where to stand too. 

We were directed to Triage room. The attending staff was surprisingly calm and helpful in the chaos. Later, we were directed to a corridor filled with patients waiting for their call numbers. Our boy stayed crying as he soiled his diaper and it was time for meal. We asked the information staff if there is any nursing room. There was none. We tried to sooth him to no avail. Fortunately, there were caring staffs in SGH. They allowed mom and child in to an empty room for breast-feeding. 

A doctor attended to us later. She needed blood sample for the test. She couldn't get uninterrupted stream of blood into a glass capillary. On the second try, baby's blood got clotted. Another doctor who was there helped. He prepared a kidney tray with warm water and placed our boy's foot into it. This helped to sooth our boy and also improved circulation (especially in air-con room). Then he used a gel and applied on the sole. With swift movement, he pricked and collected our baby's blood sample. 

It would take 1 to 2 hours for the result. Mom and child had no where to go but to be seated in the overcrowded room. There is no place to change diaper and for nursing baby. 

It took three hours to get admitted to the ward from A&E to Ward 53.

Good news is that there are plenty of empathetic and passionate nurses, caretakers, and doctors.

Bad news is that the chaotic situation recurs daily and until a brilliant solution is found, that's the status quo.

I'll update with my thought about this topic next time. For now, our boy's bilirubin level had gone down to 260. 

Reference
Convert bilirubin concentration from micromol/l to mg/dl here.

Our girl was sad that her time is less with us

With new arrival at home, and having been without Mummy for two days, our lil girl was sad. Although she was accommodating with her brother, she was so overwhelmed with feeling that she broke down on the third night. 

We felt sorry for her. Our time, or Mummy's time was so much reduced now. Mummy had to feed and change diaper at less than 2 hours intervals. There was really no time to spend on our girl, let alone having shut eyes.

I tried to fill the gap without success. Mummy is indeed unique to children. Truly respect that. However, the past few days, Daddy and daughter bond has grown stronger. 

Whenever my girl said, "Daddy love me". I would reply, "Yes. Mummy, Daddy, Grandma, Grandpa, Uncle, Aunt, teacher, and everyone loves you because you are a good good girl".

When Mummy was feeding lil brother, she did not try to take her Mummy away. Instead, she was teary-eyed and said "I want to snuggle towards Mummy". There, she rested her back to Mummy and laid there waiting for mummy to finish nursing. 

Sigh. It's a heartbreaking experience seeing our kids going through this. We are constantly trying to let the lil brother to accommodate our girl rather than the other way. However we try, or lil girl knows.

3.485 kg boy

He's here. At 3.485 kg. Exhausted. 

No epidural nor any pain medication, just gas (nitrous oxide). After oxytocin induction to pick up the rate of contraction, pain reigned over as nature intended. Such sacrifice and bravery that moms have to go through! More than 10 hours of pain to bring a life. Yet, they are never considered the heroes. 

Purple hearts should be given to moms instead. 

Updates:

• Contraction started getting unbearable at 7 am while frequency was sparse at one per 7 min. Mommy used only laughing gas (or nitrous oxide).
• At 11.50 am, a nurse measured 9 cm on mommy and asked her to push (but didn't realize that the baby was too big for mommy, i.e. 3.6 kg heavy baby in 145 cm tall mommy). Mommy got "boo boo" (vaginal hematoma). The nurse asked us to stop the push immediately and went to see the doctor. The doctor measured 8 cm (how subjective was that!). We were told to wait for another 2 hours for mommy to dilate to 10 cm.
• Waiting for another 2 hours was unbearable for mommy. She took in the gas regularly (as the contractions became frequent at 4 min intervals). It was so unbearable that we decided to get the anesthetic injection (I think it was Pethidine; other types are Diamorphine or Meptazinol; see pain killing injections). However, we were later told that if the delivery falls short of 2 hours, then the baby will be warded to high dependency (HD) room for monitoring, which means that mommy will not be able to see our baby as regularly.We were too late to opt for the injection.
• Mommy opted to bear the pain (without injection) for the sake of baby. Daddy cringed each time mommy had pain. Soon, we overheard the staff saying that there was no attending gynaecologist for us. Ours was in Myanmar, while one was going off work after 12 pm, and the other one was on leave. Must be a shock to anyone, no?
• At 2 pm and the dilation was at max. All the equipment were made ready. Midwife, nurses, attending doctor, and last-minute gynaecologist (who was supposed to be on leave) attended.
• The pushes lasted almost an hour. Final push saw the gynaecologist pulling our baby's head and twisting his body to orientate him out from mommy.
• I was so happy to see the baby while mommy was exhausted.
• After the postpartum procedure, the gynaecologist came over to tell us that during the delivery, one of the midwife/nurse heard a cracking sound (suggesting that there could have been a broken bone, and probably the collar bone). The gynaecologist said that it was a common thing, considering that babies need to traverse a narrow canal from mother's pelvic cavity. She said that normally the broken clavicle (or collarbone) will heal by itself. Anyway, she said that a pediatrician will attend to our baby shortly for assessment.That was not what all parents wanted to hear... but for the doctor to come clean and thorough is better than hiding this fact from us.
• In retrospect, during the whole waiting time, I was irritated by the nurse (who had asked mommy to push earlier) who kept on telling everyone that the patient had vaginal hematoma because the patient pushed prematurely and how the nurse stopped mommy from pushing. It was an irritating lie but we bore with it. What was more important to me was asking these questions to the attending midwife, (1) how common is vaginal hematoma? she said it was a common problem, (2) is it treatable and how do you treat it? she replied that you just have to apply a cooling pad (with ice) to sooth the swell and keep monitoring if the swelling recede over time. Thank goodness!

 In conclusion, I am happy to be with my wife. I saw how awfully painful labour is and how much braver mothers really are. If the Purple heart goes to soldiers, a Gold or Diamond heart belongs to mothers.

Sparse contraction at one per 7 min

Waiting at the machine showing mom and baby heart beats and the frequency of contraction. Right now it's at one time per 7 min.

6.10 am, waiting for available bed

Mummy experienced more intense pain. The nurse said Mummy will need to be pushed to labour ward soon. However, the time depends on how soon a room is made available. 

Daddy seeing Mummy in more pain couldn't do anything.

I guess, the "we are waiting for the bed" will be unavoidable.

Three hours later at labour ward

I have gone to registration counter at A&E in block 1. Got all the required documents and RFID tag for mom.

SGH security is a bane. No complain though. Except, if they can be more helpful to clueless dad like me.

Daddy already fed mom with sandwich. I'm worried that mom might not have enough strength with empty stomach. 

It's 3.14 am and mom is in pain. Will have to wait until morning for the doctor to make round.

Our gynaecologist is currently in Myanmar to train doctors there. It seems that we won't be waiting for her return next week. 

Mummy can't sleep tonight. Daddy is sleeping in the waiting area. 

Glad that baby is engaged ready to meet us.

My daughter is going to be a sister soon

Mommy water broke with discharge at 11.30 pm on 14 th Jan. We called SGH ward 52A and got connected in the fourth try. The person on the line said it is sign for labour and asked us to be on our way.

We took a Comfort taxi 6509 and arrived at 12.30 am. There was no one on the counter, but we got in the ward 52A finally from visitor's help. Rang the bell and a nurse came to assist us. 

Mummy felt contraction and pain. She went with the nurse for check up. Daddy waited outside. Daddy remembered now that he should have gotten a warm pair of socks for mummy. The ward was cold.