Weaning Baby

Webster’s Dictionary defines weaning as “accustoming a young mammal to take food otherwise than by nursing.” Although this event may be very cut and dried in the animal world, for humans the process of weaning is much more complicated, but only because we make it that way.

Weaning your baby is part of the natural breastfeeding experience. It doesn’t have to be a time of unhappiness for you or your baby. If done “gradually, and with love” (the La Leche League motto), weaning can be a positive experience for both you and your little one.

Ideally, your baby will nurse until he outgrows the need. This is called natural, or baby-led weaning. Every baby has different “needs” in different areas. For example, some babies need to be held almost constantly, while others squirm and wiggle if you try to hold them too long, and are perfectly content to sit in their playpen for an hour or so while they entertain themselves. Some babies need lots of sleep – they take regular three- hour naps, and are sleeping through the night by the time they’re a few weeks old, while others cat nap infrequently and are still waking up at night when they’re two years old. Just as you would not set an arbitrary limit on other areas of your baby’s development, such as deciding exactly when he will sit up, roll over, move into a bed instead of a crib, etc. (instead, you watch for signs that he is ready to move on to the next developmental stage), it just makes sense not to set an arbitrary time limit on how long you will nurse your baby. You actually begin weaning your baby the very first time you offer him any food other than your milk. Weaning should be a process, rather than an event. Depending on how you go about it, weaning can be abrupt or gradual, and may take days, weeks, or months.

Abrupt weaning should always be avoided, if at all possible, for the sake of both you and your baby. If you suddenly stop nursing, your breasts will respond by becoming engorged, and you may develop a breast infection or breast abscess. Your hormone levels drop abruptly, and depression can result. Mothers with a history of depression should especially consider this when making decisions about weaning.

Abruptly withdrawing the breast can cause emotional trauma in the baby. Since nursing is not only a source of food for a baby, but a source of security and emotional comfort as well, taking it away abruptly can be very disturbing. There is absolutely no way to explain to a baby why he suddenly can’t nurse anymore. Weaning gradually lets you slowly substitute others kinds of attention to help compensate for the loss of the closeness of nursing.

If you are told to wean your baby abruptly for medical reasons, you need to make sure that there are no other options. It is well worth getting a second opinion from someone who is knowledgeable about breastfeeding. Most of the time, you’ll find that there are alternatives. (See article on “Drugs and Breast- feeding” for more information.) For example, if you are prescribed a medication that is incompatible with breastfeeding, ask your doctor to see if another, safer drug can be substituted. First of all, make sure that the drug really is unsafe to take while nursing – often doctors who aren’t really sure will err on the side of caution and tell you to wean, rather than doing a little research (beyond the limited lactation information given in the PDR –Physician’s Desk Reference) to get more detailed information about the drug’s effect on the nursing infant. Pediatricians and obstetricians are more likely to have access to this detailed information than doctors in other fields, such as dentists or anesthesiologists, yet these doctors often make recommendations about weaning, without the benefit of a broad knowledge base of lactation. There are resource books available that can tell your doctor exactly how long a drug stays in your system, how much is transferred into your milk, and what side effects to look for. Unfortunately, many doctors don’t have these books in their office, and may or may not be willing to do a little research to access them. In many cases, it’s just easier for them to tell the mother to wean.

Even if you do have to take a drug that isn’t safe while nursing, you have the option of just weaning temporarily and picking up breastfeeding where you left off. This involves expressing your milk during the interim, so that you will ready to resume nursing, and also to avoid engorgement. A hospital grade electric pump is better for this purpose than a manual or small electric pump. These can be rented for short-term use.

If you absolutely have to stop nursing suddenly and permanently (this rarely happens – the most common reason would be the mother who was diagnosed with cancer, and has to begin chemotherapy immediately) see the article on “Lactation Suppression” which has tips on how to minimize the physical discomfort of abrupt weaning.

There are many, many benefits to extended breastfeeding, and very few benefits to weaning early. That is not to say that even one feeding at the breast doesn’t have value, because it does. Whether you nurse for days, weeks, or years, breastfeeding provides both you and your baby with many important benefits – but breastfeeding for a year or longer offers the most advantages. Extended breastfeeding is definitely not the norm in this country – worldwide, most babies are weaned between two and four years – but in the US, fewer than 20% of babies are still nursing when they are six months old. While you may find it hard to imagine a mother in India nursing a three year old, that same mother would probably be baffled at the idea of taking a baby off the breast when he was just a few weeks old. Through millions of years of human history, extended breastfeeding has been the norm. It’s only been in the past century that we’ve seen a shift toward earlier and earlier weaning, and the reasons are not based on scientific fact, but rather on a number of cultural influences.

One problem is that in our society, breasts have been turned into sexual objects rather than feeding devices for infants, which was, after all, their original function. Barbara Hey (the mother of a nursing toddler) wrote: “Breasts will never be considered run-of-the-mill” body parts. Pull out a bottle and a crowd gathers; lift up your shirt and the room clears”. Many people associate breasts with sexuality, and breastfeeding with something dirty, especially if your baby is a boy. The same people who totally freak out at the idea of a toddler nursing don’t think twice about an older baby who sucks his thumb, or hauls around a security blanket.

If you decide to go with natural weaning, be prepared for lots and lots of unsolicited advice. You will be told that you’re doing it for you, not the baby (this is ridiculous, because it is a proven fact that you absolutely cannot make a baby nurse if he doesn’t want to – try it sometime if you don’t believe me). You will be told that your child will become a sexual deviant (yep, I bet if you took a survey you’d find that prisons are just chock full of men who were breastfed till they were ready to wean…sure…). You will be told that your child will become hopelessly dependent on you, and you’ll be following him to Kindergarten to nurse at rest time (interestingly enough, experience and research have shown that babies who are nursed until they are ready to wean are actually less dependent because their security needs have been met as infants – they tend to separate more easily from their mothers and move into new relationships with more stability). It really boils down to following your instincts as a mother – nobody knows this little individual better than you, and you will know when he is ready to wean and move on to a new stage in your relationship.

There are many benefits of extended breastfeeding. The American Academy of Pediatrics recommends nursing for at least the first year of your baby’s life.

-Your baby continues to get the immunological advantages of human milk, during a time when he is increasingly exposed to infection. Breastfed toddlers are healthier overall.

-When he is upset, hurt, frightened, or sick, you have a built in way to comfort him. Often a sick child will accept breastmilk when he refuses other foods.

-Many of the medical benefits of breastfeeding (lower cancer risk in mother and baby, for example) are dose related – in other words, the longer you breastfeed, the greater the protective effects (see article on “Why Breastfeed?” for more details).-Human milk offers protection for the child who is allergic.

-Mothering a toddler is challenging enough – nursing makes the job of caring for and comforting him easier. There is no better way to ease a temper tantrum, or put a cranky child to sleep than by nursing.- Nursing provides closeness, security, and stability during a period of rapid growth and development.

- Letting your baby set the pace for weaning spares you the unpleasant task of weaning him before he is ready.

It is important to remember that all children wean eventually. If you are sitting at the computer with a two- week old infant in your arms, who is having marathon nursing sessions around the clock, it is probably hard to imagine nursing a toddler. Nursing an older baby is totally different from nursing a newborn. Forget those forty-five minute nursing sessions. Toddlers climb in your lap when they fall and bump their knee, nurse for a couple of minutes, and they’re done. They will have longer sessions (usually bedtime or nap-time), but they’re way too busy exploring their world to spend too much time nursing. They also don’t nurse as often – maybe every four to five hours, rather than every two to three. Because of this difference in nursing patterns, you are not nearly as tied down with an older nursing baby as you are with a newborn. There’s another phenomenon that comes into play here. When you look at your one or two or three year old, he will still be your baby. It doesn’t matter if he has skinned knees and peanut butter smeared on his mouth, he is still a tiny little person with lots of growing up to do. It’s a tough world out there, and before you know it he’ll be too big to hold your hand, much less nurse. Why rush him? Ask any mother with older children and she’ll tell you the same thing – babies grow up way too fast, and when you look back on it, the time he spent nursing (even if it was several years) is a very small piece of the pie. He’ll live at home for 18 years, and even if he nurses for 3 of those years….well, you do the math. I like this quote, but don't know how said it. "We have 18 years to teach our children independence. Why try to do it all in the first years?"

It should be obvious that I have a bias toward baby led weaning. It just makes sense to me on so many levels. If someone tells you that babies shouldn’t be nursed past six months, or one year, try asking them “Why”? They will be hard put to come up with a reason that makes sense, much less one that they can back up with any empirical evidence.

This is not to say that I think long- term nursing is right for everyone. When to wean is a very individual decision, and sometimes early weaning is the right decision. If a baby is not happy and thriving, and a mother is so stressed that she can’t enjoy her baby, then it may be time to wean. Most babies do quite well on formula, and breastfeeding at all costs is not the most important consideration. You also need to be aware than nursing for days or weeks (or even one feeding at the breast) still offers important benefits to your baby. See Article on "Breastfeeding Benefits; How They Add Up." Nursing should never be an endurance contest. If you do decide that early weaning is right for you and your baby, here are some guidelines to follow:

- Try to do it as gradually as possible. Eliminate one feeding each day for several days to allow your milk supply to decrease slowly. After a couple of weeks, he should be down to nursing just a couple of times a day. Usually the last feedings to go are the first one in the morning, and the last one at night. If you’re not in a huge rush, you may want to continue these couple of feeding for another week or two.- Talk to your baby’s doctor to find out what formula he recommends. Since babies are not ready for cow’s milk until they are a year old, it is important to find the appropriate formula.- Since young babies have a strong need to suck, offer a substitute (bottle or pacifier). Some babies will find their thumbs during this period, and there’s not much you can do about that one way or the other. There are advantages to having a thumb-sucker – those babies tend to be self-soothers, and often are better sleepers and travelers than babies who depend on pacifiers.- Offer lots of physical closeness during this time. There is a tendency to avoid cuddling, because the baby associates the nursing position with breastfeeding, but it is important to snuggle your baby and get lots of skin-to-skin contact, even if you avoid the cradle hold.

If the decision is left up to them, most babies will wean themselves gradually, beginning by cutting back on nursing around the time they start solids. Physically, most toddlers are “ready” to wean. They are eating a variety of solid foods, and breastmilk is no longer their sole source of nutrition. Nursing a child who is no longer an infant is done more out of concern for his psychological and emotional needs than for his nutritional ones. However, there are some older babies who make the transition from infancy to toddler-hood without the slightness indication of readiness to wean. Weaning an older child who isn’t ready can be a real challenge. You should not feel guilty if you decide to wean your toddler, because only you know when the time is right for you and your family. For example, you may be pregnant again, and while that in and of itself is not a reason to wean, your nipples may be so sore that you are gritting your teeth and not enjoying nursing your toddler AT ALL. He may begin to pick up on your feelings of resentment, and it may be time to wean. When deciding to wean a toddler, it is important to remember that he received the benefits of breastfeeding for many months (far surpassing the average) and so you have absolutely nothing to feel guilty about if you decide it is time to end your nursing relationship and move on to the next stage. Weaning an older baby doesn’t have to be traumatic, although it may not be easy. Here are some tips:

-If possible, allow several weeks of concentrated time and attention to the process of weaning. Any baby who has nursed for a year or more is obviously really into it, and isn’t likely to give it up easily.-Don’t offer, but don’t refuse. Nurse him only when he is really adamant about it, but don’t offer to nurse at other times.-Make sure that you offer regular meals, snacks, and drinks to minimize hunger and thirst. Remember also that babies nurse for reasons besides hunger, including comfort, boredom, and to fall asleep.

-Try to change your daily routine to minimize situations where he wants to nurse. Does he want to nurse when he is bored? Try distracting him with a snack or a walk outside. Do you usually lie down with him at naptime? Try reading him a book or rocking him instead.

-If dad is around, encourage him to take an active role in weaning. Have dad try to put him back to sleep if he wakes during the night. If he nurses first thing in the morning, try letting dad get him up instead of you and feed him breakfast.

-Watch his preferences and respect them. If he is having a really hard time giving up the first thing in the morning nursing, you may want to continue that one for a while rather than force the issue.

- With older toddlers (two years plus) you can begin by setting limits on nursing. For example, you can say “We’ll nurse when we get home, but not at the mall”. Substitute nursing on demand for nursing at your convenience. This theory also works for security objects (pacifiers or blankets) – “You can’t take your blankie to pre-school, but it will be on your bed waiting for you when you get home”).

- Shorten the duration of any given feeding. Say “That’s enough, now.” and gently remove the breast from his mouth.

In summary: weaning is a process that begins as soon as you introduce other foods into your baby’s diet. (This comes in handy when someone asks you if you have started weaning him yet – you can truthfully answer “yes”). Babies wean at different ages, just as they get teeth at different ages. When you wean your baby is a decision for you to make, ideally based on signs of developmental readiness. Breastfeeding provides benefits for both you and your baby no matter how long you nurse. Gradual weaning is always better than abrupt weaning, although there are times when this just isn’t possible.

If you and your child both enjoy nursing, and your only reason for weaning is that you are under pressure from other people who think you should, then you need to look further for outside support of your decision to continue nursing. If you no longer enjoy nursing, or if there are legitimate pressing reasons for you to wean, you should do it and feel good about the time you did nurse, without feeling guilty about what might have been.

On a personal note: I have nursed six children. The first three weaned themselves before they were a year old. I was a La Leche League leader at the time, and all my friends were nursing their toddlers. I couldn’t believe my babies were doing that to me – I was willing to nurse them till they went to college, but there was absolutely no way to convince them to keep nursing. Even withholding food didn’t work. My experience with my next three babies reminded me of the old adage “Be careful what you wish for”, because they all wanted to nurse between 2 ½ and 4 ½ years. I practically had to pry them off with a crowbar. It was interesting to me that the early weaners were all thumb-suckers and blanket holders, while the late weaners were never self-soothers, but used the breast for comfort as well as nutrition. All were breastfed on demand from day one, so I can only assume that individual differences accounted for the different weaning experiences.

I am happy to report that all six have turned out normal and well adjusted, so their radically different weaning schedules apparently didn’t have a long term effect on their development. I’m so glad – with six children, I have plenty of other things to feel guilty about.

Your Baby's Eyes

Vision contributes a great deal to an infant’s perception of the world. Many parents naturally are concerned about their child’s vision. Fortunately, serious eye conditions and blindness are rare in infants. Babies can, however have eye problems, so an eye checkup is still an important part of well-baby care. This issue of “Eye Facts” describes some eye problems that occur.

How and When Do a Baby’s Eyes Develop?
The eyes begin developing two weeks after conception. Over the next four weeks all of the major eye structures form. During this time the eye is particularly vulnerable to injury. For example, if the mother takes drugs or becomes infected with German measles, the eye can be malformed or damaged. During the last seven months of pregnancy the eye continues to grow and mature, and the nerve that connects the eye to the brain (optic nerve) is formed.

At birth a baby’s eye is about 75 percent of the size of an adult eye. During the first two years of life, the optic nerve, visual function and internal eye structures continue to develop.

What Can a Baby See?
The newborn’s visual acuity (sharpness of vision) is approximately 20/400. This is equivalent to seeing only the big letter “E” on an eye chart. Vision slowly improves to 20/20 by age 2 years. Color vision is present at birth.

Newborns at first don’t pay much attention to the visual world but normally will blink when light shines in their eye. By 6 to 8 weeks of age, infants will fix their gaze on an object and follow its movement.

A baby’s eyes should be well aligned (working as a team) by 4 months of age (see “strabismus” below). As the eyes become aligned, three-dimensional vision develops.


How Are a Baby’s Eyes Examined?
The first eye exam takes place in the newborn nursery. The pediatrician performs a screening eye exam to check for infections or structural problems with the eyes: malformed eyelids, cataracts, glaucoma or other abnormalities. When the baby is 6 months old, the pediatrician should check the baby’s eye alignment and visual fixation (how it focuses its gaze).

Pediatricians can treat simple eye problems such as pinkeye (conjunctivitis). If you or your pediatrician believes your baby has a more serious eye problem, which may require medical or surgical treatment, the infant should be referred to an ophthalmologist. No child is too young for a complete eye exam.

An eye doctor’s examination of a baby is similar to that performed on adults. The doctor evaluates the baby’s medical history, vision, eye muscles and eye structures.

The doctor assesses the baby’s vision by observing the following. Does the infant react to light shone in the eyes? Will the baby look at a face or follow a moving toy? Other, more sophisticated vision tests may be used if needed.

Eye drops are used to temporarily enlarge (dilate) the pupils for closer examination of the eyes. The drops may take 30 to 90 minutes to work. The eye doctor then uses an instrument to test the baby’s eye for a refractive error, such as nearsightedness, farsightedness or astigmatism. Most children are farsighted at birth but usually not to a degree requiring glasses. However, a baby –even a newborn- can wear glasses if needed.

Finally, the eye doctor uses a lighted instrument with a magnifying glass (ophthalmoscope) to look inside the eye.

Which Eye Problems Occur in Infants?
Infections - Some newborns may catch conjunctivitis as they pass through the birth canal. Older babies can get this eye infection through exposure to persons infected with it. Infected eyes appear red and puffy and have a sticky discharge. Antibiotic eye drops may be given as treatment.

Blocked tear ducts - Tears drain from the eye through a duct, leading from the inside corner of the eyelid, and into the nose. Some babies are born with a blocked tear duct, which causes tears to back up and overflow. As these infants are prone to eye infections, antibiotics may need to be prescribed. In most cases, the tear ducts open on their own by 1 year of age. Sometimes massage therapy of the duct may be needed. Occasionally the ophthalmologist must perform a surgical procedure to unblock the tear duct.

Cataracts - Inside the eye is a lens that helps it focus, similar to the lens on a camera. The eye’s lens normally is crystal clear. Rarely, babies are born with a cataract- cloudiness of the lens that keeps light from passing through. Cataracts in infants usually are found by the pediatrician during newborn or well-baby exams. If the cataract is severe, the pupil appears white; surgery may be required to remove the cataract.

Strabismus - Strabismus means that the eyes are misaligned. For instance, one eye may be turned in- esotropia (crossed eye)- or turned out- exotropia (walleye). There are actually many forms of strabismus. Eye alignment is normally unsteady at birth but by 4 months of age the eyes should be straight. Any infant who continues to show an eye misalignment after 4 months of age or a child who later acquires strabismus should have a complete eye exam. Untreated strabismus may lead to amblyopia (see below). It is a myth that kids outgrow strabismus.


Amblyopia - Amblyopia (commonly called lazy eye) is the medical term for a loss of vision in an apparently healthy eye. This occurs in babies and young children if there is an imbalance between the eyes. In these cases, the child may subconsciously use one eye more often. The other eye will then lose vision due to disuse. An eye imbalance can occur when there is cataract, strabismus, ptosis (droopy eyelid), eye injury or a refractive error that is worse in one eye. Amblyopia usually does not have symptoms and often is discovered at a school vision screening. It is ideally treated by an eye doctor before the child is 6 to 10 years old, or the vision loss will be permanent. Treatment encourages the child to use the lazy eye by wearing glasses, and/or wearing a patch over the “good” eye or instilling an eye drop to the good eye.

Ptosis - In a few children, the muscle that raises the upper eyelid fails to develop properly in one or both eyes. This muscle weakness, which causes the upper eyelid to droop, is called ptosis. When an eyelid droops and covers half the eye, that eye may mistakenly appear smaller than the other. Ptosis sometimes may result in amblyopia. If the ptosis is severe, surgery is required to lift the eyelid.


Retinopathy of Prematurity - If a baby is born prematurely, the blood vessels in the eye that supply the retina are not fully developed. Sometimes these blood vessels develop abnormally and may damage the inside of the eye. Retinopathy of prematurity can be detected only during an ophthalmic exam, which should be performed in premature babies during the first few weeks of life. If the disease is advanced, the eye can be treated to prevent blindness.

Visual inattention - Sometimes an infant does not begin to pay attention to visual stimuli by 6 to 8 weeks of age, as is normal. This may be due to delayed development of the visual system, common in premature infants and also occurring in some full-term babies. Often the visual system will mature normally with time. However, visual inattention can also be a sign of eye disease and may result in permanent and/or progressive vision loss. A complete eye exam is in order if a full-term, healthy baby appears visually inattentive after 3 months of age.

Lawrence M. Kaufman, MD, PhD
Assistant Professor

Eye Facts" is intended as an informational series and should not be used as a substitute for medical advice.

The Pediatric Ophthalmology and Adult Strabismus Service is located in the Eye and Ear Infirmary at 1855 W. Taylor Street, Chicago IL 60612. For eye appointments, call 312-996-6599, 312-996-8450.

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The Tooth Fairy and Losing a First Baby Tooth

Q. My son is six years old and hasn't lost his first tooth yet. He is anxious for the tooth fairy to come and we are both wondering what the going rate now is for a first baby tooth. Will he lose a tooth soon?

A. He should. Children usually lose their first tooth sometime between age six and seven years old. Some kids are a little earlier and others a little later though. One big influence seems to be the timing of when he started getting teeth and when he got his last baby tooth.

The average child gets his first baby tooth at age six months and then gets three to four new teeth every three to four months. This continues until the second molars erupt at about age two to two and a half years, at which time your child should have all twenty baby teeth.

If your child got his first tooth early or finished getting all of his baby teeth early, then he might start losing his baby teeth early too. On the other hand, if he didn't get his first tooth until age twelve or fifteen months, then he might be a little later than average in shedding or losing his first tooth.

Once he does start losing his teeth, the pattern will seem like a reverse of how these baby teeth came in. He should first lose the bottom two middle teeth, which are called the mandibular central incisors. Next, the top two middle teeth will fall out, followed by his canines, first molars, and then second molars. By age eleven to thirteen, the process should be complete and all of his baby teeth will be gone.

The secondary or permanent teeth soon begin erupting as your child loses baby teeth. This process isn't complete until your child gets his third molars or wisdom teeth at age seventeen to twenty two years of age.

So how much money should your child expect the tooth fairy to bring? It varies, from a few quarters to a few dollars, although the tooth fairy often brings more for the first baby tooth that is lost.

Feeding Your Baby

Feeding Your Baby There seems to always be controversy or discussion about whether breastfeeding is best for your baby and for what length of time. One thing I know for sure is that popular opinion sways and changes from decade to decade. I think that at some point, we all need to relax and do what is best for everyone involved, including baby and baby's mom.

Personally, I believe breastfeeding is best whenever possible, however, I found out very quickly with my first daughter that trying to keep her hunger at bay with only breast milk was impossible. I thought I had enough milk ... it was just so hard trying to feed her every hour (or so it seemed) only to have her cry for more when I was sure she'd had plenty. As soon as I gave her a bottle to supplement nursing, she was quite content, thank you. So was I. ;-)

If you're a mom who is firm about breastfeeding and you'll go to every extreme to insure your baby is nursed for as long as possible, by all means go for it. Your baby will inherit your immunities (to a point) and be receiving nature's very best food source. You'll find plenty of nursing outfits and cover-ups available today to support you in your decision and life style. And you'll save so much money that would have been spent on bottles and formula, you can start baby's college fund earlier. :-)

If you're a mom who just can't bear the thought of breastfeeding, whether it's because your breasts are too tender to start or continue nursing or the thought of having baby attached to you at inopportune times and 24/7 is something that makes you squeamish, then speak with your doctor before baby arrives (or shortly thereafter if it's a decision you've come to after the fact) and find the best infant formula for your particular baby. You might also have a physical condition that prevents you from nursing or a baby who can't/won't nurse. Whatever you do, don't let anyone (Baby's father, your mother, father, mother-in-law, grandmother, doctor, etc.) make you feel guilty.

If your baby's father is stressed because you won't or can't breastfeed, talk with him openly about it. As this could become a touchy subject which neither of you need right about now, try to have this conversation before it becomes an issue. If it's too late for pre-baby negotiations, try to understand his point of view and explain yours as clearly and unemotionally as possible. This is not a good time to have marital discord. For everyone's sake, if you're a dad who feels your baby's mother should be breastfeeding your child and she isn't or doesn't want to, please try to let it go. Mom needs as much understanding and support right now as is humanly possible. Baby will be just fine either way.

At about four months of age, baby will be ready for a little cereal and a touch of smashed up solid foods. This is the fun part! There are countless processed baby foods on the market. I made my own, with the exception of a few jars of pre-prepared mushy organic fruit varieties to make my life a little easier. Besides, I needed those little jars to fill with my own baby food creations. And yes, I will share my recipes with you on the solid foods page. :-)

Go forth into the world of feeding your baby ...

* Breast Feeding
Yes, it's a good thing. :-)

* Bottle Feeding
Sometimes, it's the only way or a necessary supplement.

* Solid Foods
Oh yum ... this is when feeding becomes fun!

Your Baby's Eyes

Vision contributes a great deal to an infant’s perception of the world. Many parents naturally are concerned about their child’s vision. Fortunately, serious eye conditions and blindness are rare in infants. Babies can, however have eye problems, so an eye checkup is still an important part of well-baby care. This issue of “Eye Facts” describes some eye problems that occur.

How and When Do a Baby’s Eyes Develop?
The eyes begin developing two weeks after conception. Over the next four weeks all of the major eye structures form. During this time the eye is particularly vulnerable to injury. For example, if the mother takes drugs or becomes infected with German measles, the eye can be malformed or damaged. During the last seven months of pregnancy the eye continues to grow and mature, and the nerve that connects the eye to the brain (optic nerve) is formed.

At birth a baby’s eye is about 75 percent of the size of an adult eye. During the first two years of life, the optic nerve, visual function and internal eye structures continue to develop.

What Can a Baby See?
The newborn’s visual acuity (sharpness of vision) is approximately 20/400. This is equivalent to seeing only the big letter “E” on an eye chart. Vision slowly improves to 20/20 by age 2 years. Color vision is present at birth.

Newborns at first don’t pay much attention to the visual world but normally will blink when light shines in their eye. By 6 to 8 weeks of age, infants will fix their gaze on an object and follow its movement.

A baby’s eyes should be well aligned (working as a team) by 4 months of age (see “strabismus” below). As the eyes become aligned, three-dimensional vision develops.


How Are a Baby’s Eyes Examined?
The first eye exam takes place in the newborn nursery. The pediatrician performs a screening eye exam to check for infections or structural problems with the eyes: malformed eyelids, cataracts, glaucoma or other abnormalities. When the baby is 6 months old, the pediatrician should check the baby’s eye alignment and visual fixation (how it focuses its gaze).

Pediatricians can treat simple eye problems such as pinkeye (conjunctivitis). If you or your pediatrician believes your baby has a more serious eye problem, which may require medical or surgical treatment, the infant should be referred to an ophthalmologist. No child is too young for a complete eye exam.

An eye doctor’s examination of a baby is similar to that performed on adults. The doctor evaluates the baby’s medical history, vision, eye muscles and eye structures.

The doctor assesses the baby’s vision by observing the following. Does the infant react to light shone in the eyes? Will the baby look at a face or follow a moving toy? Other, more sophisticated vision tests may be used if needed.

Eye drops are used to temporarily enlarge (dilate) the pupils for closer examination of the eyes. The drops may take 30 to 90 minutes to work. The eye doctor then uses an instrument to test the baby’s eye for a refractive error, such as nearsightedness, farsightedness or astigmatism. Most children are farsighted at birth but usually not to a degree requiring glasses. However, a baby –even a newborn- can wear glasses if needed.

Finally, the eye doctor uses a lighted instrument with a magnifying glass (ophthalmoscope) to look inside the eye.

Which Eye Problems Occur in Infants?
Infections - Some newborns may catch conjunctivitis as they pass through the birth canal. Older babies can get this eye infection through exposure to persons infected with it. Infected eyes appear red and puffy and have a sticky discharge. Antibiotic eye drops may be given as treatment.

Blocked tear ducts - Tears drain from the eye through a duct, leading from the inside corner of the eyelid, and into the nose. Some babies are born with a blocked tear duct, which causes tears to back up and overflow. As these infants are prone to eye infections, antibiotics may need to be prescribed. In most cases, the tear ducts open on their own by 1 year of age. Sometimes massage therapy of the duct may be needed. Occasionally the ophthalmologist must perform a surgical procedure to unblock the tear duct.

Cataracts - Inside the eye is a lens that helps it focus, similar to the lens on a camera. The eye’s lens normally is crystal clear. Rarely, babies are born with a cataract- cloudiness of the lens that keeps light from passing through. Cataracts in infants usually are found by the pediatrician during newborn or well-baby exams. If the cataract is severe, the pupil appears white; surgery may be required to remove the cataract.

Strabismus - Strabismus means that the eyes are misaligned. For instance, one eye may be turned in- esotropia (crossed eye)- or turned out- exotropia (walleye). There are actually many forms of strabismus. Eye alignment is normally unsteady at birth but by 4 months of age the eyes should be straight. Any infant who continues to show an eye misalignment after 4 months of age or a child who later acquires strabismus should have a complete eye exam. Untreated strabismus may lead to amblyopia (see below). It is a myth that kids outgrow strabismus.

Amblyopia - Amblyopia (commonly called lazy eye) is the medical term for a loss of vision in an apparently healthy eye. This occurs in babies and young children if there is an imbalance between the eyes. In these cases, the child may subconsciously use one eye more often. The other eye will then lose vision due to disuse. An eye imbalance can occur when there is cataract, strabismus, ptosis (droopy eyelid), eye injury or a refractive error that is worse in one eye. Amblyopia usually does not have symptoms and often is discovered at a school vision screening. It is ideally treated by an eye doctor before the child is 6 to 10 years old, or the vision loss will be permanent. Treatment encourages the child to use the lazy eye by wearing glasses, and/or wearing a patch over the “good” eye or instilling an eye drop to the good eye.

Ptosis - In a few children, the muscle that raises the upper eyelid fails to develop properly in one or both eyes. This muscle weakness, which causes the upper eyelid to droop, is called ptosis. When an eyelid droops and covers half the eye, that eye may mistakenly appear smaller than the other. Ptosis sometimes may result in amblyopia. If the ptosis is severe, surgery is required to lift the eyelid.

Retinopathy of Prematurity - If a baby is born prematurely, the blood vessels in the eye that supply the retina are not fully developed. Sometimes these blood vessels develop abnormally and may damage the inside of the eye. Retinopathy of prematurity can be detected only during an ophthalmic exam, which should be performed in premature babies during the first few weeks of life. If the disease is advanced, the eye can be treated to prevent blindness.

Visual inattention - Sometimes an infant does not begin to pay attention to visual stimuli by 6 to 8 weeks of age, as is normal. This may be due to delayed development of the visual system, common in premature infants and also occurring in some full-term babies. Often the visual system will mature normally with time. However, visual inattention can also be a sign of eye disease and may result in permanent and/or progressive vision loss. A complete eye exam is in order if a full-term, healthy baby appears visually inattentive after 3 months of age.

Lawrence M. Kaufman, MD, PhD
Assistant Professor

Eye Facts" is intended as an informational series and should not be used as a substitute for medical advice.

The Pediatric Ophthalmology and Adult Strabismus Service is located in the Eye and Ear Infirmary at 1855 W. Taylor Street, Chicago IL 60612. For eye appointments, call 312-996-6599, 312-996-8450.

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Caring for your baby's skin

Your baby's skin is thinner, more fragile and less oily than an adult's. It also produces less melanin, the substance that helps ward off sunburn. It is less resistant to bacteria and harmful substances in the environment, especially if it is irritated. Babies also sweat less efficiently than the rest of us, so it is harder for them to maintain their inner body temperature. On the other hand, most babies are less likely to react to allergens. In the first few weeks after birth, your baby will retain some of your hormones. As a result, several minor skin conditions can result which will usually disappear fairly quickly. In addition, there are a few other skin conditions that are common during childhood which are normal and, most often, easily managed:

1. Heat rash: Small pink pimples, often across the body. This condition results from high heat and humidity and undeveloped sweat glands. Do not overdress baby or overheat room, keep clothing loose and cleanse and dry skin thoroughly.
2. Infant acne: Pink spots on the face. When infants are born, they still retain their mother's hormones for a short time and, as a result, infant acne can occur. This usually goes away on its own in the first few weeks. If not, talk to your health care professional.
3. Cradle cap: Crusty patches on scalp. Overactive glands in your baby's scalp can cause cradle cap. Wipe gently with baby oil, leave on a few minutes, shampoo with baby shampoo, then use baby brush or comb
4. Chafing: When there is friction between baby's clothing and skin, or where areas of skin rub together, chafing can result. Remove or minimize anything that is tight or rubs against the skin, like rubber pants or straps. Cleanse, rinse and dry skin thoroughly, then apply cornstarch baby powder, lotion or cream
5. Eczema: Red, irritating, scaly skin. Atopic dermatitis or eczema is a genetically determined common skin condition. Clean and dry skin thoroughly. Talk to your pediatrician or health care professional; you may want to try sensitive-skin products especially designed for babies.

Johnson & Johnson

Choosing a Pediatrician for Your Baby

Choosing a Pediatrician for Your Baby :Choosing a doctor for your baby may not be something you've given a lot of thought to during pregnancy. Many women don't realize that this is something that should be done well before baby is born to prevent any hiccups in baby's care after the birth. In many areas, unless you're using a family practitioner and sometimes a nurse midwife, the moment the cord is cut the obstetrician or other doctor is technically no longer responsible for your child. By allowing yourself time to interview and select a pediatrician or family practitioner for your baby you will be able to research your feelings of parenting and your partner's feeling as well as how likely of a match you are with your particular candidate. This person is going to be someone that you will be seeing quite frequently for well baby care and in cases of illness and emergency.

It's very important that you find someone who has a style, personality and skills to match your needs.

In determining whether your philosophies are similar, ask yourself how you and your partner feel about the following issues, and then ask your potential pediatricians:

* Antibiotics: In the past many pediatricians have over prescribed antibiotics. Due to the potential ramifications of over use and the questionable benefits in some cases, many pediatricians are using them less frequently. When do you feel that they should be used? What about your potential doctor?

* Breastfeeding: Is this person knowledgeable in the subject? Do they have a myriad of resources available or will they suggest weaning at the first sign of trouble?

* Parenting Style: While it's really hard to determine how you will parent before having the baby and adapting your lives accordingly, is this person someone that you would agree with on parenting issues like discipline, the family bed, feeding issues, etc.? If not you may be setting yourself up for a lot of strife.

There are many other issues which may be important to you, like office hours, on call schedules, vaccination issues, waiting rooms situations, etc. Anything that you think is important should be addressed in an interview prenatally. This interview is usually best done in person. It allows you to get a feel for how the office is run and what the staff and nurses are like. It will give you a chance to check out the location for convenience, cleanliness, and atmosphere. It's also much easier to get a feel for the practice in this hands on manner.

When you have your appointment, bring your birth plan with you. Show it to the potential doctor(s). Since they will be the ones in charge of your baby's care in the hospital or birth center you will need to know if they will support your ideas at the birth. Things you might address are rooming in, breastfeeding, doing newborn exams in the room instead of the nursery, what will happen if baby needs to transfer to the intensive care nursery, when will you see the doctor at the hospital, etc. If you're planning a homebirth, ask when they would like to see the baby. Will they do a home visit or are you required to come in with the baby within a certain amount of time? Most pediatricians are very used to dealing with these types of questions.

While there are certainly a lot of factors that will go into your final decision (insurance, hospital affiliation, gender preference, etc.), your gut feeling about the partnership you will have with this person is often a very good indicator. Don't hesitate to check with your local medical association to see if complaints have been lodged or with local moms and dads to see how their experience have been.