Here is another picture I took recently, which is extremely cute. There are a whole series of her playing on this path in her Granny's garden, but since she is minus a nappy I won't post them here.
Monday, April 25, 2011
Gullible New Parent Gets A Makeover
I thought it was time to personalise my blog a bit, and have a picture of Bethany and I in the title. This picture was taken at the hospital when she was about two days old.
Here is another picture I took recently, which is extremely cute. There are a whole series of her playing on this path in her Granny's garden, but since she is minus a nappy I won't post them here.
Here is another picture I took recently, which is extremely cute. There are a whole series of her playing on this path in her Granny's garden, but since she is minus a nappy I won't post them here.
Sunday, April 24, 2011
You Know You're Tired When... Your Car Smells Like You Are Hiding A Body In The Boot
Loved a discussion recently on my online mother's group where everyone had to finish the sentence: 'You know you're tired when...'
Some of my personal favourites were:
How could I have forgotten to bring in the chicken? How, when I was wondering what to possibly cook, did I not remember I had bought these chicken parcels, to solve this very problem?
I'm too tired, I thought.
Some of my personal favourites were:
- when you repeat the same story over and over because you forgot you said it the first time;
- when you put orange juice in your morning coffee;
- then you forget too pull your knickers down when you go to the loo;
- when you think 2 consecutive hours sleep is a good sleep;
- when your house is full of sticky notes, and notepads, and you have a whiteboard prominently displayed in the kitchen;
- and you still can't get the days of your appointments right, or remember milk;
- when you put a disposable through the washing machine;
- when you keep putting the washing machine on but forgetting to put the clothes in;
- when you say the wrong way around all your sentences;
- when you spray deodorant in your hair and hairspray under your arms;
- when you repeat the same story over and over because you forgot you said it the first time...
I think by and large you adjust to the lack of sleep and you think that most of the time you are doing just fine. Sure, you feel a bit groggy, but other than that most of the time you don't feel any stupider.
It's only when one of the little mistakes you make has consequences that you suddenly realise you are not as in control as you thought you were. I was congratulating myself the other day for attending work for the third week of very little sleep due to my sick baby, and for successfully wading through some ten thousands words of dense legal submissions on one of my cases, that I overlooked the fact I spelled my email address wrong in one of the letters. "Oh well," I said to my PA, "I'm still doing pretty well considering. These things happen."
It's only when one of the little mistakes you make has consequences that you suddenly realise you are not as in control as you thought you were. I was congratulating myself the other day for attending work for the third week of very little sleep due to my sick baby, and for successfully wading through some ten thousands words of dense legal submissions on one of my cases, that I overlooked the fact I spelled my email address wrong in one of the letters. "Oh well," I said to my PA, "I'm still doing pretty well considering. These things happen."
"You make a lot of typos these days," she informed me, helpfully.
Most typos aren't too bad. I do have to type the word 'public' a lot in my government job, and as long as I have the 'l' in there, typos generally aren't too much of a problem.
But today I did one of those things that made me think I don't have my shit together after all. I went to jump in the car to take Bethany to the shops. I was carrying a bag in one hand and a wrap in the other, and juggling Bethany and an iPad as well. I had to put the iPad on the roof of the car while I loaded it up, and as I put it there I thought maybe I shouldn't because what if I forgot and drove off, so I promised myself not to forget....
...and opened the door to the most putrid smell.
Bethany was wriggling and upset so I strapped her in the car seat and spent a few moments trying to distract her with various toys before she was taken by a clothes peg. Then I could turn my attention to the smell. At least it didn't seem to bother Bethany.
Was it the empty Maccas wrappers? No. The old Big M carton? No. It took some searching before I located a bag of Lenard's chicken on the back seat. I had bought it the day before yesterday, so it had only been in there for 48 hours, but in a town where the temperature at night is close to 30 degrees Celcius, 48 hours is well and truly too long to leave chicken in the car. I ran the bag to the bins while trying to hold my breath.
Had I really not been in the car for 48 hours? Apparently not. I'd been trying to keep Bethany at home cause she was sick. What to do? Probably best to drive it with the windows down and the fan running.
How could I have forgotten to bring in the chicken? How, when I was wondering what to possibly cook, did I not remember I had bought these chicken parcels, to solve this very problem?
I'm too tired, I thought.
Bethany started to cry so I quickly wound down my windows, wondering whether I should tell my husband about this or whether he would use it as an excuse to lecture me about the state of my car. The state of my car is not particularly attractive. It's a bomb of an old Corolla, where only two of the window winders work and only the driver's door handle has not broken off. There are about twenty baby toys, several spare nappies and some those orange plastic bags for putting dirty nappies in, changes of clothes for me and the baby, water bottles, iced tea bottles, unused but crumpled tissues, clothes pegs, one of those shade things that's supposed to stick to the windows but has fallen down, and various unread books strewn over the seats and floor, a mess I always intend to clean up tomorrow.
I drive several minutes down the road before I decide there is not enough air flow and it would work better if I opened Bethany's window too. I pull over by the Botanic Gardens and rush round to her side, remove the shade sock, and wind the window down. It is only when I rush back around to the driver's side that I notice, out of the corner of my eye, that my iPad is still on the roof of the car.
Apparently promising myself to remember things is not a very reliable technique for a sleep-deprived mum.
I grab the iPad and wonder how long before I make the next stupid mistake, and when I will eventually make a serious one.
Saturday, April 23, 2011
Treating A Fever
I threw it out to the facebook page for people to vote on what I should write on next, and the topic of most interest was the use of Panadol in treating fever.
My poor little munchkin has had 2 fevers in the last three weeks, and a snotty nose cold in between. I feel like a walking zombie from all the night-wakings, and I imagine she doesn't feel too crash hot either. In the process of dealing with these fevers, I learned that the taste of Panadol makes my baby gag and throw up. (Amazingly, we got to 9 months without really having a situation arise where we thought Panadol might be necessary.) Panadol can, however, be successfully administered to her by an over-the-counter suppository.
Having to administer Panadol by suppository does make you think fairly hard about whether you really need to give it. So I started to do some research. As a result of this research, I have come to the conclusion that in most cases I will not give Panadol (or Neurofen for that matter) to my baby in order to bring down her temperature.
Fancy Word Alert
Just so there's no confusion, here's a quick rundown on some of the fancy words used in this post.
The active ingredient in Panadol is paracetamol which is also known as acetaminophen and occasionally APAP. One of the uses of paracetamol is to reduce fever. A substance which reduces fever is called an antipyretic. Other well-known antipyretics are aspirin (acetylsalicylic acid), and ibuprofen which is the active ingredient in Nurofen. A child with a fever is sometimes referred to as being 'febrile' and fever is sometimes called 'pyrexia'.
What is a Fever?
Fevers are different from hyperthermia. A fever is when your body deliberately raises its core temperature, usually in response to a virus or bacteria. Hyperthermia is when your temperature rises from other sources, such as heat stroke or taking a drug stimulant like cocaine (just in case, you know, your baby decides to smoke crack). Babies who are hot because they bundled up in too much clothing and bedding do not have a fever. They have hyperthermia. Unwrap them and they cool down. Babies with fever may develop cooler skin if they are stripped down, but if you... ahem... stick a thermometre up their bum, it will still read hot.
On one view, any temperature above 37.8 degrees Celcius is considered to be a fever in a baby (Carson, Walsh 2007). However, it should be noted that infant body temperature can vary quickly by about a degree just from excessive clothing, hot weather, digestion, and bathing (Walsh 2007). Body temperature may also be hottest in the early afternoon and lowest in the middle of the night (Walsh 2007).
Over 37.8 but under 40 degrees Celcius is considered a 'low grade' fever. Only fevers over 41.5 degrees Celcius are considered a 'high grade' fever (sometimes called 'hyperpyrexia').
What is the Best Way To Take a Temperature?
A recent Italian review of the literature of fevers found that the best way to take a baby's temperature is a digital thermometre under the arm (axillary temperature). A thermometre in the mouth (oral temperature) is unreliable. A thermometre in the anus (rectal temperature) is very reliable but quite invasive so shouldn't be used unless necessary. An ear thermometre (tympanic temperature) can be very reliable if you know how to use it, but if you don't can be difficult, and in newborns the ear canal is too curved to get a reliable reading.
I actually find that I can tell whether my baby has a temperature by feeling the top of her head and her tummy, or in any 'folds' like under her arms. Once I was used to her usual temperature, an elevated temperature felt like the skin was 'burning'. Even a fever of 38.2 has been quite obvious to the touch. The temperature of her skin other than in these places seems to reflect the room temperature and not necessarily whether she has a fever.
We have an ear thermometre and an underarm thermometre. The ear thermometre is great because it takes about 1 second to do a reading, whereas with the underarm thermometre we have to persuade our unhappy, squirmy baby to stay still for about 90 seconds. So far, our ear thermometre readings have been confirmed by underarm readings, so I prefer it because it is less distressing / invasive for our baby.
Fever Helps Your Baby
When a baby is a newborn, fever can often be an indication of some serious problem, so parents are instilled with a terror of fevers in their babies. This is not helped by health practitioners following out of date information. But the overwhelming opinion of leading health organisations based on current medical evidence is that in most cases, you are better not to treat your baby's fever.
You should worry about a fever if:
Otherwise, no. The fever is not a problem, it is actually helping your baby!
Fever is your body's equivalent of a 'scorched earth' strategy in the fight against the virus. The body raises its core temperature in order to make it a hostile environment to invading bacteria / viruses, and the fever also triggers the production of large numbers of cells to fight the illness.
The most recent statement by the American Academy of Pediatrics in February 2011 states:
But I was Told To Give Panadol and/or Ibuprofen by a Health Professional
The evidence about the beneficial properties of fevers has only emerged recently (particularly in the last five years), so many health professionals have not caught up. It is well documented that inaccurate advice on treating fevers is still given by large numbers of health professionals (see Sullivan, Scrase and Tranter, Carson, Walsh 2006, Edwards et al). The practice of paediatric nurses in this respect have been described as 'inconsistent, ritualistic antipyretic use in fever management' (Edwards et al). The same study observed that nurses often administer antipyretics following insistence from an anxious parent, not because they believe it is necessary (Edwards et al). A recent study showed that almost a third of paediatric nurses believed that fever itself was dangerous and that paracetamol should be administered (Warwick).
I am not a health professional, and I'm not telling you to ignore the advice of your health professional. But the American Academy of Pediatrics are undeniably health professionals who have looked at the most up to date research on this topic and their view is that low-grade fever is usually a beneficial response. So I would encourage you to challenge your health professional (perhaps with the AAP statement) or seek a second opinion if they insist you must bring down a low-grade fever with an antipyretic.
Fever and Immunisations
In the 1980s, scientists began to look at ways to make immunisations less stressful for babies and parents, and so studied whether paracetamol could help deal with or prevent fever in babies who were immunised. It was found that paracetamol was pretty effective at lowering or preventing fever, and so it became common to recommend to parents to give Panadol before vaccines and then again every 4 hours for a couple of days (Pedulla).
It was not until 2007 that scientists noted that the original studies dealt with vaccines that were no longer used and some up-to-date studies were conducted. A 2008 study of 270 babies found that paracetamol had no noticeable effect with respect to reducing comfort or fever.
In 2009, a study monitored the extent to which children who were immunised produced antibodies. It found that children given paracetamol (as opposed to a placebo) produced significantly less antibodies in response to the vaccine (Prymula). Whether children produced enough antibodies seemed to vary dramatically depending upon the vaccine. There were vaccines (eg. polio) where the children given paracetamol still produced protective levels of antibodies, but others where many did not reach that protective level (eg. some strains of pneumococcal). (Prymula) This study also found that fevers greater than 39.5 degrees Celcius were uncommon regardless of whether paracetamol was given. Interestingly, this study had not aimed to look at paracetamol's effect on antibodies, but rather children's antibody responses to various vaccines, and separately what effect paracetamol had on fever (Prymula).
It should be noted that these are only preliminary studies, and further studies would be necessary to confirm the effect, and also to establish whether it is dependent upon the timing and dosage of paracetamol. However, the initial results are concerning enough for most health care providers to recommend that paracetamol not be routinely before or following immunisation (see, for example, Sullivan). Whether paracetamol should be given in cases where an adverse reaction does occur is a subject of debate, and it is likely we will soon see further research on this topic.
Effect of Antipyretics on Fever
Paracetamol and ibuprofen have both been shown to be fairly effective in lowering the core body temperature of babies with fevers, although there is some evidence that ibuprofen is a bit more effective with high grade fevers and has a longer-lasting effect (Perrott, Sullivan). There was a review of 12 studies that found paracetamol was no more effective than a placebo, but the studies included in this review had only small numbers of patients (Chiappini et al).
Aspirin is also effective, however, it is widely accepted that aspirin should not be used to treat fever in children. It is believed to be linked to a condition called 'Reye syndrome', which involves nausia, vomiting, delirium, and coma. Reye syndrome appears to be a severe, though not necessarily common side-effect of aspirin. Only 555 cases were reported in its peak year in 1980. Reye's syndrome is almost unknown since the introduction of warnings not to give aspirin to children (Beutler and Jamieson).
Possible Issues With Antipyretics
There are concerns that antipyretics like Panadol and Neurofen:
There are some incidents where it appears that paracetamol and ibuprofen led to such a drop in temperature as to cause hypothermia (a temperature that is too low), but studies have not been conducted to confirm how often this occurs (Richardson).
Antipyretics Do Not Prevent Febrile Convulsions
Studies indicate that use of antipyretics do not prevent febrile seizures (Fetveit, Sullivan). Febrile seizures are usually benign and resolve themselves, and the only treatment necessary is to protect the child from hurting themselves during the seizure (Fetveit). However, you should probably seek medical advice if your child has a seizure, since they can have additional issues. Particularly seek help if seizures are recurrent during the same illness, go on for longer than 15 minutes, or start on one side of the body (Fetveit).
While febrile seizures can be very scary, children with febrile seizures have no risk of increased mortality (Leung and Robson).
Side Effects of Paracetamol (Panadol)
In a large International New Zealand-based study of 205 487 children, use of paracetamol to treat fevers in the first year of life was linked to a significant increase in the risk of asthma by age 6-7. It was also also associated with increased risk of rhinoconjunctivis and eczema in the first year of life and at age 6-7 years (Beasley et al). This study controlled for maternal education, antibiotic use, breasftfeeding, parental smoking, diet, and siblings. The study interviewed parents of 6-7 year olds about their child's current asthma, and their paracetamol usage recently and in the first year of the child's life.
It found that developing severe asthma by age 6-7 was about 1.5 times more likely if paracetamol was used for fever in the first year of life. Further, rhinoconjunctivis and eczema were also almost 1.5 times more likely with paracetamol usage in the first year of life.
An additional independent risk existed for paracetamol use in school-aged children. If paracetamol had been used a few times in the 12 months prior to the study, the child was 1.5 times more likely to have severe asthma symptoms, and if used once or more per months was over 3 times more likely to have severe asthma symptoms.
There are two likely explanations for these results. The first is that use of paracetamol increases susceptibility to asthma. The second is that paracetamol is frequently used to treat an illness that increases susceptibility to asthma (and so the two become associated, though it is in fact the illness, rather than the paracetamol that is the problem). An Editorial in the American Journal of Respiratory and Critical Care Medicine suggested that as lower respiratory tract rhinoviruses is associated with development of asthma, perhaps treating such viruses with paracetamol actually prolongs and worsens the illness by inhibiting antibodies, and this results in the higher rate of asthma (Holgate). A smaller Australian study of 620 children found that when the incident of early lower respiratory tract infections was controlled for, the link between asthma and paracetamol disappeared. However, one of the weaknesses of this study (apart from its size) is that nearly all the children in the study had taken at least some paracetamol, and that all the children in the study were those with a family history of symptoms for asthma or allergic diseases (Lowe).
The idea that paracetamol itself is a problem is also supported by a study which found that children whose mothers used paracetamol during pregnancy were at increased risk of asthma at 5 years of age (Holgate).
Side Effects of Ibuprofen (Neurofen)
Ibuprofen is a 'nonsteroidal anti-inflammatory drug' (a NSAID). NSAIDs can cause gastritis, bleeding, and ulcers of the stomach, duodenum and esophagus. Such symptoms are rare with ibuprofen, but have occurred even with the typical 'safe' doses used to reduce fever (Sullivan). By rare, the rate has been estimated as 7.2-17 children per 100,000 treated with ibuprofen (Chiappini).
NSAIDs also make extra work for the kidneys, and so seek medical advice before using in children with dehydration, cardiovascular disease, and preexisting renal disease. However, in two large studies of infants over 6 months who were given paracetamol or ibuprofen, the total rate of hospitalisation was 1-1.6%, and none were hospitalised for acute renal failure (Chiappini). The safety of ibuprofen for children under 6 months has not been established (Sullivan).
Alternating Paracetamol and Ibuprofen
It is a common practice among many mums I know to alternate Panadol and Neurofen. Because they work in different ways, they using them together does not cause an overdose, and so it has become a popular way to provide relief to a baby when the soothing effect of one of the drugs has worn off but it is too soon to give another dose. It is apparently a common treatment in the US (Carson).
In terms of its effect in reducing fever, it does not significantly bring down fever any more quickly (Erlewyn-Lajeunesse et al). However, over time paracetamol and ibuprofen together do have more of an effect at lowering fever and keeping down the temperature (Nabulsi et al).
There is no scientific research into whether this is a safe practice. The rate of short term and long term side effects is unknown. The American Academy of Paediatricians urge health care providers to 'exercise discretion' when recommending alternating paracetamol and ibuprofen because of the lack of research (Carson).
One possible problem is that paracetamol and ibuprofen tax the kidneys. The kidneys produce a chemical called glutathione in order to process some of the otherwise toxic chemicals in paracetamol. However, ibuprofen reduces the amountof glutathione the kidneys produce and blocks blood flow in the kidneys generally. This means that if the two drugs are taken together this could in theory lead to a build up of a toxic substance that the kidneys are unable to process (Carson).
The AAP position is: “there is insufficient evidence to support or refute the routine use of combination treatment.” However, they express concerns that it is more difficult to keep track of dosing and so is associated with overdosing, and that most of the time it is used to help the parents feel better about their 'fever phobia' rather than because it helps the child (Sullivan).
Overdosing on Panadol
According to Panadol's website, 15mg of paracetamol for every 1kg of body weight up to 4 times a day is the recommended dosage for children under 12 years. The liquid Baby Panadol has 100mg/1ml. So, a 6kg baby could have 1ml up to four times in a 24 hour period. The suppositories have 125mg, which is more than the recommended dose for a baby under 8kg, which is presumably why this product is suggested for 6mths+.
Overdosing on panadol can cause liver damage and death (Vale). A substance called N-acetylcysteine can help combat an overdose of panadol is given within 8-10 hours of the panadol overdose. If left untreated mortality is about 5% (Vale). In a baby under 12 months, over 100 mg/kg/day is likely to be toxic, particularly if continued over several days, and over 300mg/kg/day is likely to be fatal (Shann). A one-off dose of 150mg/kg can also be toxic (Aripin and Choonara).
Children with diabetes, obese children, dyhydrated or malnutritioned children or those who are not eating are at particular risk of paracetamol toxicity (Chiappini, Shivbalan) In an Indian study of paracetamol poisoning, all poisoned children were given more than 90mg/kg/day and had one of the risk factors (Shivbalan). Children under 1 month should not be given paracetamol except under medical advice and with monitoring.
To avoid overdosing:
Physical Treatments for Fever
Physical treatments include the cool baths, stripping off clothing, cool compresses, air-conditioning etc.
Physical methods for treating fever remain controversial. Lukewarm sponge baths do not seem to cause adverse effects, but more abrupt or significant methods (eg. cold baths, ice bags, rubbing the body with alcohol) have been shown to cause adverse effects including increasing the fever and depleting the patient's energy (Chiappini et al). Physical methods do not effectively lower a fever, although they are very effective for heat stroke.
Tepid (lukewarm – water about 30 degrees Celcius) sponging has been studied in various studies, some of which showed no or very little result, and one which showed a lowering of up to 0.8 degrees Celcius after about 15 minutes of sponging (Purssell). When combined with an antipyretic, sponging does not seem to have any additional effect on lowering body temperature (Newman). Sponging causes only a short-term fall in temperature, but it appears to have no negative side-effects, such as a rebound temperature when sponging is dicontinued (Purssell).
Removing clothing and turning on fans have been shown to have little to no effect on reducing the core body temperature of a fever (Purssell).
It should be noted that during the initial phase of a fever, a patient feels cold and will not appreciate being further cooled, and excess cooling may trick the body into thinking it needs to heat up more to reach the temperature it is aiming for with the fever. It is therefore important not just to 'cool' the patient because they seem hot to you, but to look at whether cooling measures seem to actually make them more comfortable (Scrase and Tranter).
Treating the Child's Discomfort
If fever itself is not a problem, then it is not the fever itself we must treat but the underlying illness. Parents nevertheless need support to feel that they are 'doing something' to look after their sick child, and need to look at ways to relieve their child's discomfort. The latest medical opinion supports the use of paracetamol or neurofen, not to reduce fever, but in those situations where it could provide pain relief to the child (Sullivan).
For quick discomfort, such as injection, giving the child something sweet to suck on (eg a dummy dipped in a sweet substance) has been shown to reduce pain for 2-5 minutes in infants (Harrison et al). This isn't very feasible or effective for something ongoing like a fever, though is worth bearing in mind if blood tests or catheters become necessary. If trying this at home also remember that honey and corn syrup are not suitable for babies because of the risk of botulism.
Other proven pain management techniques in infants include kangaroo care (holding the baby with your skin touching their skin), and breastfeeding (Harrison et al). Kangaroo care has been shown to have greater pain reduction for the pain of immunisation (Harrison et al).
With the second fever my baby had recently, I found that kangaroo care really helped. We usually sleep near each other on separate mattresses, but during the fever she wanted to sleep on my exposed stomach and chest, and this really did seem to help her relax and sleep.
Psychological Issues In Treating a Fever
It is important to recognise that many parents and health practitioners have an abiding fear of fever to the extent that the medical literature now speaks of 'fever phobia' (Chiappini et al, Clinch et al, Walsh 2006). Febrile convulsions are particularly scary and almost certainly create a situation of parental anxiety. Parental anxiety can lead to unnecessary drug use or other interventions (eg. unnecessary invasive tests).
For my part, I remember being so worried with my baby's first fever above 39 degrees Celcius that I took her to hospital and had a sample of urine taken by catheter (necessary for a girl to get an uncontaminated sample). I was advised that the catheter was a little uncomfortable but not painful. What I didn't realise is that it would take 3 goes to get the catheter in, while my baby was held down screaming, and that the later test results revealed the scratching around drew blood (presence of red blood cells in sample). Afterwards Bethany cried and cried in my arms, more distressed than after her immunisations. It was at that point that I realised that my need to be reassured and feel like I was 'doing something' had led me to request my baby go through an unnecessarily stressful and painful procedure.
Now when I decide not to administer paracetamol for a fever, I tell myself I am doing something - I am helping my baby's body have the best shot at fighting the infection itself.
References:
Aripin and Choonara, 'The management of paracetamol poisoning' (2009) Vol 19, Paediatrics and Child Health 11.
Beasley et al, 'Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years: analysis from Phase Three of the ISAAC programme' (2008) Vol 372 The Lancet 1039.
Beutler and Jamieson 'Aspirin Use in Children for Fever or Viral Syndromes' (2009) Volume 80(12) American Family Physician 1473.
Carson 'Alternating Acetaminophen and Ibuprofen in the Febrile Child: Examination of the Evidence Regarding Efficacy and Safety' (2003) Volume 29(5) Pediatric Nursing 379.
Chiappini, 'Management of Fever in Children: Summary of the Italian Pediatric Society Guidelines' (2009) Vol 31(8) Clinical Therapeutics 1826.
Edwards et al, 'Promoting evidence-based childhood fever management through a peer education program based on the Theory of Planned Behaviour' (2007) Vol 16(10) Journal of Clinical Nursing 1966.
Erlewyn-Lajeunesse et al, 'Randomised controlled trial of combined paracetamol and ibuprofen for fever' (2006) Vol 91 Arch Dis Child 414.
Fetveit, 'Assessment of febrile seizures in children' (2008) Vol 167 European Journal of Pediatrics p17.
Holgate, 'The Acetaminophen Enigma in Asthma' (2011) Vol 13 American Journal of Respiratory and Critical Care Medicine 147.
Leung and Robson, 'Febrile Seizures' (2006) Vol 21 Journal of Pediatric Health Care 250.
Lowe et al, 'Paracetamol use in early life and asthma: prospective birth cohort study' (2010) Vol 341 British Medical Journal c4616.
Moltz, 'Fever: Causes and Consequences' (1993) Vol 17 Neuroscience and Biobehavioural Reviews p237.
Nabulsi et al, 'Alternating ibuprofen and acetaminophen in the treatment of febrile children: a pilot study' (2006) Vol 4(4) BMC Medicine 1741.
Newman, 'Evaluation of sponging to reduce body temperature in febrile children' (1985) Vol 132 Canadian Medical Association Journal p641.
Paul et al, 'Efficacy of Standard Doses of Ibuprofen Alone, Alternating, and Combined With Acetaminophen for the Treatment of Febrile Children' (2010) Vol 32(14) Clinical Therapeutics p2433.
Pedulla et al, 'Prophylactic Use of Antipyretic Agents With Childhood Immunizations and Antibody Response: Reason for Concern?' (2011) Vol 10 Journal of Pediatric Health Care 1016.
Perrott et al, 'Efficacy and safety of acetaminophen vs ibuprofen for treating children's pain or fever: a meta-analysis' (2004) Vol 158(6) Archives of Paediatric and Adolescent Medicine p521.
Prymula et al, 'Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials' (2009) Vol 374 The Lancet p1339.
Purssell, 'Physical treatment of fever' (2000) Vol 2 Arch Dis Child 23.
Richardson, 'Hypothermia following fever' (2004) Vol 89 Arch Dis Child 1177.
Scrase and Tranter, 'Improving evidence-based care for patients with pyrexia' (2011) Vol 25(29) Art and Science p37.
Shann, 'Paracetamol: use in children' (1995) Vol 18 Australian Prescriber 33
Shivbalan, 'Therapeutic misadventure with paracetamol in children' (2010) Vol 42(6) Indian Journal of Pharmacology 412.
Sullivan et al, 'Clinical Report Fever and Antipyretic Use in Children' (2011)
Vale, 'Paracetamol (acetaminophen)' in (2007) Vol 35(12) Medicine 643.
Walsh and Edwards, 'Management of childhood fever by parents: literature review' (2006) Vol 54(2) Journal of Advanced Nursing p217
Walsh, ''Childhood Fever' (2007) Nursing Review 10
Warwick, 'Paracetamol and fever management' (2008) Vol 128 Perspectives in Public Health, p320.
My poor little munchkin has had 2 fevers in the last three weeks, and a snotty nose cold in between. I feel like a walking zombie from all the night-wakings, and I imagine she doesn't feel too crash hot either. In the process of dealing with these fevers, I learned that the taste of Panadol makes my baby gag and throw up. (Amazingly, we got to 9 months without really having a situation arise where we thought Panadol might be necessary.) Panadol can, however, be successfully administered to her by an over-the-counter suppository.
Having to administer Panadol by suppository does make you think fairly hard about whether you really need to give it. So I started to do some research. As a result of this research, I have come to the conclusion that in most cases I will not give Panadol (or Neurofen for that matter) to my baby in order to bring down her temperature.
Fancy Word Alert
Just so there's no confusion, here's a quick rundown on some of the fancy words used in this post.
The active ingredient in Panadol is paracetamol which is also known as acetaminophen and occasionally APAP. One of the uses of paracetamol is to reduce fever. A substance which reduces fever is called an antipyretic. Other well-known antipyretics are aspirin (acetylsalicylic acid), and ibuprofen which is the active ingredient in Nurofen. A child with a fever is sometimes referred to as being 'febrile' and fever is sometimes called 'pyrexia'.
What is a Fever?
Fevers are different from hyperthermia. A fever is when your body deliberately raises its core temperature, usually in response to a virus or bacteria. Hyperthermia is when your temperature rises from other sources, such as heat stroke or taking a drug stimulant like cocaine (just in case, you know, your baby decides to smoke crack). Babies who are hot because they bundled up in too much clothing and bedding do not have a fever. They have hyperthermia. Unwrap them and they cool down. Babies with fever may develop cooler skin if they are stripped down, but if you... ahem... stick a thermometre up their bum, it will still read hot.
On one view, any temperature above 37.8 degrees Celcius is considered to be a fever in a baby (Carson, Walsh 2007). However, it should be noted that infant body temperature can vary quickly by about a degree just from excessive clothing, hot weather, digestion, and bathing (Walsh 2007). Body temperature may also be hottest in the early afternoon and lowest in the middle of the night (Walsh 2007).
Over 37.8 but under 40 degrees Celcius is considered a 'low grade' fever. Only fevers over 41.5 degrees Celcius are considered a 'high grade' fever (sometimes called 'hyperpyrexia').
What is the Best Way To Take a Temperature?
A recent Italian review of the literature of fevers found that the best way to take a baby's temperature is a digital thermometre under the arm (axillary temperature). A thermometre in the mouth (oral temperature) is unreliable. A thermometre in the anus (rectal temperature) is very reliable but quite invasive so shouldn't be used unless necessary. An ear thermometre (tympanic temperature) can be very reliable if you know how to use it, but if you don't can be difficult, and in newborns the ear canal is too curved to get a reliable reading.
I actually find that I can tell whether my baby has a temperature by feeling the top of her head and her tummy, or in any 'folds' like under her arms. Once I was used to her usual temperature, an elevated temperature felt like the skin was 'burning'. Even a fever of 38.2 has been quite obvious to the touch. The temperature of her skin other than in these places seems to reflect the room temperature and not necessarily whether she has a fever.
We have an ear thermometre and an underarm thermometre. The ear thermometre is great because it takes about 1 second to do a reading, whereas with the underarm thermometre we have to persuade our unhappy, squirmy baby to stay still for about 90 seconds. So far, our ear thermometre readings have been confirmed by underarm readings, so I prefer it because it is less distressing / invasive for our baby.
Fever Helps Your Baby
When a baby is a newborn, fever can often be an indication of some serious problem, so parents are instilled with a terror of fevers in their babies. This is not helped by health practitioners following out of date information. But the overwhelming opinion of leading health organisations based on current medical evidence is that in most cases, you are better not to treat your baby's fever.
You should worry about a fever if:
- your baby is under 3 months;
- your baby has some significant complication to their immune system like cancer or HIV;
- your baby's temperature is over 41 degrees Celcius (and even then it might be ok if it's just a fever and not hyperthermia);
- your baby has other symptoms that indicate they are not coping with an illness, such as dehydration, significant distress, vomiting or diarrhoea, or becoming limp.
Otherwise, no. The fever is not a problem, it is actually helping your baby!
Fever is your body's equivalent of a 'scorched earth' strategy in the fight against the virus. The body raises its core temperature in order to make it a hostile environment to invading bacteria / viruses, and the fever also triggers the production of large numbers of cells to fight the illness.
The most recent statement by the American Academy of Pediatrics in February 2011 states:
“fever is not an illness but is, in fact, a physiological mechanism that has beneficial effects in fighting infection. Fever retards the growth and reproduction of bacteria and viruses, enhances neutrophil production and T-lymphocyte proliferation, and aids in the body's acute-phase reaction. The degree of fever does not always correlate with the severity of illness. Most fevers are of short duration, are benign, and may actually protect the host. Data show beneficial effects on certain components of the immune system in fever, and limited data have revealed that fever actually helps the body recover more quickly from viral infections, although the fever may result in discomfort in children.” (Sullivan)This statement also says:
In various animals, the positive effects of a moderate fever have been well documented. In a study of iguanas injected with a deadly bacteria, 50% of those whose fevers were kept down died, whereas of those who were untreated and ran a temperature 2 degrees above normal, only 15% died. Similar results have been found in tests on goldfish, grasshoppers, crickets, and rabbits. In studies of lizards and rabbits given aspirin to lower a fever, most of those that were not given the aspirin survived, but all those given the aspirin died, except a few who managed to produce a fever despite the aspirin. A number of studies in humans also show a link between fever and survival in serious bacterial illnesses (Moltz).
- “There is no evidence that children with fever, as opposed to hyperthemia, are at increased risk of adverse outcomes such as brain damage.”
- “There is no evidence that reducing fever reduces morbidity or mortality from a febrile illness.”
- “There is no evidence that antipyretic therapy decreases the recurrence of febrile seizures.”
- “Studies of health care workers, including physicians, have revealed that most believe that the risk of heat-related adverse outcomes is increased with temperatures above 40 degrees Celcius, although this belief is not justified.”
But I was Told To Give Panadol and/or Ibuprofen by a Health Professional
The evidence about the beneficial properties of fevers has only emerged recently (particularly in the last five years), so many health professionals have not caught up. It is well documented that inaccurate advice on treating fevers is still given by large numbers of health professionals (see Sullivan, Scrase and Tranter, Carson, Walsh 2006, Edwards et al). The practice of paediatric nurses in this respect have been described as 'inconsistent, ritualistic antipyretic use in fever management' (Edwards et al). The same study observed that nurses often administer antipyretics following insistence from an anxious parent, not because they believe it is necessary (Edwards et al). A recent study showed that almost a third of paediatric nurses believed that fever itself was dangerous and that paracetamol should be administered (Warwick).
I am not a health professional, and I'm not telling you to ignore the advice of your health professional. But the American Academy of Pediatrics are undeniably health professionals who have looked at the most up to date research on this topic and their view is that low-grade fever is usually a beneficial response. So I would encourage you to challenge your health professional (perhaps with the AAP statement) or seek a second opinion if they insist you must bring down a low-grade fever with an antipyretic.
Fever and Immunisations
In the 1980s, scientists began to look at ways to make immunisations less stressful for babies and parents, and so studied whether paracetamol could help deal with or prevent fever in babies who were immunised. It was found that paracetamol was pretty effective at lowering or preventing fever, and so it became common to recommend to parents to give Panadol before vaccines and then again every 4 hours for a couple of days (Pedulla).
It was not until 2007 that scientists noted that the original studies dealt with vaccines that were no longer used and some up-to-date studies were conducted. A 2008 study of 270 babies found that paracetamol had no noticeable effect with respect to reducing comfort or fever.
In 2009, a study monitored the extent to which children who were immunised produced antibodies. It found that children given paracetamol (as opposed to a placebo) produced significantly less antibodies in response to the vaccine (Prymula). Whether children produced enough antibodies seemed to vary dramatically depending upon the vaccine. There were vaccines (eg. polio) where the children given paracetamol still produced protective levels of antibodies, but others where many did not reach that protective level (eg. some strains of pneumococcal). (Prymula) This study also found that fevers greater than 39.5 degrees Celcius were uncommon regardless of whether paracetamol was given. Interestingly, this study had not aimed to look at paracetamol's effect on antibodies, but rather children's antibody responses to various vaccines, and separately what effect paracetamol had on fever (Prymula).
It should be noted that these are only preliminary studies, and further studies would be necessary to confirm the effect, and also to establish whether it is dependent upon the timing and dosage of paracetamol. However, the initial results are concerning enough for most health care providers to recommend that paracetamol not be routinely before or following immunisation (see, for example, Sullivan). Whether paracetamol should be given in cases where an adverse reaction does occur is a subject of debate, and it is likely we will soon see further research on this topic.
Effect of Antipyretics on Fever
Paracetamol and ibuprofen have both been shown to be fairly effective in lowering the core body temperature of babies with fevers, although there is some evidence that ibuprofen is a bit more effective with high grade fevers and has a longer-lasting effect (Perrott, Sullivan). There was a review of 12 studies that found paracetamol was no more effective than a placebo, but the studies included in this review had only small numbers of patients (Chiappini et al).
Aspirin is also effective, however, it is widely accepted that aspirin should not be used to treat fever in children. It is believed to be linked to a condition called 'Reye syndrome', which involves nausia, vomiting, delirium, and coma. Reye syndrome appears to be a severe, though not necessarily common side-effect of aspirin. Only 555 cases were reported in its peak year in 1980. Reye's syndrome is almost unknown since the introduction of warnings not to give aspirin to children (Beutler and Jamieson).
Possible Issues With Antipyretics
There are concerns that antipyretics like Panadol and Neurofen:
- interfere with the body's natural immune response;
- mask the symptoms of the illness, making it harder to diagnose (Scrase and Tranter).
There are some incidents where it appears that paracetamol and ibuprofen led to such a drop in temperature as to cause hypothermia (a temperature that is too low), but studies have not been conducted to confirm how often this occurs (Richardson).
Antipyretics Do Not Prevent Febrile Convulsions
Studies indicate that use of antipyretics do not prevent febrile seizures (Fetveit, Sullivan). Febrile seizures are usually benign and resolve themselves, and the only treatment necessary is to protect the child from hurting themselves during the seizure (Fetveit). However, you should probably seek medical advice if your child has a seizure, since they can have additional issues. Particularly seek help if seizures are recurrent during the same illness, go on for longer than 15 minutes, or start on one side of the body (Fetveit).
While febrile seizures can be very scary, children with febrile seizures have no risk of increased mortality (Leung and Robson).
Side Effects of Paracetamol (Panadol)
In a large International New Zealand-based study of 205 487 children, use of paracetamol to treat fevers in the first year of life was linked to a significant increase in the risk of asthma by age 6-7. It was also also associated with increased risk of rhinoconjunctivis and eczema in the first year of life and at age 6-7 years (Beasley et al). This study controlled for maternal education, antibiotic use, breasftfeeding, parental smoking, diet, and siblings. The study interviewed parents of 6-7 year olds about their child's current asthma, and their paracetamol usage recently and in the first year of the child's life.
It found that developing severe asthma by age 6-7 was about 1.5 times more likely if paracetamol was used for fever in the first year of life. Further, rhinoconjunctivis and eczema were also almost 1.5 times more likely with paracetamol usage in the first year of life.
An additional independent risk existed for paracetamol use in school-aged children. If paracetamol had been used a few times in the 12 months prior to the study, the child was 1.5 times more likely to have severe asthma symptoms, and if used once or more per months was over 3 times more likely to have severe asthma symptoms.
There are two likely explanations for these results. The first is that use of paracetamol increases susceptibility to asthma. The second is that paracetamol is frequently used to treat an illness that increases susceptibility to asthma (and so the two become associated, though it is in fact the illness, rather than the paracetamol that is the problem). An Editorial in the American Journal of Respiratory and Critical Care Medicine suggested that as lower respiratory tract rhinoviruses is associated with development of asthma, perhaps treating such viruses with paracetamol actually prolongs and worsens the illness by inhibiting antibodies, and this results in the higher rate of asthma (Holgate). A smaller Australian study of 620 children found that when the incident of early lower respiratory tract infections was controlled for, the link between asthma and paracetamol disappeared. However, one of the weaknesses of this study (apart from its size) is that nearly all the children in the study had taken at least some paracetamol, and that all the children in the study were those with a family history of symptoms for asthma or allergic diseases (Lowe).
The idea that paracetamol itself is a problem is also supported by a study which found that children whose mothers used paracetamol during pregnancy were at increased risk of asthma at 5 years of age (Holgate).
Side Effects of Ibuprofen (Neurofen)
Ibuprofen is a 'nonsteroidal anti-inflammatory drug' (a NSAID). NSAIDs can cause gastritis, bleeding, and ulcers of the stomach, duodenum and esophagus. Such symptoms are rare with ibuprofen, but have occurred even with the typical 'safe' doses used to reduce fever (Sullivan). By rare, the rate has been estimated as 7.2-17 children per 100,000 treated with ibuprofen (Chiappini).
NSAIDs also make extra work for the kidneys, and so seek medical advice before using in children with dehydration, cardiovascular disease, and preexisting renal disease. However, in two large studies of infants over 6 months who were given paracetamol or ibuprofen, the total rate of hospitalisation was 1-1.6%, and none were hospitalised for acute renal failure (Chiappini). The safety of ibuprofen for children under 6 months has not been established (Sullivan).
Alternating Paracetamol and Ibuprofen
It is a common practice among many mums I know to alternate Panadol and Neurofen. Because they work in different ways, they using them together does not cause an overdose, and so it has become a popular way to provide relief to a baby when the soothing effect of one of the drugs has worn off but it is too soon to give another dose. It is apparently a common treatment in the US (Carson).
In terms of its effect in reducing fever, it does not significantly bring down fever any more quickly (Erlewyn-Lajeunesse et al). However, over time paracetamol and ibuprofen together do have more of an effect at lowering fever and keeping down the temperature (Nabulsi et al).
There is no scientific research into whether this is a safe practice. The rate of short term and long term side effects is unknown. The American Academy of Paediatricians urge health care providers to 'exercise discretion' when recommending alternating paracetamol and ibuprofen because of the lack of research (Carson).
One possible problem is that paracetamol and ibuprofen tax the kidneys. The kidneys produce a chemical called glutathione in order to process some of the otherwise toxic chemicals in paracetamol. However, ibuprofen reduces the amountof glutathione the kidneys produce and blocks blood flow in the kidneys generally. This means that if the two drugs are taken together this could in theory lead to a build up of a toxic substance that the kidneys are unable to process (Carson).
The AAP position is: “there is insufficient evidence to support or refute the routine use of combination treatment.” However, they express concerns that it is more difficult to keep track of dosing and so is associated with overdosing, and that most of the time it is used to help the parents feel better about their 'fever phobia' rather than because it helps the child (Sullivan).
Overdosing on Panadol
According to Panadol's website, 15mg of paracetamol for every 1kg of body weight up to 4 times a day is the recommended dosage for children under 12 years. The liquid Baby Panadol has 100mg/1ml. So, a 6kg baby could have 1ml up to four times in a 24 hour period. The suppositories have 125mg, which is more than the recommended dose for a baby under 8kg, which is presumably why this product is suggested for 6mths+.
Overdosing on panadol can cause liver damage and death (Vale). A substance called N-acetylcysteine can help combat an overdose of panadol is given within 8-10 hours of the panadol overdose. If left untreated mortality is about 5% (Vale). In a baby under 12 months, over 100 mg/kg/day is likely to be toxic, particularly if continued over several days, and over 300mg/kg/day is likely to be fatal (Shann). A one-off dose of 150mg/kg can also be toxic (Aripin and Choonara).
Children with diabetes, obese children, dyhydrated or malnutritioned children or those who are not eating are at particular risk of paracetamol toxicity (Chiappini, Shivbalan) In an Indian study of paracetamol poisoning, all poisoned children were given more than 90mg/kg/day and had one of the risk factors (Shivbalan). Children under 1 month should not be given paracetamol except under medical advice and with monitoring.
To avoid overdosing:
- use only 'Baby Panadol' (or other brand equivalent) suitable for children under 12 months;
- measure the amount carefully according to the instructions, and using a proper measuring syringe (not, for example, a teaspoon); and
- write down when each dose is given and make sure to communicate with other persons who may also be looking after your baby.
Physical Treatments for Fever
Physical treatments include the cool baths, stripping off clothing, cool compresses, air-conditioning etc.
Physical methods for treating fever remain controversial. Lukewarm sponge baths do not seem to cause adverse effects, but more abrupt or significant methods (eg. cold baths, ice bags, rubbing the body with alcohol) have been shown to cause adverse effects including increasing the fever and depleting the patient's energy (Chiappini et al). Physical methods do not effectively lower a fever, although they are very effective for heat stroke.
Tepid (lukewarm – water about 30 degrees Celcius) sponging has been studied in various studies, some of which showed no or very little result, and one which showed a lowering of up to 0.8 degrees Celcius after about 15 minutes of sponging (Purssell). When combined with an antipyretic, sponging does not seem to have any additional effect on lowering body temperature (Newman). Sponging causes only a short-term fall in temperature, but it appears to have no negative side-effects, such as a rebound temperature when sponging is dicontinued (Purssell).
Removing clothing and turning on fans have been shown to have little to no effect on reducing the core body temperature of a fever (Purssell).
It should be noted that during the initial phase of a fever, a patient feels cold and will not appreciate being further cooled, and excess cooling may trick the body into thinking it needs to heat up more to reach the temperature it is aiming for with the fever. It is therefore important not just to 'cool' the patient because they seem hot to you, but to look at whether cooling measures seem to actually make them more comfortable (Scrase and Tranter).
Treating the Child's Discomfort
If fever itself is not a problem, then it is not the fever itself we must treat but the underlying illness. Parents nevertheless need support to feel that they are 'doing something' to look after their sick child, and need to look at ways to relieve their child's discomfort. The latest medical opinion supports the use of paracetamol or neurofen, not to reduce fever, but in those situations where it could provide pain relief to the child (Sullivan).
For quick discomfort, such as injection, giving the child something sweet to suck on (eg a dummy dipped in a sweet substance) has been shown to reduce pain for 2-5 minutes in infants (Harrison et al). This isn't very feasible or effective for something ongoing like a fever, though is worth bearing in mind if blood tests or catheters become necessary. If trying this at home also remember that honey and corn syrup are not suitable for babies because of the risk of botulism.
Other proven pain management techniques in infants include kangaroo care (holding the baby with your skin touching their skin), and breastfeeding (Harrison et al). Kangaroo care has been shown to have greater pain reduction for the pain of immunisation (Harrison et al).
With the second fever my baby had recently, I found that kangaroo care really helped. We usually sleep near each other on separate mattresses, but during the fever she wanted to sleep on my exposed stomach and chest, and this really did seem to help her relax and sleep.
Psychological Issues In Treating a Fever
It is important to recognise that many parents and health practitioners have an abiding fear of fever to the extent that the medical literature now speaks of 'fever phobia' (Chiappini et al, Clinch et al, Walsh 2006). Febrile convulsions are particularly scary and almost certainly create a situation of parental anxiety. Parental anxiety can lead to unnecessary drug use or other interventions (eg. unnecessary invasive tests).
For my part, I remember being so worried with my baby's first fever above 39 degrees Celcius that I took her to hospital and had a sample of urine taken by catheter (necessary for a girl to get an uncontaminated sample). I was advised that the catheter was a little uncomfortable but not painful. What I didn't realise is that it would take 3 goes to get the catheter in, while my baby was held down screaming, and that the later test results revealed the scratching around drew blood (presence of red blood cells in sample). Afterwards Bethany cried and cried in my arms, more distressed than after her immunisations. It was at that point that I realised that my need to be reassured and feel like I was 'doing something' had led me to request my baby go through an unnecessarily stressful and painful procedure.
“In 1980 48% to 53% of parents woke sleeping febrile children. Today [2006], this has increased ot between 66% and 92%. Parents need reassurance that they are managing their febrile child appropriately. They often contact medical practitioners for low fevers or fevers of short duration. Although this creates guilt in some parents, they feel they have little choice; their concern for their child needed a shared responsibility.”Apart from creating stressful experiences for the child, a child may actually find a parent's anxiety stressful, and that this stress taxes their body and makes it harder for them to fight the illness:
“The sense of loss of control when faced with a febrile child contributes to parental anxiety. Parents' control refers to the adequate control of the observed effects of an illness and protecting their child from potential harm. … Similarly to childhood fever, pain in children is also a significant source of anxiety for the parent and adequate pain management helps reduce parental anxiety, which may reduce the child's anxiety and aid recovery” (Clinch)It is therefore important that parents support each other in order to make an informed choice about whether to administer antipyretics or have tests conducted looking at all the circumstances.
Now when I decide not to administer paracetamol for a fever, I tell myself I am doing something - I am helping my baby's body have the best shot at fighting the infection itself.
References:
Aripin and Choonara, 'The management of paracetamol poisoning' (2009) Vol 19, Paediatrics and Child Health 11.
Beasley et al, 'Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years: analysis from Phase Three of the ISAAC programme' (2008) Vol 372 The Lancet 1039.
Beutler and Jamieson 'Aspirin Use in Children for Fever or Viral Syndromes' (2009) Volume 80(12) American Family Physician 1473.
Carson 'Alternating Acetaminophen and Ibuprofen in the Febrile Child: Examination of the Evidence Regarding Efficacy and Safety' (2003) Volume 29(5) Pediatric Nursing 379.
Chiappini, 'Management of Fever in Children: Summary of the Italian Pediatric Society Guidelines' (2009) Vol 31(8) Clinical Therapeutics 1826.
Edwards et al, 'Promoting evidence-based childhood fever management through a peer education program based on the Theory of Planned Behaviour' (2007) Vol 16(10) Journal of Clinical Nursing 1966.
Erlewyn-Lajeunesse et al, 'Randomised controlled trial of combined paracetamol and ibuprofen for fever' (2006) Vol 91 Arch Dis Child 414.
Fetveit, 'Assessment of febrile seizures in children' (2008) Vol 167 European Journal of Pediatrics p17.
Holgate, 'The Acetaminophen Enigma in Asthma' (2011) Vol 13 American Journal of Respiratory and Critical Care Medicine 147.
Leung and Robson, 'Febrile Seizures' (2006) Vol 21 Journal of Pediatric Health Care 250.
Lowe et al, 'Paracetamol use in early life and asthma: prospective birth cohort study' (2010) Vol 341 British Medical Journal c4616.
Moltz, 'Fever: Causes and Consequences' (1993) Vol 17 Neuroscience and Biobehavioural Reviews p237.
Nabulsi et al, 'Alternating ibuprofen and acetaminophen in the treatment of febrile children: a pilot study' (2006) Vol 4(4) BMC Medicine 1741.
Newman, 'Evaluation of sponging to reduce body temperature in febrile children' (1985) Vol 132 Canadian Medical Association Journal p641.
Paul et al, 'Efficacy of Standard Doses of Ibuprofen Alone, Alternating, and Combined With Acetaminophen for the Treatment of Febrile Children' (2010) Vol 32(14) Clinical Therapeutics p2433.
Pedulla et al, 'Prophylactic Use of Antipyretic Agents With Childhood Immunizations and Antibody Response: Reason for Concern?' (2011) Vol 10 Journal of Pediatric Health Care 1016.
Perrott et al, 'Efficacy and safety of acetaminophen vs ibuprofen for treating children's pain or fever: a meta-analysis' (2004) Vol 158(6) Archives of Paediatric and Adolescent Medicine p521.
Prymula et al, 'Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials' (2009) Vol 374 The Lancet p1339.
Purssell, 'Physical treatment of fever' (2000) Vol 2 Arch Dis Child 23.
Richardson, 'Hypothermia following fever' (2004) Vol 89 Arch Dis Child 1177.
Scrase and Tranter, 'Improving evidence-based care for patients with pyrexia' (2011) Vol 25(29) Art and Science p37.
Shann, 'Paracetamol: use in children' (1995) Vol 18 Australian Prescriber 33
Shivbalan, 'Therapeutic misadventure with paracetamol in children' (2010) Vol 42(6) Indian Journal of Pharmacology 412.
Sullivan et al, 'Clinical Report Fever and Antipyretic Use in Children' (2011)
Vale, 'Paracetamol (acetaminophen)' in (2007) Vol 35(12) Medicine 643.
Walsh and Edwards, 'Management of childhood fever by parents: literature review' (2006) Vol 54(2) Journal of Advanced Nursing p217
Walsh, ''Childhood Fever' (2007) Nursing Review 10
Warwick, 'Paracetamol and fever management' (2008) Vol 128 Perspectives in Public Health, p320.
Wednesday, April 20, 2011
And So Starts a Beautiful Dry Season
The dragonflies have been hovering around Darwin for almost a month now, tossed about by the wind, seemingly confused as another cyclone formed almost on top of us. Then, two days ago, as if God had flicked a switch, we woke to cool, crisp air. The dragonflies danced against a brilliant blue sky.
And my first thought was - hoorah, I can finally get all the laundry done!
On the First Day I hung sheets and towels and marvelled at how they were dry two hours later. Really really dry. I went crazy and stripped all the beds, and washed them, and dried them, and it was all done in a day. And I stood back and surveyed my handiwork, and I saw that it was good.
All Ye who do not have babies, this laundry obsession is not because stay at home parents do not have a life, but because babies are leaky, and the leaks are kind of organic and start creating funky smells and growing small colonies if you do not attend to them regularly.
As the sun dawned on the Second Day, and I was disappointed that the laundry basket was empty and the sheets did not need washing for a second time. Then it dawned on me that I did not have to rush to do all the washing because the Dry Season was really here and laundry could be done at leisure without having to worry about rain for months.
I strapped Bethany on my back in a wrap and took a leisurely walk past the Botanic gardens. We walked through the cool shade with the morning sun dappling the ground and bringing the leaves alive in emerald and gold. I am getting much better at wrapping. I joined The Babywearer Forums and learned that the key to wrapping is to get the baby up high and the wraps nice and tight, and learned some tricks for doing this, as well as some various styles of wrapping:
I cannot describe how liberating getting the hang of babywearing has been, particularly given I have such a velcro baby.
Whinging? Put her on my back and keep cooking dinner. Sleep? Put her on my back and keep doing whatever till she's asleep (then either leave her there or put her down). Need some exercise? Put her on my back and go for a walk. I now get all the housework done while she is awake. When she fell asleep yesterday, I made my lunch, then lay down near her snacking and reading. It was just wonderful.
And my first thought was - hoorah, I can finally get all the laundry done!
On the First Day I hung sheets and towels and marvelled at how they were dry two hours later. Really really dry. I went crazy and stripped all the beds, and washed them, and dried them, and it was all done in a day. And I stood back and surveyed my handiwork, and I saw that it was good.
All Ye who do not have babies, this laundry obsession is not because stay at home parents do not have a life, but because babies are leaky, and the leaks are kind of organic and start creating funky smells and growing small colonies if you do not attend to them regularly.
As the sun dawned on the Second Day, and I was disappointed that the laundry basket was empty and the sheets did not need washing for a second time. Then it dawned on me that I did not have to rush to do all the washing because the Dry Season was really here and laundry could be done at leisure without having to worry about rain for months.
I strapped Bethany on my back in a wrap and took a leisurely walk past the Botanic gardens. We walked through the cool shade with the morning sun dappling the ground and bringing the leaves alive in emerald and gold. I am getting much better at wrapping. I joined The Babywearer Forums and learned that the key to wrapping is to get the baby up high and the wraps nice and tight, and learned some tricks for doing this, as well as some various styles of wrapping:
Bethany asleep in what I now know is called a 'back wrap cross carry' (bwcc)
Bethany in a 'ruck', which means the straps go up over the shoulders first. The trick is you have to get them up high and the wrap really tight.
Through the Babywearer forums I met another woman in Darwin who wraps and we met for morning tea the other day and exchanged tips. We have both just taught ourselves by watching youtube videos and asking questions on forums. She showed me how to do a 'superman toss' to get the baby on my back, which is a lot quicker and more fun than the 'hip scooting' method I use (where she sits on my hip and I pass her to my back).
My solarveil Mei Tai from Keoni Slings also arrived today, and it has been excellent for Bethany to sleep in, either on my front or my back:
Whinging? Put her on my back and keep cooking dinner. Sleep? Put her on my back and keep doing whatever till she's asleep (then either leave her there or put her down). Need some exercise? Put her on my back and go for a walk. I now get all the housework done while she is awake. When she fell asleep yesterday, I made my lunch, then lay down near her snacking and reading. It was just wonderful.
Monday, April 11, 2011
Cooking and Cleaning
Cleaning and cooking and other domestic activities have never been my forte. Neither of my parents took any pleasure in household chores. They preferred to be workaholics and hire a cleaner to do most of it. My mum says she cooked when I was very little, but for as long as I can remember, my dad made the meals, and he believed in no fat, no salt, no sugar, and no herbs and spices. In his view, his mutton casseroles were very tasty, and the only good carrot is an over-microwaved carrot that has been doused liberally in mint and vinegar.
I failed 'Craft' (read sewing and knitting) at my posh girls' school in Yr 9, and my 'Home Ec' (read cooking) teacher never quite trusted me after I almost blew up the kitchen. We had an electric oven at home, so I didn't realise you weren't supposed to press the ignition button after the gas had been on for a while in a gas oven. Oops.
After that incident, I sulkily resorted to working out how to blow awesome bubbles using the dishwashing detergent and blowing through the hole made by my thumb and index finger.
Anyway, I saw the cooking and sewing as hangovers from the not-very-distant days when my school's purpose was to raise proper young ladies to become good wives. This was, after all, the school where a classmate lamented she was sweating in the hot weather was reprimanded by the Principal with words that have stuck with me to this day: 'Girls do not sweat! Horses sweat. Boys perspire, and girls glow.'
The Home Ec and Craft teachers were buttoned-up starchy older women whose idea of an adventurous meal was shepherd's pie and apple crumble. I don't think they instilled any respect for their knowledge of cookery by making us start with making vegemite sandwiches. I became too busy making an amateurish feminist protest that I did not realise that cooking and cleaning might also be useful to me, and possibly even enjoyable. I thought only take-away food tasted any good, and planned to make enough money to eat only take-away once I left home.
Fast forward to leaving home and the financial reality of being a uni student. I realised with horror that I was going to have to learn to cook or face several long years of eating 2 minute noodles and toasted cheese sandwiches - which was pretty unappetising even without considering the implications nutritionally. My cooking repertoire at that stage extended to chucking some chicken and Chicken Tonight sauce in the frying pan, burning it, and adding some over or undercooked rice. As for cleaning, I was so naive that I in fact did not realise you had to clean a toilet until I moved into a place of my own at 18 and was startled to discover the toilet grew increasingly brown and gunky. Even so, much to the horror of various flatmates, it took me many, many years before I accepted that I would actually have to spend hours of my time each week doing something as monotonous as cleaning.
By the time I became a mum, I was moderately proficient at a range of basic meals, and reluctantly accepted that every now and then I did have to vacuum and clean the loos. I knew that having a baby would come with an exponential increase in laundry. But since my baby started rolling around on and gumming the floor, I started to realise my general cleaning standards might need to be lifted as well. Then as she started crawling and leaving food crumbed and smooshed up all over the place I realised I would really have to lift my game. I didn't want to be wiping everything down with chemicals that would just be getting in her mouth, but I didn't really know what else to do. As for food, I suddenly started thinking about choking hazards, and pesticides, and developing healthy eating habits and all those other things.
I found this handy guide to making a cheap non-toxic cleaning kit, mostly using bicarb soda, vinegar, and an earth-friendly liquid soap. I had to look up what 'washing soda' was - it is a chemical called 'sodium carbonate', and I have not tried it. The Back-to-Basics Cleaning website is also very useful. I also invested in a very cheap steam mop and do the kitchen floor with it every 1-2 days just to sort out the residue of any munchkin meals - which is very quick, dries instantly, and is completely chemical free. Many essential oils can also be good for cleaning (here is a 'starter kit', and see here and here for ideas), but most also have to be avoided while pregnant, so check this list if you might be pregnant.
On the food front, my baby continues to eat very little of anything, but she usually joins us for dinner and will play with/taste the food we are eating. She loves meat and anything with flavour. She eats almost nothing in the way of traditional baby food, so I'm glad I learned about introducing them to the house-hold meals, since it is largely pointless to make baby food up especially for her. I found the Baby-Led Weaning Cookbook was a great guide with lots of simple ideas, and ran through the basics of nutrition and safe eating for bubs. It has recipes for home-made curry pastes, pesto, gravy etc. so that you can control the salt, chilli, and skip the preservatives.
But I also put Christmas vouchers to good use and invested in some quality cookbooks generally, including Stephanie Alexander's The Cook's Companion and the Women's Weekly 1000 Best Recipes. My in-laws may have been trying to give me a hint, because I also acquired a Women's Weekly World Table cookbook and Clare Richard's Tropical Cuisine.
I find putting paprika, garlic, and a little chilli or cayenne pepper makes the food tasty without adding salt. I am trying to buy fruit and vegies at Darwin's organic store and buy in season so this is not much more expensive (recently bananas and pumpkins have been much cheaper at the organic store). The organic store also has curry pastes and sauces which are low salt and preservative free, that you can't find in the supermarket.
I failed 'Craft' (read sewing and knitting) at my posh girls' school in Yr 9, and my 'Home Ec' (read cooking) teacher never quite trusted me after I almost blew up the kitchen. We had an electric oven at home, so I didn't realise you weren't supposed to press the ignition button after the gas had been on for a while in a gas oven. Oops.
After that incident, I sulkily resorted to working out how to blow awesome bubbles using the dishwashing detergent and blowing through the hole made by my thumb and index finger.
Anyway, I saw the cooking and sewing as hangovers from the not-very-distant days when my school's purpose was to raise proper young ladies to become good wives. This was, after all, the school where a classmate lamented she was sweating in the hot weather was reprimanded by the Principal with words that have stuck with me to this day: 'Girls do not sweat! Horses sweat. Boys perspire, and girls glow.'
Morongo Girls' College (homestead c. 1863)
The Home Ec and Craft teachers were buttoned-up starchy older women whose idea of an adventurous meal was shepherd's pie and apple crumble. I don't think they instilled any respect for their knowledge of cookery by making us start with making vegemite sandwiches. I became too busy making an amateurish feminist protest that I did not realise that cooking and cleaning might also be useful to me, and possibly even enjoyable. I thought only take-away food tasted any good, and planned to make enough money to eat only take-away once I left home.
Fast forward to leaving home and the financial reality of being a uni student. I realised with horror that I was going to have to learn to cook or face several long years of eating 2 minute noodles and toasted cheese sandwiches - which was pretty unappetising even without considering the implications nutritionally. My cooking repertoire at that stage extended to chucking some chicken and Chicken Tonight sauce in the frying pan, burning it, and adding some over or undercooked rice. As for cleaning, I was so naive that I in fact did not realise you had to clean a toilet until I moved into a place of my own at 18 and was startled to discover the toilet grew increasingly brown and gunky. Even so, much to the horror of various flatmates, it took me many, many years before I accepted that I would actually have to spend hours of my time each week doing something as monotonous as cleaning.
By the time I became a mum, I was moderately proficient at a range of basic meals, and reluctantly accepted that every now and then I did have to vacuum and clean the loos. I knew that having a baby would come with an exponential increase in laundry. But since my baby started rolling around on and gumming the floor, I started to realise my general cleaning standards might need to be lifted as well. Then as she started crawling and leaving food crumbed and smooshed up all over the place I realised I would really have to lift my game. I didn't want to be wiping everything down with chemicals that would just be getting in her mouth, but I didn't really know what else to do. As for food, I suddenly started thinking about choking hazards, and pesticides, and developing healthy eating habits and all those other things.
I found this handy guide to making a cheap non-toxic cleaning kit, mostly using bicarb soda, vinegar, and an earth-friendly liquid soap. I had to look up what 'washing soda' was - it is a chemical called 'sodium carbonate', and I have not tried it. The Back-to-Basics Cleaning website is also very useful. I also invested in a very cheap steam mop and do the kitchen floor with it every 1-2 days just to sort out the residue of any munchkin meals - which is very quick, dries instantly, and is completely chemical free. Many essential oils can also be good for cleaning (here is a 'starter kit', and see here and here for ideas), but most also have to be avoided while pregnant, so check this list if you might be pregnant.
On the food front, my baby continues to eat very little of anything, but she usually joins us for dinner and will play with/taste the food we are eating. She loves meat and anything with flavour. She eats almost nothing in the way of traditional baby food, so I'm glad I learned about introducing them to the house-hold meals, since it is largely pointless to make baby food up especially for her. I found the Baby-Led Weaning Cookbook was a great guide with lots of simple ideas, and ran through the basics of nutrition and safe eating for bubs. It has recipes for home-made curry pastes, pesto, gravy etc. so that you can control the salt, chilli, and skip the preservatives.
But I also put Christmas vouchers to good use and invested in some quality cookbooks generally, including Stephanie Alexander's The Cook's Companion and the Women's Weekly 1000 Best Recipes. My in-laws may have been trying to give me a hint, because I also acquired a Women's Weekly World Table cookbook and Clare Richard's Tropical Cuisine.
I find putting paprika, garlic, and a little chilli or cayenne pepper makes the food tasty without adding salt. I am trying to buy fruit and vegies at Darwin's organic store and buy in season so this is not much more expensive (recently bananas and pumpkins have been much cheaper at the organic store). The organic store also has curry pastes and sauces which are low salt and preservative free, that you can't find in the supermarket.
Sunday, April 3, 2011
Babies Learning Language
Bethany said her first word the other day. "Da!" for Dad. I'm not surprised because it is the one word we have been repeating to her more than any other word. She's been babbling "dahdahdah" for a month or so now, so she has the hang of forming the syllable. But now she seems to direct it towards her Dad. She does it if she wants his attention and he's ignoring her, or when he first comes into view, and it's a sharper 'a' sound than he usual 'dah'. He walked out of the room yesterday and she chased after him saying 'Da! Da! Da!'
I think it is so exciting that she is finally connecting sounds to specific objects. Not very many objects, yet, but I figure it's a big mental leap to make the connection that when we talk we're not just making sounds, but conveying meaning. I heard most babies understand words before they speak them, but with Bethany I reckon she's just made the conceptual connection at the same time she spoke it. I have been trying in vain to get her to look at objects when I name them (including her Dad), or respond to her name, for months, but she has seemed completely oblivious. I mind as well have been babbling nonsense myself, as far as she was concerned. It is as though she has had a lightbulb moment and got the idea of language and decided to try it out at once.
So I thought I'd do a bit of reading on language development.
Lise Eliot has a whole chapter on 'Language and the Developing Brain' in What's Going On In There? and I've drawn much of this blog post from what she's written. I've also drawn on An Introduction to Language by Victoria Fromkin, Robert Rodman, and Nina Hyams.
Babies apparently start to comprehend language as meaningful language around nine or ten months. By twelve months an average child understands about seventy words!
Babies start by learning vocab. Our brain uses two main areas to comprehend language. One part, which is up the back of the brain, stores the meaning of words like a dictionary. The other part, which is in the left frontal area, stores grammatical rules. The connections in the back 'dictionary' brain grow crazily between eight and twenty months, whereas the left frontal area grows rapidly between fifteen and twenty-four months, which explains why children start by saying single words and progress to combinations and sentences later. The neural pathways that make for quick processing of information in these two parts of the brain are not fully developed until about four to six years.
There appears to be a critical period for learning grammar and pronunciation. Children who are not exposed to language before the age of seven can be taught vocabulary later, but find it very difficult to pick up the grammar necessary to put words in the right order, or distinguish between singular and plural forms of words. It is not necessary that language exposure be to spoken language. Deaf children who are exposed to a proper, fully grammatical sign language, will learn this at much the same rate that hearing children learn to speak. Indeed, deaf children with deaf parents who are signed to and in front of from birth, babble signs the way hearing children babble speech. (Following from this, one bloke has proposed that babies can be taught to read at the same rate they are taught to understand verbal words, as shown here in an early baby reading program of videos, although see my note on videos below)
Babbling is a baby's natural way of learning the motor control to form speech, be that control of the voicebox, tongue and lips, or control of one's hands. The rate of development of babbling is faster if carers pay attention to the babbling, interact, and respond.
When it comes to specific words, babies brains are biased to assume that words refer to whole objects. So, if you show a baby a book, and call it a 'book', she is likely to assume you are referring to the whole object by the word, and not assume you mean the page, the cover, or the picture on the cover. If you want a baby to learn the world 'apple', it seems that they will learn it faster and more instinctively if you give them an apple that they can feel, hold, bang, and mouth, than if you show them a picture of an apple in a book, or sit them in front of Sesame Street. Learning from 2D passive media doesn't really work as effectively, certainly not until they are older. Babies pay attention to words addressed to them. So before you rush out an buy a 'Your Baby Can Read' video, bear in mind that teaching word recognition will work much more effectively if you are showing them the word yourself and using it to describe a real 3D object they can immediately interact with. (I don't think it matters that the symbol or word is 2D, so long as the object you are describing is 3D, and so long as you present the word to them, be it in spoken or written form.)
Their brains are also biased to assume a word refers to a generic category, and to over-extend that category. So a baby will assume 'dog' refers to all dogs, rather than a specific dog, and moreover may assume 'dog' refers to all animals looking vaguely like a dog, including sheep, cats, pigs etc.
The number of words they say tends to begin slowly, and then become extremely rapid around 18 months, when they start adding 1-3 words to their vocabulary every day, and around this time also start to master grammar. They start making two-word sentences. Over the following 6-12 months they start understanding tenses, using plurals etc. From hearing you use the grammatical rules over and over, they start to pick up the patterns and generalise them into rules that they can apply to new words. You can tell a three or four year old child "I have one bik. If someone give me another bik I will have two..." and they will obligingly supply, "Biks!" Children learn grammatical rules long before they learn the exceptions to those rules.
Babies learn language at different rates depending on:
I think it is so exciting that she is finally connecting sounds to specific objects. Not very many objects, yet, but I figure it's a big mental leap to make the connection that when we talk we're not just making sounds, but conveying meaning. I heard most babies understand words before they speak them, but with Bethany I reckon she's just made the conceptual connection at the same time she spoke it. I have been trying in vain to get her to look at objects when I name them (including her Dad), or respond to her name, for months, but she has seemed completely oblivious. I mind as well have been babbling nonsense myself, as far as she was concerned. It is as though she has had a lightbulb moment and got the idea of language and decided to try it out at once.
So I thought I'd do a bit of reading on language development.
Babies apparently start to comprehend language as meaningful language around nine or ten months. By twelve months an average child understands about seventy words!
Babies start by learning vocab. Our brain uses two main areas to comprehend language. One part, which is up the back of the brain, stores the meaning of words like a dictionary. The other part, which is in the left frontal area, stores grammatical rules. The connections in the back 'dictionary' brain grow crazily between eight and twenty months, whereas the left frontal area grows rapidly between fifteen and twenty-four months, which explains why children start by saying single words and progress to combinations and sentences later. The neural pathways that make for quick processing of information in these two parts of the brain are not fully developed until about four to six years.
Babies are born with the ability to distinguish between the sounds of all human languages, but over the first year they lose this ability as they become attuned only to the sound of the language (or languages) they hear. By 6 months their language perception is already becoming targeted, and by 10 months, they are almost completely attuned to their native language.
I met a paediatrician recently who told me of a study where it was arranged for a native speaker of a foreign language to come and spend several hours a week talking to and interacting with babies between about 7 and 10 months. Those babies retained the ability to hear the different sounds of the foreign language as well as their native language, as opposed to the babies who did not get this exposure, and who became unable to distinguish between the unusual parts of the foreign language sounds. Interestingly, another group of babies who were played videos featuring a foreign language speaker did not show any ability to perceive the foreign language. It seems babies are hardwired to pay attention to real, three-dimensional, interactive speakers - and videoed speakers may as well be background noise.
There appears to be a critical period for learning grammar and pronunciation. Children who are not exposed to language before the age of seven can be taught vocabulary later, but find it very difficult to pick up the grammar necessary to put words in the right order, or distinguish between singular and plural forms of words. It is not necessary that language exposure be to spoken language. Deaf children who are exposed to a proper, fully grammatical sign language, will learn this at much the same rate that hearing children learn to speak. Indeed, deaf children with deaf parents who are signed to and in front of from birth, babble signs the way hearing children babble speech. (Following from this, one bloke has proposed that babies can be taught to read at the same rate they are taught to understand verbal words, as shown here in an early baby reading program of videos, although see my note on videos below)
Babbling is a baby's natural way of learning the motor control to form speech, be that control of the voicebox, tongue and lips, or control of one's hands. The rate of development of babbling is faster if carers pay attention to the babbling, interact, and respond.
When it comes to specific words, babies brains are biased to assume that words refer to whole objects. So, if you show a baby a book, and call it a 'book', she is likely to assume you are referring to the whole object by the word, and not assume you mean the page, the cover, or the picture on the cover. If you want a baby to learn the world 'apple', it seems that they will learn it faster and more instinctively if you give them an apple that they can feel, hold, bang, and mouth, than if you show them a picture of an apple in a book, or sit them in front of Sesame Street. Learning from 2D passive media doesn't really work as effectively, certainly not until they are older. Babies pay attention to words addressed to them. So before you rush out an buy a 'Your Baby Can Read' video, bear in mind that teaching word recognition will work much more effectively if you are showing them the word yourself and using it to describe a real 3D object they can immediately interact with. (I don't think it matters that the symbol or word is 2D, so long as the object you are describing is 3D, and so long as you present the word to them, be it in spoken or written form.)
Their brains are also biased to assume a word refers to a generic category, and to over-extend that category. So a baby will assume 'dog' refers to all dogs, rather than a specific dog, and moreover may assume 'dog' refers to all animals looking vaguely like a dog, including sheep, cats, pigs etc.
The number of words they say tends to begin slowly, and then become extremely rapid around 18 months, when they start adding 1-3 words to their vocabulary every day, and around this time also start to master grammar. They start making two-word sentences. Over the following 6-12 months they start understanding tenses, using plurals etc. From hearing you use the grammatical rules over and over, they start to pick up the patterns and generalise them into rules that they can apply to new words. You can tell a three or four year old child "I have one bik. If someone give me another bik I will have two..." and they will obligingly supply, "Biks!" Children learn grammatical rules long before they learn the exceptions to those rules.
Babies learn language at different rates depending on:
- genetics - apparently up to 50% of the difference (based on twin studies) can be put down to genetics;
- gender - on average, girls learn language faster than boys for the first few years of life;
- baby's environment - the more verbal stimulation and interaction with real people, the faster they learn - allow the baby to have 'conversations' with you where they 'talk' and you talk back;
- more yesses, less no's - studies have indicated that talking to children about what they can and are doing, rather than what they cannot and are not doing, improve language acquisition (which makes sense, given that what you are not doing is an abstract concept that is difficult to understand, and because too much naysaying can discourage a child from the experimentation that is necessary to develop language skills);
- whether the words are connected to immediate objects and things - babies are focused on what's in front of them, not what they were doing five minutes ago or what you will be having for dinner tonight, so unless you talk about what they can do and see right now, it's just confusing;
- whether they are exposed to properly pronounced language (a sing-song voice is fine), or cutesy baby language;
- the amount of repetition - ideally, start with simple nouns and verbs ('that's a tree, tree, tree' or 'you're standing up, standing up, standing up, you're standing up') then slowly expand by adding adjectives ('that's a tree, a green tree, a big green tree, tree') or adverbs ('we're talking, we're talking quietly, we're talking very very quietly') etc.;
- whether language is fun - the more engaging language play is, the more attention a baby will pay to it;
- whether you over-correct - babies need to hear the correct pronunciation, but they need encouragement more, it helps to respond to their efforts by showing you understand, rather than insisting they perfect their pronunciation - keep modelling correct pronunciation and they will self-correct most mistakes (eg. give your baby a banana when they say 'nana', but don't start calling it 'nana' yourself or they will come to think that is the word, just say 'here's the banana' as though that was what they said);
- once your baby is past the eating books stage, try to read to him often - asking questions and pausing to let the child interact is better than requiring the child to be silent so you can read the book 'properly'.
Basically, it comes down to talking to your child about things that will be meaningful to them, simply then with growing complexity, and responding positively to their attempts to communicate. However, if you run out of inspiration, here is a website with a huge range of ideas for language games and activities.
Final note: Recently a number of people have asked me whether I am teaching Bethany sign language because there was a program on TV recently about babies who sign early. I looked into this a lot before Bethany was born, and after a while came to a couple of conclusions:
- there is no independent research that shows babies who learn sign, sign earlier than speaking babies speak - the only people who suggest it are those selling baby sign-language packs;
- judging by the testimonials, babies taught sign do not necessarily sign earlier, but the people marketing baby sign language pick the earliest signers and use these in their anecdotes;
- babies who sign before they speak may do so because they have been encouraged to sign - otherwise they may well just have made a poor attempt to speak the word instead;
- deaf associations object to teaching baby sign language - on account of it encouraging a perception that sign language is not a properly language but something babies do, and because baby sign languages are made up languages when babies could be taught their native sign language - like AUSLAN. For a baby signing program that uses AUSLAN, see this website.
I have noticed that Bethany has communicated what she wants and does not want very clearly by pulling things to her or pushing them away (notably food and drink) since about 5 months. But she has not shown the slightest inclination to use hand signals to communicate - and despite all my efforts will not even raise her hand to 'wave bye-bye', although we have done it on every occasion possible for months. I daresay that most babies will find a way to communicate their basic needs to you with or without teaching them sign language, provided you keep being responsive and trying to figure out their cues.
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