Here are some tips on how to keep your baby from biting:

• Use teething soothers before breastfeeding. Give your child other things to chew on for a few minutes before breastfeeding him. A clean washcloth that has been moistened with cool water and placed in the freezer for a few minutes works well, or a firm rubber ring designed especially for teething babies. Rubbing a clean finger gently across your baby’s gums may also provide temporary relief. Or you can put a few pieces of ice in a clean baby sock and tie off the top. If your baby is older than 6 months and eating complementary foods, he may enjoy cold foods such as applesauce, yogurt, or a frozen banana.
• Use a pain reliever. If teething pain is especially troubling to your baby and the soothers are not working, a dose of children’s pain reliever, such as ibuprofen or acetaminophen (but never aspirin) 30–45 minutes before breastfeeding may help. Topical anesthetics (such as Orajel) should never be used in children under 2 years of age due to the risk of methemoglobinemia, a serious condition that limits the amount of oxygen in the blood.
• Check your baby’s latch. A baby who is latched on correctly—with a wide open mouth and the nipple far back in his mouth—cannot bite. Keep in mind that if he gets sleepy and nipple is slipping away, he may bite reflexively.
• Watch for signs of fullness. Biting is most likely to happen when your baby is full and has lost interest in nursing, so watch for signs that he is full (stops sucking and swallowing, falls asleep) and take him off the breast before he has a chance to bite.
• Pay attention. Some babies will bite if your attention is elsewhere—on the phone or TV, for example. Engage with your baby while breastfeeding, and see if this helps. You may also minimize distractions by dimming lights, turning off the TV, playing music, or going to a quiet room.

Many mothers instinctively pull back and cry out when bitten, startling their babies. This negative reinforcement can be a deterrent to ever biting again. Some mothers couple this with putting the baby down for few minutes and walking away before returning to the feeding.

If you can, try to pull your baby into the breast for a few seconds when he bites instead of pushing him away. This will keep your nipple from being stretched out, and will enable you to slide your finger into your baby’s mouth to release his latch before taking him off the breast. Once you soothe his gums, try completing the feeding.

Problem: The latches that attach the bassinet base onto the metal frame can appear to be locked in place but still remain unlocked. This allows the bassinet to become detached from the metal frame, causing the bassinet to fall and the infant to be injured.

Action: Consumers should immediately stop using the recalled bassinets and contact the firm by phone toll-free at (888) 624-1908 between 7 a.m. and 6 p.m. ET Monday through Friday or visit the firm’s website at www.kolcraft.com to receive a repair kit and instructions for securing the latches to the metal frame. In the meantime, parents are urged to find an alternate, safe sleeping environment for the child, such as a crib that meets current safety standards or play yard depending on the child’s age. To learn more, click here.

Albow is not alone in his criticism. TODAY Moms invited comments on the cover photo from its readers by posing the question, “We know you have opinions about the cover. Sure, it got everyone’s attention, but does it ultimately hurt or help the perception of breast-feeding?” Most of the 3,126 comments were critical of the cover: “I have cancelled my subscription.” “An infant OK, a kid that age NO.” “I consider this picture child abuse.” Sadly, I had to dig deep to find a positive comment: “This is a good thing, and the more mothers do it the better.”

Calculated or misguided?
“It’s [extended breastfeeding] not socially normal. The more people see it, the more it’ll become normal in our culture. That’s what I’m hoping. I want people to see it,” Grumet tells Kate Pickert, author of The Man Who Remade Motherhood, the TIME magazine article marking the 20^th anniversary of attachment parenting.

Whether TIME’s choice of cover photo was calculated or misguided, it’s clear that Grumet’s photo (along with the photos inside the magazine) has reignited the Attachment Parenting debate (a parenting approach largely characterized by babywearing, co-sleeping, and child-led weaning). Lost in the debate, however, is the fact that attachment parenting is more than the sum of its parts. It is a parenting method designed to make children confident and compassionate by responding to their needs, nurturing strong physical and emotional connections, and modeling appropriate social behavior.

Sound familiar? It should. Because it’s a parenting method that every parent embraces—keep your child warm, well nourished, and safe; stimulate their senses; calm their fears; and behave in a way that says to your child, “Do as I say and as I do.”

Is the cover photo good for breastfeeding?
“Time” will tell whether negative media is better than no media. However, when only 1 in 10 U.S. babies breastfeed exclusively for six months perhaps it’s time to tone down the rhetoric and stop arguing about the small number of mothers who breastfeed three, four, or more years, and focus instead on the many mothers who try to breastfeed but can’t. Perhaps it’s time to acknowledge that how long a mother breastfeeds—six days, six weeks, six months, six years, or not at all—was never meant to be a measure of motherhood.

So you might think.

But formula companies these days are up against a formidable alternative: breastfeeding. The benefits of breastfeeding for mothers and babies—and, along with that, the high cost of not breastfeeding—are widely recognized.

What’s more Nestlé, Gerber’s parent company since 2007, has been charged with marketing strategies designed to undercut breastfeeding at the expense of infant health. Positioning itself as the breastfeeding moms’ best friend is an attempt to overcome its troubled past. Thus, the company has rebranded its “Nestlé Good Start” label with the smiling Gerber baby, developed a series of videos about “how to nourish Generation Healthy through the milestones,” (more about that in a minute) and launched its new feel-good marketing campaign.

But there’s nothing to feel good about with this advertisement. Beyond the adorable baby and the mother’s gentle touch, this ad has nothing to offer the breastfeeding mothers who are its intended audience. “You want your baby to have your imagination, your smile, your eyes … not your allergies,” it declares. After acknowledging that “breastfeeding is the best way to naturally protect your baby” from this danger, it gets to the heart of its message: “If you do introduce formula, choose the Gerber Good Start Comfort Proteins advantage.” Such statements are well-recognized as “booby traps” to breastfeeding.

According to the ad, this formula is “inspired by breast milk” and produced by a company that is “nourishing” what it calls “Generation Healthy.” But what it isn’t—and cannot be—is a replacement for breastfeeding.

And while the final screen promises “expert feeding advice 24/7,” it seems best to remember that this company has at its heart one goal: selling formula, and, after that, a line of complementary foods.

Simply put, breastfeeding promotion is not the job of a company whose products compete with breast milk. Nor should it be. The company’s marketing bias cannot help but affect its advice.

Take, for example, Gerber’s video series, mentioned above. The first video promises to cover “all about breastfeeding,” a tall order indeed for just over 10 minutes of screen-time. The advice here is generally sound, given by a self-described breastfeeding mother named Francesca as she guides her friend through using several breastfeeding positions with her newborn. However, while Francesca notes that the American Academy of Pediatrics recommends mothers breastfeed for at least a year or as long as the mother and baby want, she ignores the group’s call for exclusive breastfeeding for the first six months.

The second video tackles pumping and storing milk, perplexingly recommending that mothers stop pumping when their breasts are “somewhat emptied,” rather than fully emptied. The third video turns to bottle-feeding and bottle care and by this video, Francesca is no longer said to be breastfeeding. The fourth is about “choosing a formula for your baby,” which Francesca explains she did when she decided to supplement her breast milk. The “milestones” the series is designed to address, then, are a short period of breastfeeding followed by supplemented feeding (or, the company’s narrator points out, exclusive formula-feeding), and then the introduction of complementary foods. The implicit message? We’re here for you when you give up breastfeeding—which you will.

We recognize that some women choose never to breastfeed and that only 1 in 10 U.S. mothers breastfeed exclusively for six months. But it is disingenuous, at best, for formula companies to promote breastfeeding, knowing that they profit only when mothers choose not to breastfeed.

While Gerber might promise that its “experts are here to help,” breastfeeding mothers are best advised to get their help elsewhere. Talk with your health care provider or a lactation consultant about the breastfeeding resources in your area. La Leche League has trained leaders available to answer questions in many areas, and breastfeeding counselors from the newly-minted Breastfeeding USA may be able to help with breastfeeding questions and concerns.

When it comes to breastfeeding, don’t look to Gerber for a “good start.”

Until recently, foremilk was thought to contain less fat and fewer calories than hindmilk. Consequently, foremilk was described as thin and runny, and hindmilk was described as thick and creamy.

When you compare samples of foremilk and hindmilk expressed during the same feeding, it’s true that the foremilk usually has less fat and fewer calories than the hindmilk. However, if you compare a sample of foremilk expressed at one feeding with a sample of hindmilk expressed at another feeding, the foremilk may actually contain more fat than the hindmilk. Confused? You’re not alone!

Fat content varies with milk volume—the smaller the milk volume, the higher the fat content. Feeding patterns determine milk volume. The longer the period of time between feedings, the greater the milk volume and the lower the fat content. When the time between feedings is short (1–2 hours), babies get smaller amounts of high fat milk. More time between feedings (3 or more hours) causes babies to get larger amounts of low fat milk. Most babies get the nutrients they need to grow by following their own unique pattern.

Breast fullness is a measure of fat content. The fuller the breast, the lower the fat content of the milk and the greater the difference in fat content between the milk obtained first and the milk obtained last. The emptier the breast, the higher the fat content and the lesser the difference between the milk obtained at the start of the feeding and the milk obtained at the end.

One of the amazing things about human milk is its ability to change from month-to- month, week-to-week, day-to-day, feeding-to-feeding, and from start to finish during a single feeding. To ensure that your baby gets all the fat and calories she needs to grow, breastfeed at the first sign of hunger and continue to breastfeed until your baby is full. Remember, it is important to always watch your baby, not the clock, for signs of hunger and fullness.

Yes, that’s right: bike to school. May 9, 2012 is the first-ever Bike to School Day, scheduled in conjunction with National Bike Month. The event is organized by the National Center for Safe Routes to School, a group dedicated to “connecting the trip to school with safety, health, community, and choice.”

For 15 years, Safe Routes has coordinated a Walk to School Day each autumn; in 2011, the event involved 3,700 schools and “hundreds of thousands” of schoolchildren. Participation for this year’s bike event is small by comparison, but a total of 700 events in 49 states is still robust for an inaugural event.

Why participate?
The purpose of the event is threefold:

• to enhance children’s health by increasing physical activity
• to improve air quality and the environment by reducing automotive pollution
• to create safer routes for walking and bicycling

Participants are invited to register their event, map their route, and download materials on the event website.

Bike safely
Although bicycle riding is recommended by the Let’s Move initiative, many children don’t ride their bikes regularly. The National Wildlife Federation maintains a searchable database of trails that may be useful to parents planning family bike outings designed to help children develop biking skills. After all, according to one Boston initiative to bring bicycles to low-income children, two of the leading barriers to biking to school are not feeling comfortable on a bike in traffic and not understanding how to properly operate a bike.

If your children bike to school, you’ll want to keep some safety tips in mind:

• Use a proper fitting helmet. In the event of a crash, bike helmets can reduce the risk of head and brain injury by as much as 85–88 percent. Make sure your child’s helmet fits and that she knows how to put it on correctly. Teach your child the Eyes, Ears, and Mouth Test: (1) Eyes: With the helmet on their head, your child should be able to look up and see the bottom rim of the helmet; it should be one to two finger-widths above the eyebrows, (2) Ears: The straps must form a snug but comfortable “V” under your child’s ear when buckled, (3) Mouth: Have your child open her mouth as wide as she can. The helmet should “hug” her head, and the buckle should be flat against her skin.
• Use a proper fitting bike. An oversized bike is especially dangerous, since your child may not have the coordination needed to keep it under control. Sitting on the seat of her bike, your child should be able to put both of her hands on the handlebars and both of her feet on the ground. Bikes with footbrakes ensure better control for younger bike riders.
• Stay on sidewalks and bike paths. Safe Kids USA recommends that children should bike only on sidewalks and bike paths until they are 10 years of age and understand the rules of the road, including hand signals, riding on the right side of the road (with traffic), and interpreting and following traffic signals.
• Plan the safest route. Choose a route with the fewest street crossings, and whenever possible, plan crossings at intersections with crossing guards. Tell your children to obey all traffic signals, signs, and authorities.
• Supervise your child. Until you know your child is a skilled bicyclist, you should not let her ride to school on her own. Even older children who ride their bikes to school should use the “buddy system,” and ride with a friend.
• Don’t bike in the dark, or in low-visibility conditions. Equip your child’s bike with reflectors and have her wear light-colored clothes and accessories to improve her visibility to motorists.

For more tips about bike safety, check out Safe Kids USA or the American Academy of Pediatrics. Also see our school safety tips here on baby gooroo.

And remember: If you like Bike to School Day, you just might love National Bike to Work Week. That event kicks off Monday, May 14, 2012.

Montessori Schools are based on the educational methods of Dr. Maria Montessori who, after scientifically observing children’s learning processes, concluded that children teach themselves. Surrounded by developmentally appropriate activities in classrooms typically comprised of mixed age groups (ages 3 to 6 can be in one class), each child is given the freedom to choose the activity he or she would prefer to focus on and is given uninterrupted time to pursue the activity. With few group lessons, students are encouraged to learn at their own unique pace and are free to move around the room and explore different subject areas. This independence is also encouraged as children tackle daily tasks in the classroom such as cleaning up after play and helping to prepare snacks.

The word “Montessori” is not legally protected and is widely used. To ensure that a preschool advertising as a Montessori school actually incorporates the Montessori practices, research what to look for here.

Waldorf Schools are rooted in the spiritual scientific philosophy of Austrian scientist Rudolf Steiner and strive to educate the whole child (spirit, soul, body). “Waldorf nursery schools,” says Jenifer Wana, author of How to Choose The Best Preschool For Your Child:  The Ultimate Guide To Finding, Getting Into, and Preparing for Nursery School, “use hands-on activities and imaginary play to foster a love of learning, a sense of teamwork, and concentration skills.” A Waldorf curriculum engages children within an environment focused on artistic and domestic activities such as painting, baking, gardening, and handicrafts. Toys and educational tools are typically natural materials collected by the students during walks and learning happens through imitation and activities such as storytelling, creative play, puppetry and finger plays, singing, and artistic movement. The Waldorf program aims to help students develop a healthy imagination and a love and appreciation of nature and community.

Highscope Approach Schools were first developed for at-risk children by Dr. David Weikart, a Michigan public school educator, and emphasize “active participatory learning” meaning students have direct, hands-on experiences with people, objects, and ideas that interest them. In the course of a day that involves a typical, predictable routine, children make choices about which activities they plan to participate in during their time in the classroom. At the end of the day, they report whether they ended up doing what they intended. This daily report is referred to as the “plan-do-review” and teaches children not only to plan their own activities based on their area of interest but also to talk about what they did and what they learned in the process. Teachers offer support to each student as they make and follow through with decisions. This type of teaching encourages initiative, goal setting, independence, and creativity, with the intent to prepare kids for continued school readiness and success.

Reggio Emilio Approach Schools were founded in the Italian region of the same name in the 1940s by Loris Malaguzzi, and encourage every child to creatively express ideas. Reggio Emilio schools share the Montessori view that the school environment is the “third teacher” (after the parent and teacher) according to Nancy Hertzog, Ph.D, author of Ready for Preschool: Prepare Your Child For Happiness and Success at School. As a project-based program, classroom lessons are based on the interests of the students. Students are encouraged to work in small or large groups to search for answers to their questions and to actively engage in their own learning process. This results in a unique class experience for each group of students as projects can last anywhere from a few days to a full year, notes Wana. There is great focus on visual arts, creative, dramatic play, and music. The school documents student projects and creations in detail not only in the interest of continued educational research, but as a way of communicating to each child their inherent value to the group.

Early learning centers While typical preschool programs are, on average, three hours per day, early learning centers provide a preschool curriculum tailored to a child’s age group during typical day care center hours (in other words, some are open 52 weeks a year, five days a week, giving parents full and part time options). Children 2–12 months of age are regularly read to, surrounded by developmentally appropriate toys and manipulatives, and exposed to simple activities that help develop motor and language skills. The 1-year-olds are finger painting, coloring, working with play-doh, and able to participate in dramatic play. By the time they are 2 years old, the children have that first exposure to group learning (sharing, taking turns, following a routine, and cleaning up their toys). By the time children reach the 3- to 4-year-old room (a typical preschool age room), they are engaged in more involved Pre-K lesson plans, focusing on science activities, literacy, and math concepts. Early learning centers can also offer a valuable socialization opportunity a few days a week to children who are otherwise cared for at home by a nanny or relative.

Making preschool personal
Despite many different types of preschool programs to choose from, many parents opt to make their child’s early education experience a more personal one. Cooperative programs (often referred to as “co-ops”) allow parents to actively participate in their child’s preschool environment, taking on various roles from helping the teacher in the classroom to assisting with office administration duties, site maintenance tasks, and school policy decisions. “I think the biggest misconception is underestimating the excellence of cooperative schools,” says Kathy Ems, president of Parent Cooperative Preschools International (PCPI), a non-profit membership organization that serves as a support system for cooperative early childhood education programs. Ems suggests parents benefit from being involved in co-op programs by gaining the community of other parents. “And children gain the sense that they and their education is very important,” adds Ems, “because Mom or Dad are there working.”

Often a co-op is a practical solution when other programs prove to be unavailable or unaffordable. In her New York Times article, The Pre K Underground, Soni Sangha writes about her experience setting up a Pre-K co-op with other parents when her son didn’t get one of the coveted and limited available slots at his neighborhood public program in New York. “The school on our street had 432 applicants,” she says, “for 36 seats.” And the alternative private programs she found often came at costs that rivaled college tuition. “My husband and I,” notes Sangha, “products of suburban public elementary schools, certainly were not prepared for the cost of early education in New York City.” Although Sangha admits it can require a lot of weekly planning work for parents and involve plenty of red tape to secure a classroom site, a co-op can often mean the difference for many families between their children experiencing a classroom environment prior to kindergarten, or not.

For parents interested in setting up a cooperative program on their own as Sangha did, Ems stresses it takes a dedicated group of people who are willing to pay upfront costs or find a sponsoring organization to help, such as a religious group, community center, or park district. Adds Ems, “Finding a space is often the most difficult thing” and, after that is accomplished, you need to secure a core group of students, a teacher, insurance, and supplies. “There is usually a year’s lead time to doing this,” stresses Ems, “and it is also important to look at the demographics of your area to be sure there is a demand for your program.” For parents interested in finding an established co-op preschool, the PCPI website lists all schools that have “signed on that they support the cooperative ideal and the importance of parent education and involvement,” says Ems.

Finding the right preschool requires that you take into consideration your family’s circumstances, finances, and philosophy. But it’s also critical that your preschooler feels comfortable in the classroom. Including your future student in school tours is a great way to see what catches his attention and invites questions you may not have considered. School fundraisers and festivals are often open to the community and attending these can be a great way to get an informal peak into the school’s culture without the pressure of a formal tour. While plentiful preschool options may make the selection process seem challenging at first, the right fit is often clear once you and your child start to explore.

To learn more about how to start your preschool search, read “P Is For Preschool”.

Kim Brooks is a Phoenix, Arizona-based writer who loves to cook and create. She recently pressed the pause button on her career in interior design to spend more time with her daughters. She is mom to Natalie and Audrey.

1. When is my child ready to start preschool?
2. What are my preschool options?
3. When do I begin the search?
4. How do I know it’s “the one”?
5. Why is preschool important?

When is my child ready to start preschool?
Most preschool programs are geared toward 3- to 5-year-olds, while some schools offer classes to children as young as 2 (although 2-year-old classroom environments and activities should differ from those geared toward older preschoolers). As children grow, so does their need for mental stimulation and physical activity. And as young children’s energy levels rise and naptimes shrink (most kids give up their morning nap by 18 months and all naps by 3 years of age), parents often see the benefit of socialization opportunities beyond the occasional playdate with friends. As with most milestones of early childhood, there is no right age to start preschool. But when children show an interest in exploring the world around them and playing with or even next to others, they are most likely ready to be part of a classroom community.

What are my preschool options?
Before you begin your search for “the one,” it is important to evaluate all your options. Each child is unique, and while a trusted friend’s daughter may be thriving in a large school with organized group activities, yours may do better in a more intimate program with one-on-one attention. There is no shortage of options and it’s best to arm yourself with a basic understanding of the various preschool philosophies before narrowing in on a specific school.

There are two main philosophies in any school environment outside of the home: play-based programs and project-based programs.

• Play-based programs: Preschool programs that are play-based, often referred to as developmentally appropriate, are the most common. A typical preschool day consists of a predictable schedule and is a mix of organized group activities such as art, music, story, and circle times (often centered on themes that change weekly or monthly) and unstructured choice time (play time where children can explore different interests on their own). Diane Trister Dodge and Toni Bickart, president and vice president of Teaching Strategies, Inc. (a publishing company specializing in early education resources), teachers, and co-authors of Preschool for Parents: What Every Parent Needs to Know about Preschool suggest a quality classroom contains areas designated for building with blocks, creating art projects, reading, dramatic play, and playing with table toys such as puzzles and items to sort and match. In a play-based program, learning through play is not only encouraged but believed to be the best way for children to first explore math, science, and language concepts. Play-based programs are a nice fit for kids who like socializing with other children and can handle a bustling classroom filled with lots of activity.

• Project-based programs: Classroom activities in project-based programs follow the interests of the students. Instead of adhering to a predetermined schedule of theme-based instruction, these classrooms change course based on the interests of the students. Questions the students have and subjects they are interested in become topics to be studied. Students then work together researching a topic and the teacher acts as facilitator. For instance, if students find a caterpillar on the playground, a butterfly study may be born that could last a few days or even weeks. Activities might involve field trips, data collecting, observation and discovery, and expert interviews to learn more about a subject matter. According to Nancy Hertzog, Ph.D, author of Ready for Preschool: Prepare Your Child for Happiness and Success at School, project-based learning challenges students and provides opportunities to seek more in-depth knowledge in areas of interest to them. Project-based programs are great for kids who work well in a group and enjoy investigating solutions and discussing ideas. These programs are less common than play-based programs and may be harder to find, but they will be advertised specifically as “project-based.”

Among all play-based and project-based programs, there are a lot of different types of preschools. For an in-depth look at a variety of preschools, read “It’s Choice Time!” Most preschools fall into one of two teaching style categories: child centered or teacher directed. Child-centered classrooms involve a lot of free choice for kids to decide what they want to work on. Most play- and project-based programs fall into the child-centered category. Teacher-directed classrooms, on the other hand, involve little choice amongst students as activities are planned and implemented at the same time for the entire class. Academic preschool programs tend to be teacher directed as they aim to prepare children for kindergarten by focusing on math and reading skills through more formal instruction.

When do I begin the search?
Often the schools that come most highly recommended have lengthy waiting lists. It’s important to start the school search early; in some areas, that may even mean a couple of years before your child will attend. Preschool registration schedules vary but programs that follow the September through May calendar usually open registration in January or February of the prior school year. This means tours and discussions with the directors of the schools you are considering need to happen well in advance of the registration deadline. Many schools offer priority to siblings of current students and fill spots in 4- and 5-year-old classrooms with students moving up from younger classes prior to offering places to new applicants or children on the waiting list.

Fortunately, incidents like this are rare, but in 2007 an estimated 3 million U.S. children under 18 years of age had a reported food allergy and 150–200 children died as a result. “Although any child can be at risk for food allergies, children are at greater risk if they are younger than age 3 or have a family history of asthma and allergies, a genetic predisposition to allergic disease, or elevated allergen-specific serum immunoglobulin levels (IgE concentrations),” says the Centers for Disease Control and Prevention (CDC). Eight foods account for 90 percent of all food allergies—cow’s milk, eggs, peanuts, tree nuts, fish, shellfish, soybeans, and wheat. Peanut is among the most common food allergens, along with milk and shellfish.

What is peanut allergy?
Peanut allergy, like most allergies, is an over-reaction of the immune system to a protein that would otherwise be harmless. When individuals with peanut allergy are exposed to peanut protein through ingestion, skin contact, or inhalation, they make allergic antibodies known as immune globulin E (IgE).  These antibodies attach to the surface of cells in the nose, eyes, skin, throat, stomach, and lungs. Peanut protein binds to the IgE antibodies, which in turn release histamine and other chemicals into the surrounding tissues causing allergic symptoms such as runny nose, watery eyes, itching, sneezing, wheezing, swelling of the throat and tongue, and hives.

How does my child get peanut allergy?
It’s unclear why some children develop peanut allergies but genetics play a role. Children whose parents or siblings have food allergy may be at greater risk for developing peanut allergy and may be tested prior to eating peanut products. The allergy community previously recommended that children at high risk for food allergy avoid cow’s milk for the first year of life, egg for the first two years, and peanuts, tree nuts, fish, and shellfish for the first three years. However, there is no strong evidence that these recommendations successfully prevent food allergy in these high-risk children. As a result, in 2008, the American Academy of Pediatrics (AAP) revised its recommendations. “We just do not have the studies to back this up. If a child is going to be allergic to peanuts or eggs, it doesn’t seem to matter [after 4 to 6 months] when you introduce these foods,” says study co-author Frank Greer, MD.

Similarly, the American Academy of Allergy, Asthma, and Immunology does not recommend that breastfeeding mothers (even those with a family history or allergy) change their diets in an effort to reduce their babies’ risk of food allergy. Although not fully understood, several recently published studies imply that earlier exposure to common food allergens (around 6 months) may actually help prevent food allergy in newborns.

What are the signs/symptoms of food allergy?
Food allergic individuals typically experience stomach upset or nausea within 30 minutes to two hours after ingestion. Hives or red, itchy welts are probably the second most common symptom to develop but may occur along with:

• difficulty breathing and wheezing
• red, itchy eyes
• swelling of the hands and face
• difficulty swallowing
• hoarseness
• light-headedness

Small children might grab their tongue or make comments like “there’s a bug in my throat” to communicate their symptoms. In more severe cases, children may experience a loss of consciousness and even death, a rare but devastating occurrence. If symptoms begin more than two hours after ingestion, food allergy becomes less likely. Most food allergy symptoms resolve within 24–36 hours.

What is the treatment?
Peanut avoidance is currently the recommended treatment for patients with peanut allergy. Several academic centers are successfully desensitizing children with peanut and other food allergies but this process involves a high risk of allergic reaction and is not recommended as a routine treatment. In these special centers, children and adults with food allergy are fed their culprit food in gradually increasing amounts until they can tolerate significant portions. Patients continue to eat the food on a daily basis to ensure that an accidental ingestion will not result in allergic symptoms. It’s not known how long an individual may have to continue to eat the culprit food before they actually become tolerant and lose their allergy.

How is peanut allergy diagnosed?
If you want to know more definitively whether your child may be allergic to peanut or other food allergens, skin or blood testing by a pediatrician or a board certified allergist is advised. Unfortunately, both of these tests are plagued by a high false positive rate (up to 50 percent!). However, these tests are quite sensitive, which means that a negative result rules out food allergy with better certainty.

A food challenge (having the child eat a small amount of the culprit food) is the gold-standard method for diagnosing food allergy. However, it presents significant risk for an allergic reaction, therefore it should be conducted by a board certified allergist. Up to 20 percent of patients with peanut allergy will outgrow the allergy, but the real challenge is to determine at what age. Skin or blood tests every 1–2 years may help patients and their allergists figure out when would be a safe time conduct a food challenge.

How can peanut allergy be prevented?
Most allergists advise peanut allergic children to avoid all nuts, including tree nuts such as almonds, pecans, walnuts, etc. Peanuts are actually part of the legume family but approximately 35 percent of peanut-allergic patients may also be allergic to tree nuts.  Parents often find a policy of total nut avoidance easier to follow for their peanut allergic children, especially given the chances for cross-contamination in cafeterias, restaurants, or factories. Breastfeeding mothers with peanut-allergic infants must avoid peanut protein themselves to avoid transfer via their breast milk, as well as oral to oral transfer. (Transfer of peanut protein can occur when a mother eats peanut products and then kisses her baby.)

Still, in spite of the distress immunizations cause for children, parents, and health care providers, they’re widely accepted as a necessary part of preventive care. A recent study suggests that although childhood shots may be unavoidable, the pain they cause may be reduced by applying a set of strategies known collectively as “the 5 S’s”.

“Happiest babies” know 5 S’s
“The happiest baby on the block” is what Dr. Harvey Karp promises you’ll have if you apply his “5 S” approach to baby-calming, which has become the basis for a complete line of books, videos, and training products (and even a “happiest toddler” spin-off).

This strategy involves five steps—swaddling, side/stomach position, shushing, swinging, and sucking—delivered in a prescribed order. The steps must be delivered just so, according to Dr. Karp’s website, which asserts that the steps trigger a “calming reflex” and that while “centuries” of parents “have tried these methods,” they have “fail[ed] because … the calming reflex only works when it is triggered in exactly the right way.” [emphasis Karp’s]

The literature on Karp’s approach is sparse, and one recent study found the video training to be ineffective in reducing infant crying. Still, the program continues to draw attention for its baby-calming potential.

Could vaccinated babies be “happiest babies”?
For the purposes of this research study, a team led by pediatrician Dr. John Harrington of the Eastern Virginia University Medical School sought to assess the “analgesic, pain-relieving effectiveness of using [the 5 S’s] … during routine immunizations given to infants at 2 and 4 months of age.”

The researchers tested Karp’s strategies both alone and in combination with a small amount of sucrose (sugar water), which is itself widely recognized for its pain-relieving properties and recommended by an international committee of pediatricians.

Study participants included 230 infants during their 2- or 4-month well-child visit. None had received acetaminophen or ibuprofen within four hours of receiving their immunization. Participants were predominantly urban, Medicaid-enrolled, and African American. Nearly three-quarters were 2 months old at the time of the survey. All injections were given with the infants lying on the examination table.

Infants were randomized into one of four groups:

1. Group 1 (water only) received 2 ml of water two minutes before immunization. (Water has no analgesic quality, but was administered so that study participants and researchers would not be biased by knowledge of whether or not the child received sucrose.) Parents were able to comfort the babies in this group immediately after immunization.
2. Group 2 (sucrose only) received 2 ml of sucrose two minutes before immunization. Parents were able to comfort the babies in this group immediately after immunization.
3. Group 3 (S’s only) received 2 ml of water two minutes before immunization. A study researcher initiated Karp’s strategies immediately after immunization.
4. Group 4 (sucrose and S’s) received 2 ml of sucrose two minutes before immunization. A study researcher initiated Karp’s strategies immediately after immunization.

The researchers responsible for administering the 5 S’s learned the approach by watching a video, and practiced swaddling until they could wrap a baby in 15 seconds or less.

Those in groups 3 or 4, who were to be calmed by the researcher, were immediately swaddled. They were held in the side/stomach position with shushing and swinging/swaying, and offered a pacifier (for “sucking”) at 30 seconds. Many babies refused pacifiers, some because their parents had chosen not to use them (you can read more on the pacifier controversy here), but researchers were required to use at least four of the five S’s.

Assessing infant response
Babies’ responses were assessed using a pain scale that assigned numeric scores to three types of behaviors: verbal (no cry, whimpering/complaining, pain crying, screaming/high-pitched cry), facial (neutral/smiling, frowning/grimacing, clenched jaw/mouth, full cry expression), and body movement (calm/relaxed, restless/fidgeting, moderate agitation or mobility, thrashing/flailing or voluntary immobility). Babies’ behavior was scored every 15 seconds for the first two minutes, and then every 30 seconds until five minutes post-vaccination.

Four of the five S’s were completed by researchers for all of the intervention (groups 3 and 4) babies. No data were collected on comfort strategies employed by parents in the non-intervention (groups 1 and 2) babies.

Study findings
Not surprisingly, Harrington and colleagues found that the mean pain score was highest for the water-only group. The scores of the sucrose-only group were also higher than those of the “5 S” groups. The lowest mean pain scores were reported for the group that received both sucrose and the “5 S” strategies.

The researchers write that “the 5 S’s appear to be a viable option for clinics to implement when providing analgesia.” However, this study should be read with caution for several reasons:

1. Parent behavior is unknown. Researchers did not track the calming behaviors used by the parents in the non-intervention groups. It is probable that some parents incorporated some of the studied behaviors (swaying, shushing, swinging) with their babies.
2. Baby calming may have been a function of “who” rather than “what.” Some research suggests—as surprising as it may be—parents may be the least effective “calmers” of their children during vaccinations, since they tend to focus on reassurance rather than distraction.
3. Assessment included “body movement” even though swaddled babies—those in the intervention, 5 S groups—are hardly capable of free movement. As a result, the researchers may have overestimated pain response in unswaddled babies. Other research on infant pain has measured factors such as heart rate variability and salivary cortisol levels, in addition to crying time and behavior.
4. The 5 S approach seems counter to other, well-researched calming methods, such as breastfeeding, kangaroo care, facilitated tucking, and pressure at the injection site.
5. The infants in this study were all laid down on the exam table for their injections, a position which may unnecessarily heighten their anxiety before the first jab occurs.
6. The 5 S process is time-consuming. The researchers note that topical anesthetics are “generally not used in a busy practice” because of expense and time, making the 5 S approach especially untenable in light of the researchers’ observation that the approach was more difficult to implement with the “bigger and heavier” 4-month-olds.

Ultimately, Harrington and colleagues call for further research on this approach, and this seems warranted. Research into use of the 5 S’s during vaccination by parents themselves would be helpful, since this strategy may be both unnatural to many parents and difficult for them to implement during the stress of vaccination. Given the small number of 4-month-olds included in this study, research into use of this approach with older infants also would be appropriate.

Tips for relieving vaccination pain
In light of this research, what can parents do to alleviate their babies’ distress during vaccinations?

• Breastfeed! Harrington and colleague note that research shows breastfeeding combines several analgesic effects “(a comforting person [mother], skin-to-skin contact, diversion of attention, and the sweetness of lactose)” as effective for procedural pain. They do not recommend the “5 S” approach when breastfeeding is an option.
• Distract and stimulate! It’s possible that Karp’s “5 S” approach appears to work because it fully consumes the baby’s attention. Parents can do that without following a step-by-step routine.
• Hang tight! Immunizations are an annoyance, but they’re an important part of building a child’s immune system and reducing their risk of contracting a vaccine-preventable disease. If you have any concerns, talk to your child’s pediatrician; otherwise, rest assured—you’ll get through this.

Above all, trust your instincts. Vaccinations can be difficult for babies and parents alike, but by responding to your baby with support and distraction—with or without a 5 S instructional—you’ll likely succeed in calming both your baby and yourself.