Looking Out for Number Two
Contents
Introduction 000
Part I: What goes in (or, Into the mouths of babes) 000
1. Your baby from the inside out 000
Baby plumbing | Mapping the digestive tract 000
2. The Babybiome | The power of the creatures within
000
th
Bugs and the 4 trimester: Zero to 100 trillion in a few days 000
How the babybiome is built 000
The babybiome and the immune system 000
3. Milk | Power fuel for the fledgling digestive tract 000
Milk as medicine
000
Breast milk as the ultimate power fuel 000
Almost magical formula 000
More on milk and how it gets in the tummy 000
4. Baby food and other forms of advanced bowel fuel 000
The conversation of feeding 000
When to put in food | The not-so-mysterious reality of feeding 000
What to feed 000
Table food and beyond 000
Part II - What goes out
000
5. The art and science of the burp 000
Burp basics
000
The art of of the killer burp
000
6. From the mouths of babes | Spits, urps and wet burps 000
What is reflux? 000
Fixing reflux
000
Tests and studies
000
7. Poo basics | Understanding number two 000
Poo patterns 000
50 shades of brown | Decoding your Diaper 000
Diapers and going diaperless 000
8. When there’s not enough poo 000
Constipation basics 000
Battling baby constipation
000
9. When there’s too much poo
000
Diarrhea basics 000
What to do when your baby has diarrhea
000
10. Gut reactions | Allergy, intolerance and things that go bump inside your baby
Allergy basics 000
Fixing your baby’s allergy 000
Solid food and the allergic baby
000
000
Can you prevent allergy to begin with? 000
11. Farts, colic and other things that make noise 000
Understanding baby farts 000
The vast colic conspiracy 000
Gas drops and other forms of modern witchcraft 000
12. Probiotics and your baby’s health 000
Probiotic basics 000
Conditions where probiotics may prevent problems or fix your baby
Practical issues of giving a probiotic to a baby 000
Beyond milk and supplements | The probiotic shopping cart 000
Acknowledgements
000
Suggested Further Reading 000
Index
000
About the Author 000
000
Understanding a baby’s digestive state of wellness
So how do you know if your baby’s in a digestive state of wellness? How do you know when she’s
getting enough or that her gut is doing what it’s supposed to do?
Bottom line: When stuff’s coming out it’s a good indicator that there’s enough going in.
More specifically:
Pee. Perhaps the single best indicator that a baby is receiving enough milk is wet diapers.
A baby should produce 6-8 wet diapers in a 24-hour period. The urine should be light
colored and it shouldn’t smell very strong. Wet diapers tell us that a baby’s fluid intake is
up to par. And when milk intake is adequate to meet fluid needs, a baby’s nearly always
getting what she needs nutritionally.
You can probably stop there, but there are a few other things you can look at as well.
Other signs of hydration. A baby should have moist lips and even the ability to make little
raspberry bubbles around the corner of her mouth. Tears are a great indicator of hydration
but don’t look for them until 6-12 weeks of age.
Poo. While a less reliable indicator than pee, your baby will initially poo a handful of times
each day. After a month or two of age, this will slow down to once a day or even less.
Chapters 8 and 9 will cover the roller coaster of poo frequency and appearance in more
detail.
Growth. The ultimate measure of whether a baby’s gut is doing what it’s supposed to do
is how she grows. If she’s getting the groceries, she’ll build muscle and fat. The most
reliable way to know if she’s growing is to plot her on a growth curve. This requires
weighing her on a consistent scale so that growth can be followed over time in comparison
to other babies her age.
Weighing baby (Don’t try this at home)
I discourage parents from following their baby’s weight at home. Why?
 Reliable info calls for reliable measurement. Most consumergrade scales aren’t up to par for measuring the subtle differences in
growth in a baby.
 It’s hard to know when to get concerned. Assessing the normal
variants of growth takes a lot of experience. Almost universally, selfassessment of growth leads to unnecessary worry.
 There’s no way to act on it. When there’s something to be concerned
about, there’s no way for you to act on it. You can’t control how your
baby feeds, and if your baby isn’t getting enough you will likely need the
professional help of a pediatrician or lactation consultant to take the
right action.
So please don’t try this at home. It will just make you crazy. (The only exception is when you’re
under the care of a lactation consultant. Pre and post feeding weights are often used to see if a
baby’s getting enough.)
Milk: Warm, cold, or somewhere in between
On our growing list of parental preoccupations with feeding is warm milk. We’ve all been
brainwashed into believing that a baby can only drink milk that’s been carefully warmed by mama.
While warm milk is fine, your baby is also fine drinking milk at refrigerator or room temperature.
There is no evidence that normal variations in temperature impact a baby’s sense of fullness or
digestion.
But this is a good case where maternal impulse tends to trump the evidence. If mama always wants
to give warm milk, that’s ok. Just avoid the microwave and warm the milk by immersing the bottle
in a basin of warm water.
Why does my baby poo when she eats?
Some things in life are fairly predictable. And one of those things is that after a young baby eats,
she’ll often poo. Why is this? It’s due to a mechanism in the body called the gastrocolic reflex.
When the stomach stretches with milk, it stimulates the colon to push and squeeze, resulting in (as
some of my poo research colleagues like to say) a bowel action.
This effect is more pronounced in some babies than others, and it can even persist into adulthood.
This may also explain why Uncle Joe makes a predictable disappearance every year after
Thanksgiving dinner.
Breast or bottle: Who poos more?
The gastrocolic reflex explains some of the differences in poo patterns that we see between breast
and bottle-fed babies. As it turns out, breast fed babies poo more frequently than formula-fed
babies. In fact, we see about 25% fewer bowel movements in breastfed infants who are
supplemented with formula when compared to purely breastfed babies. Breast-fed babies feed
more often, and so the reflexive connection between stomach and colon kicks in more frequently.
More feeds means more diapers.
Nutritional factors play a key role as well. Breast milk is rich in non-digested oligosaccharides and
protein, which adds to the volume, density, and ultimately frequency of the poo. On the formula
side, the fatty acids and mineral content are higher in formula-fed poo and carbohydrates happen
to be lower. These differences can lead to a firmer formula-fed poo and can impact how often a
baby eliminates.
As we’re seeing, what goes in impacts what comes out—which means there’s different poo for
different milk.
How to tell if your baby is dehydrated
Babies are tricky when it comes down to the physical signs of getting dry. They don’t do things like
big people, so it’s important to know where and what to look for. And while a trained poo
professional should have their eyes on a baby with diarrhea, there are things that you can look for
on your own as well.
Fewer wet diapers. Babies who are getting dehydrated pee less, and that will
mean fewer wet diapers. Unless you’re counting diapers, this one may catch you
by surprise. Just like poo, this comes down to knowing your baby’s normal routine
and how it’s changing.
Won’t blow bubbles. While babies can’t really blow bubbles very well, one sign
of hydration is wet lips that, with a little wind behind them, can create itty bitty
bubbles. When a baby is dry, this won’t happen. In fact, the lips and tongue will
look tacky and dry.
No tears when crying. Just like the inability to blow raspberries, the failure to
mount a proper crocodile tear can be a solid sign of dehydration in babies. But
remember that while babies are born with the apparatus to pump out tears, don’t
count on them until 1-3 months of age (in other words, don’t count on a lack of
tears as a sign of dehydration during the first few months of life).
Sunken soft spot. You’ve likely run your hand over your baby’s soft spot while
shampooing her hair. Or maybe you haven’t; a lot of parents feel that the soft spot
shouldn’t be touched, or they freak out at the idea of running their hands over it.
You need to get over this and get to know your baby’s soft spot (or anterior
fontanelle, as we say in the business).
Normally, this squareish region near the front of the top of the head is pretty flat
and in line with the bones around it. But the soft spot will sink or become
depressed when babies are dry. This is something to look out for in babies under
19 months of age; around or after that time, the soft spot closes.
Irritability. Babies don’t have a lot of ways to tell us when something’s up, but
irritability is one of them. Irritability is that crazy, inconsolable state beyond
fussiness. And in the context of some of the stuff listed above, it can mean your
baby is getting behind the eight ball with respect to fluid. On this flip side, though,
dehydrated babies may also be sleepy or lethargic. Look for either of these states
in conjunction with some of the warning signs above.
Why “taking a probiotic” may be on the way out
It’s a pretty regular conversation in my office: I’ll talk with a mother who has come in for a specific
problem, and she proudly tells me that she “just started probiotics last week.” When I ask what
strain, I get the probiotic deer in the headlights look (that’s the look from a mother when it’s clear
that she has absolutely no idea what she’s giving her child or why).
Since the earliest days of probiotics, parents have jumped on board with the primitive idea that
giving probiotics is good. And a lot like the whole organic food thing, we’ve seen a market explosion
of products willing to fuel the craze for good bugs. But the reality is that just giving probiotics
doesn’t make much sense.
We have to give the right probiotic for the right reason.
Think about that UTI you had after you were pregnant. When you went to your OB, she didn’t say,
“we need to give you some antibiotics.” Rather, she chose an antibiotic that’s known to specifically
target the bad bugs that we know live around your bottom. It wasn’t just any old antibiotic, because
if she chose the antibiotic that treats the stuff that grows on your skin, you would never have gotten
better.
Antibiotics have to be targeted to suspect organisms. And this is the way that our thinking about
probiotics is going as well. We’re learning that certain strains are good at certain things, and that
not all probiotics are created equal.
Yogurt is not exactly medicine
Parents like to give their children yogurt when they are sick or on antibiotics. While I love the
concept of food as medicine, the job of fixing an obliterated babybiome may not be as simple as it
looks.
As our understanding of the microbiome has evolved, we’ve learned that you need to take in
substantial numbers of organisms to treat disease. And what we get in a container of yogurt isn’t
likely to be a medicinal quantity.
Consider what we find in our friendly neighborhood yogurt tub:
Yogurt source
Serving
Probiotic serving
Yogurt with live bacteria
6-8 ounces
3-10 billion bacteria
Frozen yogurt with bacteria
4 ounces
1-3 billion bacteria
Probiotic shots
3-4 ounces
3-10 billion bacteria
Kefir
??
??
Now consider that it takes on the order of 20 billion bugs to treat the diarrhea associated with
antibiotics. You’re looking at several containers of high quality yogurt, which is more than most
babies and toddlers are able or willing to consume. As another example of how high we sometimes
need to go, we’re using around 450 billion bacteria when we use probiotics to treat ulcerative
colitis in older children.
So food as medicine is very different from food that creates healthy balance. In the end, a healthy
balanced diet rich in active cultures will serve to keep your baby healthy rather than pull them back
from the brink once you’re facing dangerous dysbiosis.