TANTRUMS & TAAI TOFFIES

“Nee, Mamma moet. Mamma moet by my lê! Nie Pappa nie. Mamma!!!”

Só kerm-huil-skreeu my groot-oog amper-3-jarige kabouter net voor slaaptyd oor wie hý besluit het vanaand by hom moet lê tot hy na Droomland weggevoer word…

Dis al weer een van dáái dae. Daai hóógs uitdagende dae: van verseg-om-my-middag-slapie-by-die-skool-te-vat-en-nou-is-ek-totaal-verby-moeg-en-aaaaaalles-is-‘n-stryd!

Moet my nie verkeerd verstaan nie. Ek is ontsettend lief vir my 2 seuntjies. Maar party dae voel dit asof my geduld en kreatiewe-redenasie-vermoeëns tot die uiterste beproef word! Veral met Oudste (Boetiebaba praat (gelukkig?) nog nie terug nie, maar gil net in sy skril stemmetjie as hy gehóór wil word).

Terug by vroeër vandag:
Die groen plastiek-eetlepel móés eintlik blou gewees het, Rupert het sy hand gelek😱, en hý wou die asmapompie se oranje doppie “SELF” (julle ken mos daai woord😉🙈) afgehaal het. Emosies het behoorlik gesneeubal in ‘n sneeu(senu-ineen)storting…

Vanaand is almal moeg. Hierdie mamma het nog soveel om te doen voor dit mý beurt is om in te kruip. En hier sit Oudste Kabouter steeds kiertsregop en verseg om te slaap. “Want Mamma moet by my lê!” (Alhoewel Pappa nog altyd die laaste paar maande goed genoeg was!)…

Ek bid vir wysheid. Ek bid vir onderskeiding: Dat ek sal weet wat om te doen, wat om te sê.
Wanneer is dit als net die moegheid wat praat en wanneer is dit pure ongehoorsaamheid (soos wanneer hy aspris kliphard geluide maak as ek met manlief probeer praat)?

Wanneer moet ek grense stel en dissiplineer en wanneer het hy net liefde en aanvaarding nodig – net vir my nodig om by hom te wéés?

Vanaand het ek die “by-hom-te-wees” opsie gekies, my arms om sy snikkende lyfie gevou en hom net vasgehou. ‘n Paar sout-trane-soentjies op die wang en twee snot-tissues later, krul sy mondhoekies weer in ‘n half-glimlag op en soek sy groot oë myne. En ek weet in my hart dit was die regte besluit. Ons siele het ontmoet en ons verhouding het verdiep.

REFLUX – part 2

Tips & Tricks for the Management of Reflux in Babies, by Dr Nické Theron

In the last few weeks I have spoken to many moms and read many blogs to do some more research regarding reflux in babies. (SEE THE PREVIOUS POST to learn more about what reflux is). There are some interesting and scary treatments suggested out there! As a mom I wish I could give you a miracle-cure that would help your baby sleep better, cry less, spit up less. Unfortunately I know such a cure does not exist, no matter how alluring some moms on social media make it sound. As a pediatrician I would like to stick to what has been proven to work and what is safe for your precious baby now and in the long run. So here goes:

General management for all babies with reflux (GER and GERD):

• Upright positioning (90°) for 20-30min after feeds.
Babywearing keeps your hands free and keeps baby happy and safe.
“Reflux pillows” that elevates your baby’s head while sleeping has not been proven to make a big difference. Please remember the safest sleeping position for a baby is flat on his back to reduce the risk of SIDS (Sudden Infant Death Syndrome).  Even though babies with reflux sleep better on their stomach or left side down, I cannot recommend this if your baby is not monitored continuously.
Placing your baby in a rocker or car seat can worsen reflux due to the scrunched up positioning and increased pressure in their stomachs.

• Feeding volume and frequency:
It helps to give smaller feeds (so that you do not overly distend the abdomen) more frequently. Working out the smaller volumes if you are bottle feeding also prevents over-feeding and unhealthy weight gain.
Breastfeeding moms can feed on demand, but try to help soothe baby in other ways (baby-wearing, sucking on your fingers or a dummy) if the previous feed was less than two hours ago so that you do not worsen the reflux symptoms. Breast milk has a protective effect against reflux, so you are doing a great job!

• Thickening of feeds:
Studies have proven that this can decrease the episodes of spitting-up, but it is a very laborious process. Formula or expressed breastmilk can be thickened with rice or oatmeal-porridge or Maizena.

• Trial of a milk-free diet:
If you are breastfeeding, you can cut out all dairy and beef products from your diet for 2 weeks to see if there are any change in symptoms. You might have to cut out soy-products too.
If you are formula feeding, you can try a trial with an “extensively hydrolyzed formula” (also called hypo-allergenic such as Neocate or Similac Alimentum). It is not recommended to change to a soy-based/ goats-milk based / lactose free formula for this trial as there can be a cross-reaction to the allergens. Once baby is diagnosed with a milk-allergy you can try these substitutes under guidance of your doctor and dietitian.

• Avoid exposure to tobacco smoke as this can further decrease the pressure in the lower esophageal sphincter (see previous post), causing more frequent episodes of reflux.

• Adding probiotics has been suggested, but there is not enough evidence to prove if it will help.

• The use of a Chiropractor is not recommended as most of their procedures are not evidence based. “Subluxations of the spine after birth” mostly cannot be proven, will not cause reflux and the interventions they apply are either too delicate to really change anything in the bony structure, or too rough to be safe for the developing spine of your child. Please be careful.

If you have tried all of these tips and your baby still shows SIGNS OF GERD (as discussed previously) you can discuss the following steps with your doctor:

1. Is it really GERD?
Many diseases can mimic reflux and will not respond to reflux medications:
• Cow’s milk-protein allergy: this is a type of food allergy that can best be diagnosed by an exclusion diet.
• Eosinophilic esophagitis – this is inflammation of the esophagus due to an allergic reaction involving a specific type of white blood cells. These babies can have trouble swallowing, vomiting and chest pain. Diagnosed with a biopsy during an endoscopy.
•  Anatomic abnormalities of the esophagus – sometimes there is a connection between the esophagus and trachea (air pipe), or a web of veins causing a partial occlusion of the esophagus. This can be diagnosed with the help of a contrast swallow.
• Celiac disease – allergy to gluten causing inflammation in the esophagus, stomach and intestines, can also have many other symptoms. Diagnosed with an exclusion diet and can be confirmed with a blood test.

👉As you can see an endoscopy (looking at the esophagus and stomach from the inside with a camera, your baby will need sedation or anesthesia) can help to clarify the diagnoses. It can also evaluate for inflammation and check the response to treatment with PPI’s.

👉Another diagnostic test often used is Ph monitoring where the height of the acid reflux and the amount of episodes over 24hours are tested. Because reflux can also happen in normal infants this test cannot give us a definitive answer.

2. Does my baby need acid suppressing medication?
PPI’s (Proton Pump Inhibitors for example Nexiam, Losec) are used to suppress the amount of acid formed in the stomach. It will NOT decrease the number of reflux episodes or the amount of vomiting, but it could make your baby more comfortable if there was inflammation and pain due to the acid.
The acid in your stomach is actually very important for your baby’s digestion and immune function, and decreasing the acid content certainly does have risks.

👉Who should get PPI’s and for how long ?
• Babies with proven esophagitis seen on endoscopy (use for 3-6months and then re-asses)
• Babies with severe symptoms of GERD that does not respond to conservative measures can be given a trial of two weeks. If there is a definitive improvement, medication can be continued for 3-6months and then re-assessed.

👉Possible complications of PPI’s:
• Higher risk of acute diarrhoea and pneumonia because you remove a line of immunity defence. This can also lead to infection of the gut with Clostridium Difficile.
• Interferes with the absorption of Iron and Vitamin B12 and lead to anemia (low red blood count).
• Can affect calcium absorption and lead to increased risk for fractures.
• Allergic sensitization – there is a link between using acid suppression in infancy and later development of allergies.

When you want to stop the PPI, it is important to wean it slowly as there can be a rebound higher acid production for the first few days after stopping the medication.

3. Are there other medications that could help?
• Antacids such as Gaviscon have been shown to provide some relief in the symptoms of reflux. It works by coating the stomach contents with an alkaline layer which makes it more difficult to push back and less painful to the esophagus. It can be used in the place of thickening feeds in breastfeeding babies. Although there are not a lot of studies done in babies, it seems safe to give for short periods (less than two weeks) or on occasion. Using it for longer periods could lead to aluminium toxicity or rickets (Vitamin D deficiency).
• Prokinetics such as Domperidone (Emex), metoclopramide or erythromycin could help to speed up the passage of feeds through the esophagus and stomach. They could however have many unpleasant side-effects affecting your baby’s movement, brain and heartrate.

4. Will surgery help?
Surgery is usually not indicated in children under 1 year of age. Even in older children and adults the results of a Fundoplication surgery are not very satisfactory.

“Be joyful in hope, patient in affliction, faithful in prayer”

Romans 12:12

If you have read all the way to here you must truly have many questions! I hope that I could give you some answers, some advice and some hope. Remember that you are not alone. Talk to other moms and share the burdens and the joys. Talk to your doctors and walk the road with them, they want to help you.

These days feel long, but the years are short and before you know it your child will be waving goodbye on their first day of school (without vomiting all the milk from their morning porridge)!


Pediatrics and Playdough
Medicine Mommy

Resources:

1. Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M; “Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)”; J Pediatr Gastroenterol Nutr. 2018 Mar; 66(3): 516–554. ; doi: 10.1097/MPG.0000000000001889
2. Rybak A, Pesce M, Thapar N, Borelli O; “Gastro-Esophageal Reflux in Children”; Int J Mol Sci. 2017 Aug; 18(8): 1671; Published online 2017 Aug 1. doi: 10.3390/ijms18081671
3. Campanozzi A, Boccia G, Pensabene L, Panetta F, Marseglia A, Strisciuglio P, Barbera C, MagazzùG, Pettoello-Mantovani M, Staiano A; “Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey.”; Pediatrics. 2009;123(3):779.
4. Davies I, Burman-Roy S, Murphy MS, Guideline Development Group ; “Gastro-oesophageal reflux disease in children: NICE guidance”; BMJ. 2015;350:g7703. Epub 2015 Jan 14
5. https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/symptoms-causes/syc-20351408
6. Safe M, Chan WH, Leach ST, Sutton L, Lui K, Krishnan U; “Widespread use of gastric acid inhibitors in infants: Are they needed? Are they safe?”; World J Gastrointest Pharmacol Ther. 2016 Nov 6; 7(4): 531–539.; doi: 10.4292/wjgpt.v7.i4.531

REFLUX

What is Reflux?

Dr Nické Theron, pediatrician, is here to empower our mommies with knowledge.

Most moms know the feeling of getting your little one all dressed up and ready to go, just to have them spit/vomit milk all over everything just before you leave!

Thank you for all your questions and comments about your journey with reflux. I will try to answer most of you in the next few paragraphs while I explain more about the what, why and how of reflux:

Gastro-Esophageal Reflux (GER) is a 100% physiological (natural) occurrence in healthy babies, children and adults where the contents of the stomach push back into the esophagus (swallowing tube). It is more prominent in babies (40-60% of healthy babies struggle with reflux) because of their immature lower esophageal sphincter (the gate that is supposed to contract to keep the stomach content inside), fluid diets (fluids push back easier), slower passage of food through the stomach and the fact that they are mostly laying down (yes, gravity does play a role here).

Preterm babies have even more trouble with reflux because the esophagus is still too immature to “swallow” the milk down and they are often fed via feeding tubes (which opens up the lower esophageal sphincter even more).

“So do flux and reflux–the rhythm of change–alternate and persist in everything under the sky.”
― Thomas Hardy, Tess of the D’Urbervilles

Symptoms of reflux can start from the first few days of life when they start drinking larger volumes of milk, and usually subside by the age of 12-18months. This is due to a combination of all the factors mentioned above improving. There are some studies that show that children who had reflux as a baby are more prone to struggle with it as they get older.

Babies who have reflux (GER) usually spit/vomit up milk after feeds (yes, it can come up through their noses), (yes, it can be quite a lot!), they can also be irritable after feeds or arch their backs. They often sleep for shorter stretches and want to feed often (the milk actually soothes their throats, but more milk can also cause more trouble). Remember this is still NORMAL baby-behaviour!

“Silent reflux” is a non-medical term applied when a baby has episodes of reflux into their esophagus and airways without vomiting it out. (Making it more difficult to diagnose). In the end the same diagnostic and treatment rules apply.

Most babies with reflux grow well, feed well, are not extremely irritable and do not have any danger signs. These babies are often referred to as “happy spitters” and do not need any further medical intervention. It is very rare for the stomach contents to contain enough acid to cause discomfort or damage to the esophagus / airways. Even in studies where they monitored the reflux episodes by pH monitoring, they often could not associate the episode with the baby being unhappy or waking up from the reflux.

If your baby is failing to thrive (not gaining weight, not reaching developmental milestones), is refusing feeds (turning away his head while arching his back – Sandifer syndrome) or has signs of esophagitis (this is painful inflammation of the esophagus that can only be diagnosed with a gastroscopy, clues will be excessive crying and irritability when lying flat, shortly after feeds and while refluxing) your baby has Gastro Esophageal Reflux DISEASE (GERD). This is pathological and should be treated.

There are many other causes for the symptoms of reflux. Your baby could be going through a growth spurt or be overstimulated or have flu or gastro-enteritis, but if your baby has any of the following Red Flags, please see your doctor asap to exclude more sinister diseases:

  • Recurrent projectile vomiting (when the vomit hits the other side of the room)
  • Yellow bile or blood-stained vomiting
  • Any other abdominal signs: distension or pain of the stomach, constipation or diarrhoea
  • Fever
  • Any seizures, abnormal movements, abnormal head size or other neurological signs
  • Recurrent pneumonias (lung infections)

When you visit your doctor with symptoms of reflux they will probably be able to exclude most of the dangerous conditions by taking a history from you and doing a good examination. Hopefully this, together with the knowledge you were armed with in this article will help you cope with the day-and-night realities of reflux.

I know the mountains of milk-stained washing and sleep deprivation are tough – check back tomorrow to see what you can do to make your little one a little more comfortable.

Resources:

  1. Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M; “Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)”; J Pediatr Gastroenterol Nutr. 2018 Mar; 66(3): 516–554. ; doi: 10.1097/MPG.0000000000001889
  2. Rybak A, Pesce M, Thapar N, Borelli O; “Gastro-Esophageal Reflux in Children”; Int J Mol Sci. 2017 Aug; 18(8): 1671; Published online 2017 Aug 1. doi: 10.3390/ijms18081671
  3. Campanozzi A, Boccia G, Pensabene L, Panetta F, Marseglia A, Strisciuglio P, Barbera C, MagazzùG, Pettoello-Mantovani M, Staiano A; “Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey.”; Pediatrics. 2009;123(3):779.
  4. Davies I, Burman-Roy S, Murphy MS, Guideline Development Group ; “Gastro-oesophageal reflux disease in children: NICE guidance”; BMJ. 2015;350:g7703. Epub 2015 Jan 14
  5. https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/symptoms-causes/syc-20351408

PEDIATRICS & ME

Mammas, ek is ongelooflik OPGEWONDE om julle hiervan te vertel!

Ek en die kinder-dokter, Dr. Nické Theron van Pediatrics and Playdough, het koppe (en harte) bymekaar gesit om vir julle ietsie spesiaals op te tower…

Een keer per maand gaan ons ‘n mediese onderwerp/toestand of siekte kies en dan het AL die mammas (en oumas) die geleentheid om hul vragies in te stuur!

Daarna gaan Dr. Nické in ‘n interessante artikel julle vrae beantwoord!

Hoe klink dit?

Vrede, ♡

@medicine.mommy.sa
@pediatrics_and_playdough

Ontmoet vir dr. Nické Theron!

Hello! My name is Nické Theron and I love kids! From as far back as I can remember I wanted to work with children and this dream was realized when I qualified as a paediatrician at the University of the Free State in Bloemfontein. In 2017 our beautiful baby boy, Eran, was born and he made me a mommy! It was the perfect mix of theory and practical experience! I have a passion to help other parents understand more of the what, why and how of these tiny humans. The wonder of neonatology and the resilience of kids in developmental paediatrics are also special interests.

In 2018 we embarked on a new adventure with my husband, André, who is doing a fellowship in Leuven, Belgium. It is a privilege to watch our son grow and develop while exploring Europe, and learning from mothers from around the world.

“For You created my inmost being; you knit me together in my mother’s womb. I praise you because I am fearfully and wonderfully made; Your works are wonderful, I know that full well.”

Ps 139:13-14

GASSKRYWER

Sy is ‘n ontwerper [brand & web design] en eienaar van Make Me Visual.
Sy is ook een van ons eie mammas!
Lekker lees & gaan ‘like’ gerus haar facebookblad, Someone’s Superwoman.

//  I  S U R R E N D E R  //
Deur Maryke van Wyk

Having a baby has probably been the biggest life challenge I’ve had to face (and I’m only 4 months in). It has been a constant struggle between self and self-sacrifice. I am used to my to-do lists, coffee, goals, time-blocking and running around until everything is done. Social media often suggests that we can “do it all” and “have it all”, the only thing standing in your way is yourself and that “hard work” and being “goal driven” will get you everywhere. This sets us on a path of always chasing the ultimate “Instagram” lifestyle and makes it extremely difficult to find joy in exactly where you are.

This has been my struggle. I had the picture of having my beautiful baby whilst working my badass mom butt off while she sleeps. Once she wakes up I’d sweep her up and play all kinds of stimulating games until she gently falls back to sleep so that mamma can put in the hours to make some money.

Only, that’s not how most babies work. When baby sleeps, I try to catch up with washing, eat something and the moment I sit down to work – she wakes up. It has been a constant challenge to get work done which has created immense stress every day. I’m tired, not so much because of a lack of sleep, but because I’m constantly behind in pretty much everything. I’m running, trying to catch up on a lifestyle that I had before that I just find impossible to maintain. I’m angry and frustrated because my baby doesn’t want to fit into my routine. I panic and find myself spiralling into a dark hole because how will I ever catch up? How will I ever maintain my “have it all” lifestyle?

And so one-day last week everything just went up in flames. Baby was crying. I was crying. I was stuck. I was being a terrible mom, waiting every moment for baby to sleep and at the same time, I was not getting any work done. I was failing at everything. And in that painful moment, I decided to give up. I decided to drop all the balls. I picked up my baby, I held her close and comforted her until whatever was wrong was better. I let her fall asleep on my chest and enjoyed her closeness while she slept. She woke up and I put her down in the sun, talking to her and playing her games and once she was tired I picked her up and helped her to gently fall asleep. We had the best afternoon in a long time.

I suddenly realised that I no longer was the person I was before, it was no longer just me. I have lost a part of me, but I have gained another and I needed to embrace the new part of me. I was now a mom.

There will come a time when the individual me will become more prominent again – maybe when she is 2 and going to a playgroup, maybe when she is 6 and going to primary school or maybe at 18 when she spreads her wings. But that time is not now. It is time now for sacrifice and for surrender – to enjoy baby legs kicking, spit on all my clothes, one-sided conversations and baby milestones. And I have found the biggest JOY in total surrender to love.

Only now can I look back and see how focused on the “self” my thoughts were. We are bombarded with the idea that you shouldn’t lose your identity in your baby. I know that was definitely one of my biggest fears – losing my time because someone else is dependant on me. But my identity right now is all about my baby and I’m tired of having to apologise for that. I am the best me for my family when I can whole-heartedly surrender to being a mom.

Yes, there are challenges that I need to find solutions for – I will need to find a better way of working and I will need to find new ways of looking after myself, but I’m not saying sorry for being a mom. I find so much joy in following my baby’s cues which means I don’t have to stress about sleep training, spoiling baby or right/wrong. I can focus on prioritising what she needs to flourish into a confident and one day, an independent young woman.

I was questioning myself on whether being a mom and sacrificing my independence is wrong and suddenly realised that the epitome of love, Jesus Christ, sacrificed himself so that we can be confident children of God, never doubting in His love. So that answers my question way better than any Facebook group or Google search could ever do. I am surrendering to motherhood and have found so much joy in doing so.

Are all my problems solved? No. Can I stop working and just bask in baby every moment of the day? No. But when everything becomes too much and the balls are starting to drop, I know which balls to drop. My biggest priority will not become my biggest burden. I will gladly face people’s persecution saying that I am doing things wrong for the joy of being a present mother. I can suddenly breathe again, deep breaths in the sweet joy of surrender, of not “doing it all” and “having it all”. I am failing spectacularly at a few things but goodness, I am achieving new heights in others. I would rather succeed in a few things than being average in many things.

This is not a struggle, it’s a victory. This is the best and hardest thing to happen to me and I would choose it over and over again. Because we can never really grow if we are not challenged and this challenge is bringing to light new parts of my identity that I never could have imagined. I am definitely still a work in progress and some days are hard – so hard. But when the storm passes and I look back I see the GRACE that carries me and I think of Paul who wrote to the Philippians saying, “And I am certain that God, who began the good work within you, will continue his work until it is finally finished on the day when Christ Jesus returns.”

Every mom’s surrender looks different, so never compare where you are to someone else, but I hope and pray that I can remind someone to find joy in where they are right now. It does require sacrifice and sacrifice is painful, but it creates the space for new joy to flourish.

– Someone’s SuperWoman –
‘because there is always someone looking up to you’

📸 LIV Maternity and Newborn Photography