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Frequently Asked Questions

Question of the week

Question: I am currently in my 2nd  trimester and have been experiencing a sudden craving for spicy food and especially curry chicken. I eat this almost every other day. Is that okay and would these affect by baby?

A. Craving is your biological feedback telling you that your body is deficient in certain nutrient(s) found in the food that you are craving. The smart thing to eat is the same old curry formulation which your body had documented to carry the deficient ingredient(s). You have to continue eating until your craving disappears. It's okay, provided you avoid excessive irritating ingredients like Capsaicin found in chilli. You should know which spices or herbs you can or cannot tolerate. You just have to reduce those that you cannot tolerable.

Question: I read that supplements are important during pregnancy and top 5 vitamins required are iron, Vitamin B, iodine, calcium and Vitamin D but does that mean I have to take many vitamin tablets? Can I just get them from daily intake of food and milk? Would that be sufficient?

A. Your O&G Doctor would have given you a daily antenatal Vitamin and Mineral pill that contains all these ingredients. Kindly follow his/her advice.

Dr Ang Poon Liat Paediatrician MBBS (NUS) | Master of Medicine (Paediatrics, NUS) | MRCP – PAEDS (UK) FAMS | MD (Singapore) Thomson Paediatric Centre 339 Thomson Road #03-06 Singapore 307677 Tel: 6258 3353 Website: http://www.thomsonpaediatriccentre.com

General Paediatrics

Q. Dear Doctor(s), my 7-week old infant has not gained any weight in the past 2 weeks and she seemed to have lost her appetite as well. Occasionally, she vomits out her milk. I'm concerned as I've been informed that infants at her age is supposed to gain 150-200grams per week. Is there anything wrong with my child?

A. Your baby needs to be examined by a doctor to rule out medical causes for the static weight and you should not delay as it has been 2 weeks already. See a doctor this week

Q. My breast fed baby of 8 months old will only poop once in 7-9 days before starting solids. Now baby is eating fish/veg porridge for lunch and baby rice cereal for dinner daily but also poop once in 7-9days is it normal? What can we do to make him poop more often. We tried the bicycle exercise and tummy massage for baby but it is not effective

A. If your child's baseline poo frequency is the same before and after starting solids, then there isn't any great concern. In general, formula-fed babies are expected to poop daily or at least once in 2 days, if not, a change of formula may help. Breastfed babies' poo frequency can range from daily to once a week. This is acceptable provided baby is happy and contended, no distended abdomen, is thriving, not straining at poo time and poo isn't hard, dry and blood-stained. To improve poo frequency, avoid giving "constipating" foods like apple, banana, carrot and brown rice. Too much volume of solids causes constipation too. Give prune juice, papaya, green bean puree, more liquid intake, probiotics help and the occasional lactulose if needed. Should your child be in discomfort, have appetite loss or poor weight gain, please get a consultation with the doctor.

Q. My daughter has running nose almost every month. We've given her the flu jab but it doesn't seem to help.

A. Its likely your child has either chronic sinusitis or allergic rhinitis . Please see your doctor to evaluate which it is. By Dr Tan Siew Pin

Q. Dear doctor, my 5 week old seems to have mucus in her nose. I can hear it especially when she gets very angry/agitated and kicks and punches her fists vigorously. Should I leave it to go away on its own?

A. It appears that your baby is very bothered by the blocked nose. It's better that you try to unblock the mucus by getting a saline spray or drops from the pharmacy to lubricate the nose just prior to auctioning of the nose. I recommend the pigeon brand nose aspirator that is not hand held vacuum type but designed for oral suction. If she is unable to feed or sleep she may need to see the doctor for the suctioning procedure to relieve it. By Dr Tan Siew Pin

Q. Hi there, my 19mo has been having a leaky nose on and off for about a month. He goes to childcare and he has been taking various antihistamines (Zyrtec, asumalife, alleryl) to stop his nose from leaking but it is only till recent date that his nose doesn't leak as much. Is there a reason why his nose has been leaking for so long? Or is it possible that he has developed a sensitive nose due to him attending childcare? Thanks :)

A. Persistent running nose can be due to allergic rhinitis or sinusitis or a combination of both. It has been proven by research that childcare does expose your child to a higher risk of infections . Most children however will eventually settle down in a couple of months and infections will get less frequent. If there is a positive family history of allergic conditions like eczema asthma allergic rhinitis / then your child may inherit this tendency and manifest the same . They are more liable to have chronic running nose and need to be managed appropriately if symptoms persist and bothers your child. By Dr Tan Siew Pin

Q. Hi my girl is 5yrs old often got asthma very badly. She is now on nab and puff now. Allergy test had do to dust mite and dry food as it may have led her to acute asthma. Bought her for TSC treatment still no much better. Pls advise she didn't miss any of the puff at all. Poor girl :(

A. Hi there may be several reasons why she isn't responding wrong technique of using the inhaler. Make sure you have that checked out she needs to be on preventative medicine and not just symptomatic medicines. Eg steroid inhaler, singular she may have allergic rhinitis which needs to be managed otherwise her asthma control will not be optimal she may need to be reviewed to ensure it's not a wrong diagnosis there may be underlying infection like sinusitis mycoplasma which affects her asthma control By Dr Tan Siew Pin

Q. I was recommended to give my 20 months old son flu vaccines as he fell sick quite regularly. I would like to know if flu vaccines is recommended for kids at this age and what are the pros and cons to look out for. WIll there be any side effect in taking flu vaccines regularly as I am aware that one needs to have such injection once a year. And also, if flu vaccines really can prevent flu

A. Flu vaccines prevent influenza not the common cough and cold . However there seems to be a beneficial effect in general. Side effects are fever and pain and swelling which is temporary. By Dr Tan Siew Pin

Q. Do vaccines cause autism? And are vaccine side effects dangerous?

A. There are side effects which occur in a small minority which includes fever, swelling at injection site and rarely gastrointestinal or appetite change . Side effects are temporary . By Dr Tan Siew Pin

Q. At what age should my son stop using a pacificer?

A. Best if the child is weaned not later than 3 years old as there will be distortion of the teeth with prolonged use. I do reccomend to try to wean your child from one year onwards. By Dr Tan Siew Pin

Q. My 14-mth old started having very loose stools (3-4 times a day) after we changed to Stage 3 formula after he turned 1. Our PD advised it could be due to lactose intolerance from cow milk formula, so we changed to goat milk formula and he is now having constipation instead. Other dietry habits like porridge, fruits (apple, papaya) has not changed. He drinks a considerable amount of water. Other than increasing fibre intake, are their other ways to soften his stools? In the meantime, we are considering changing him back to cow milk formula, on a different brand as well. Thank you.

A. The bowel change seems to be linked to the formula change . It would be wise to go back to the for milk he was previously on and once he has regular bowel movement then try another follow on cows milk. By Dr Tan Siew Pin

Q. My 5 year old daughter is drinking full cream UHT milk. Is that ok or should we switch to fresh milk or milk powder?

A. Preference is for fresh or powder milk but it depends on her current weight and whether she is a picky eater as there are pros and cons to both . Milk powder has added vitamins but tends to be sweetened . Fresh milk is not practical if you spend a long day out but tastes much better. By Dr Tan Siew Pin

Q. Hi, my 5 years old son had been on/off complaining his leg (possible ankle) easily tired when walking. Please advise the specialist to seek for. Thanks!

A. It is possible that your son has growing pains, a common condition in about a quarter of healthy children, and should not be considered a disease. This condition occurs most frequently in 2 age groups: 3-5 years, and then 8-12 years. This condition mostly likely happens due to aches after a day of running, jumping and playing, and is usually more prominent after a particularly active day. The pain usually occurs in big muscle groups, such as the thighs and calves. Do note that this condition should not cause joint swelling or pain when a joint is moved. Some simple measures to relief the pain include massaging, stretching. You can also try simple painkillers such as paracetamol if the pain is prolonged. Findings to note that would necessitate taking your son to consult a doctor include: - Redness, swelling and pain when moving a joint - Persistent pain in one particular area - Persistent pain on waking up in the morning - Any limping or inability to walk - Fever, loss of weight or poor weight gain, loss of appetite, unusual rashes, frequent mouth ulcers - Any other persistent symptoms that causes you to worry By A/Prof Daniel Goh

Q. My baby catches colds easily at the infant care, should I bring him to the doctor immediately or give his body a few days to fight off the infection on its own? I'm skeptical about giving too much western medicine to him as he had a bad experience with negative side effects of a cough and cold medicine previously.

A. You did not state your child's age, but I assume he is below a year old. The reason for the frequent infections are multifactorial. Firstly just the fact that he is so young and his immune system is still not strong or competent to ward off the infections. Secondly any child that attends any form of childcare already stands a higher risk compared to those brought up in their own home. Research has proven that. Other reasons include whether your child is picky and refuses fruits and vegetables, which are crucial to immune competence. It's hard to say exactly when to stay home or rush to see a doctor but the following are obvious reasons to consult early for eg. high persistent fever, drowsiness, vomiting, breathlessness, unexplained rash, refusal to eat etc Once you have seen your child through one illness you grow in your observation skills and confidence to have an idea when baby can be managed at home or not. If in doubt at least call for simple advise and guidelines. Self medication is not recommended for infants except safe ones like saline spray (age appropriate) and manual suction, anti fever medications. Should your doctor prescribe your baby with a medication, and you feel uncomfortable about giving -ask for more information and the necessity of it - is it critical, helpful or only if needed? Ask - What if you decide not to use it - what may happen. It's best to communicate your concerns about the medicine rather then decide on your own after you have seen the doctor and go away feeling uneasy about it. A good open discussion and good relationship with your child's doctor will remove this unnecessary worry and mistrust. I must point out too that side effects with medications are often unpredictable. We are aware of the potential ones and its written in the drug info insert. - by Dr Tan Siew Pin

Q. My son is 18th months old and he is an extreme picky eater. Up till now, I cannot get any fruit into his mouth. Whether I puree the fruits or I make them into juices, he just refuse to take them. It is also very difficult to get him to try new food. He not only don't want to put into his mouth, he don't even want to touch them. He runs away when he sees food that he is not familiar with. My question is what can I do to change his behavior and should I supplement his diet with vitamins? And, can picky eating be a mental or emotional problem?

A. Welcome to the age of the toddlers when picky eating habits are not uncommon. As for introducing fruits one suggestion is smoothie / blending the fruits with fresh milk. Or mix the fruit purée with yoghurt - looks like ice cream! Or cook it with rice and other dishes eg fried rice with diced fruits like apple or raisins or pear… To change his BEHAVIOUR try first by not being anxious about it and force feeding. It's negative conditioning. Make meal times a family time where at least you and your child are at the table together where he sees you eating and that's a positive influence. That's why some kids eat better at school than home because there is a positive effect when it's communal meal times. Do not be tempted to entertain during mealtimes but conversation is good. Allow your child to use child friendly utensils to feed himself and finger eating is fine as well. Ensure your mealtime schedule is realistic and not 3 hourly feelings as they are no longer babies and work on a more spaced out timing. The expected food portion is about their fist full. If your child is not open to trying new foods at least try to maintain a good routine with the familiar. You could also get your child to help you prepare the dishes such as doing simple things like washing the vegetables and fruits, stirring the mixture if its not a hot gravy or help lay the table. There are certain situations where the picky eating could be part of a larger problem like sensory integration disorder or infantile anorexia You may need to provide vitamins if the diet is very restricted. If there are other worrying symptoms or BEHAVIOUR please consult a doctor. - by Dr Tan Siew Pin

Development & Learning

Q, My son is 18th months old and at this age, what can I expert of his development in relation to speaking, knowing his ABC, differentiating colours and etc? Also, is there any learning program that I should start him on at home. I do not intend to send him to any school under he is 3 years old.

A. According to HealthPedia, a guide published by KK Women's and Children's Hospital Singapore, these are some milestones generally expected of a 18-month old: Runs with a lack of coordination and falls frequently, Walks up stairs while holding on with one hand, Can build a tower of two to four blocks, Can use a spoon and cup with help to feed himself, Imitates scribbling. Can turn two or three pages of a book at a time, Shows affection, Listens to a story or looks at pictures, Can say 10 or more words when asked, Explores environment, Identifies one or more parts of the body, Understands and is able to point to and identify common objects, Imitates domestic activities, Is able to take off some clothing items, such as gloves, hats, and socks, Begins to feel a sense of ownership, identifying people and objects by saying "my", Attains bowel control These milestones give us a general idea of what your child can be doing at 18th months but remember every child is unique and develops differently. However one thing for sure is that they will certainly blossom in a caring environment. Spend more time reading to your child. It is a fantastic way to bond with your child and cultivate a love for reading and he certainly understands that you are reaching out to him with love and care. A trip to the supermarket is full of learning opportunities: Talk to him about what you are taking off the shelf. If appropriate, ask for his preference as in the case of buying Yakult; ask if he would prefer the orange or grape flavor. The idea is to engage him in a conversation and describe what you do. For example, say: "I wonder how many apples I should buy? One for Mommy, one for daddy and one for you! So I need three apples. Can you help me pick three Apples?" Learning does not have to be a structured and formal programme. You can make it dynamic and fun by incorporating it as part of your daily interaction with your little one. The key is engaging the child in a conversion about life and respecting and valuing the child for his/her contributions. by Dr. Christine Chen

Lactation & Breastfeeding

Q. My two-month old wants to nurse every other hour. He only suckles for five minutes each time. How do I space out his feeds so that he drinks more per session?

Ensure he is latching well and suckle well to receive enough milk from the first side of breast and offer 2nd side after burping him to satisfy the appetite well to space the frequency of feeds. By Ms Kang Phaik Gaik

Q. My five month-old, who is exclusively breastfed, has not pooped for the last five days. Is this normal?

It is normal. It is common that from 2nd month, breastfed babies only poo a few days once as breastmilk gets digested and absorbed well. However, do observe that Urine output should be at least 6 - 8 times daily. By Ms Kang Phaik Gaik

Q. My son is 7 weeks old and we are both still getting ourselves around breastfeeding. The first few weeks have been stressful with me not being able to produce enough milk for him and his weight loss. What are some ways to increase milk production? Do you recommend formula-feed to complement breast-feeding and how often?

The more baby suckles on the breasts, the more milk you will produce. Ensure baby is latching well to stimulate the letdown effect. Giving formula may reduce the baby’s need and desire to suckle on the breast, thus may reduce mother's milk supply. By Ms Kang Phaik Gaik

Q. How much breast milk should I be able to express after feeding my baby? He is three months old and I'm going back to work soon. I can only get 20ml-40ml on the breastpump now.

There are a few reasons why we pump after breastfeeding:- (1) If baby is suckling well, usually very little will be expressed. Expressing after direct feed is a form of stimulation as after 3 months postpartum, the production of breast milk is based on autocrine reflex, ie the more you empty the breast, more milk will be produced. (2) If baby is not emptying the breasts effectively during direct suckling, then the mother’s breasts will still be full, hence a lot can be expressed after breastfeeding. (3) The important factor of expressing is to maintain a “Supply and Demand Theory”. If baby only empties one side of the breast, the other side will be full. Hence, it is a good practice to empty the full breast otherwise it may pass the wrong message to the mother’s brain that there is no need to produce anymore as the production is more than baby’s needs , thus leading to low milk supply in the long term. By Mrs Wong Boh Boi

Q. My exclusively breastfed baby, who is three months old, occasionally has poop that smells like vinegar. My mum said it's because he does not drink enough per session? Is that the reason?

(1) The reason for vinegar or foul-smelling stools in a breastfed baby is due to sensitivity to lactose and other foods. (2) Cow’s milk protein present in dairy products that the mother consumes can pass to baby through breastfeeding. Hence, this may lead to more pungent stools. (3) Feeding the baby too much foremilk, especially in cases whereby the mother switches too quickly from one breast to the other - resulting in very little hind milk being taken by the baby, and too much foremilk is consumed. Thus, the poo can smell a little sour. (4) Less common medical reason like baby having lactose intolerance will also cause sour smell in stools. (5) Unusual smelling stools often result from dietary causes by baby’s mal-absorption such as Crohn’s disease or cystic fibrosis that lead to acidic-smelling stools. By Mrs Wong Boh Boi

Q. My two-month old wants to nurse every other hour. He only suckles for five minutes each time. How do I space out his feeds so that he drinks more per session?

Frequent feeding may be due to many reasons: (1) Poor shallow latch and baby suckling on the nipples, resulting in ineffective draining of the milk from mother. (2) Low milk supply due to blockage or lumpy breasts and plugged milk ducts. (3)Low milk supply due to fatigue. Here are recommended approaches: (1) Seek consultation to rule out all of the above causing factors (2) Avoid the baby‘s bad habit of using mother as human pacifier for comfort suckling. By Mrs Wong Boh Boi

Q. My son is 7 weeks old and we are both still getting ourselves around breastfeeding. The first few weeks have been stressful with me not being able to produce enough milk for him and his weight loss. What are some ways to increase milk production? Do you recommend formula-feed to complement breast-feeding and how often?

An occurrence of low milk supply can be due to many reasons, such as poor latching of the baby, too shallow in baby suckling, baby chewing on mother’s nipple, poor positioning and baby being offered the bottles too soon. To increase milk supply, new mothers can do the following: (1)Ensure latching and positioning of the baby to breast is correct. Baby’s mouth should cover as much of the areola as possible. (2)Ensure effective drainage of the breasts and make sure that swallowing sound of the baby is present. (3)Have plenty of rest and fluids to avoid fatigue. Dehydration may also dry up milk supply. (4)Feed frequently, and suggestion is every 2 to 3 hours. (5)Try various positions when feeding the baby. One option is to lie down if you feel tired. (6)Massage the breast and express to stimulate more milk supply. (7)Try herbal remedies like fenugreek (to be taken 3 tabs/3 times a day after food). (8)Have a well-balance diet and include soups such as fish and papaya soup in your meal plan, which aid in milk production. (9)Baby may have to be supplemented with formula-feed while working to get the mother’s milk supply up. By Mrs Wong Boh Boi

Q. What are the important nutritional food that a mother should consume to enhance the quality of her breast milk?

(i) Dairy products (low fat version) are rich in calcium e.g milk, cheese, yoghurt (ii) Variety of fruits and vegetables are rich in vitamins, minerals and dietary fibre (iii) Lean meat are high in iron (iv) Oily fish such as salmon and tuna are rich in Omega-3. By: Mr For Wei Chek, Senior Consultant Dietician at Mount Alvernia Hospital

Q. I heard that the quality of breast milk will not be as good after some time and hence, it is not necessary to breastfeed a child beyond the first year. Is it true?

No, Breastmilk changes throughout the lactation period to suit the baby's growth and development. World Health organisation and HPB, Singapore recommend exclusive breastfeeding for all babies for the first six months, and continued breastfeeding with complementary foods thereafter, until two years and beyond. By: Ms Kang Phaik Gaik, Senior Lactation Consultant at Mount Alvernia Hospital

Q. Hi Doctors, I am eager to find out the answer for my critical question on breastmilk. I understand that trans fat is harmful to human health, and this trans fat will even go into breastmilk, if nursing mum consumed food containing the trans fat. Hence, (1) is it through that this trans fat will displace all the good fatty acid eg DHA in the breastmilk? (2) Is so, does it mean our breastmilk will not contain enough DHA for baby, if consumed trans fat food? (3) Then, what is the best solution, as we cannot possibly avoid all trans fat in food? (4) And, does taking additional DHA supplement helps to increase the content of this good fatty in breastmilk? Thank you so much.

Maternal diet can influence the composition of different types of fats found in the breastmilk. If the maternal diet contains high amount of trans fat, the mother's breastmilk may contain higher percentage of trans fats as compared to other types of fats. However, trans fat does not displace the other types of fats in the breastmilk. Individuals who consumes higher amount of trans fat tends to consume less amount of other types of healthy fats. It is advisable to cut down foods which are rich in trans fat such as hydrogenated margarine found in bakery products (cakes, pastries, biscuits) and deep fried foods. Meanwhile, to consume foods which are rich in DHA such as salmon or tuna. It is not necessary to take DHA supplement in order to increase the DHA amount in the breastmilk. By: Mr For Wei Chek, Senior Consultant Dietician at Mount Alvernia Hospital

Sleep Issues

Q. Hi, my 4.5 months old daughter has problem getting to sleep even though she is sleepy, night or day. This started since she rolled over on her tummy at 3 months. At 4 months+, she has begin to crawl on her tummy. She keeps doing it when she is put on any flat surface. At times, she can move around on the bed for 3 hours before going off to sleep. I wonder if this is normal and will this eventually stop? She sleeps little for her age and am worried about her brain development. She still has frequent startle reflex.

A. Thank you for your question. First of all, I’d like to reassure you that the problem you’re going through with your daughter is not unusual. It is not uncommon for infants to have sleep onset or settling difficulties up to 12 months of age. In the first 3 months of life, infants learn to “self-soothe”, where they learn to transition from wake to sleep, both at sleep onset and following normal awakenings throughout the night. They subsequently learn to consolidate their sleep and have continuous sleep without parental intervention. This ability to sleep through the night on a regular basis may not be achieved until later (up to 9 months of age for the majority). In your daughter’s case, it sounds like she’s started to achieve these skills, but after rolling and starting to crawl, she’s now having sleep onset issues. It is well recognised that temporary sleep disruption does occur during the acquisition of motor milestones, including rolling over and crawling, and may be associated with delay in going to sleep (as in your daughter’s case) and increased awakening at night. This may be more prevalent in infants like your daughter who crawl earlier than usual. Please be reassured that this is usually temporary, although it can take some time (up to 2-3 months) for your daughter to go back to sleeping as before. In the meantime it is important for you to avoid behaviours that reinforce difficulty settling to sleep or night-waking, such as resorting to rocking her to sleep or night-feeding and giving attention whenever she wakes. Stick with a regular bedtime routine leading up to sleep onset at her age, as this will help her fall asleep on her own and help with her soothe herself back to sleep whenever she wakes up in the night. Routines can include bathing, story-telling, music, and massage before bedtime. Place her in the cot when she is drowsy but still awake. It is beneficial to help your daughter develop appropriate sleep associations that are independent of parental intervention (for example, letting her fall asleep independently in her own crib, or using a transitional object such as a blanket for her to help with self- soothing). If she cries, do not respond immediately (she may develop a habit of crying to gain attention) but consider letting her cry it out (not all parents accept this) or waiting for progressively longer periods before attending to her. The startle reflex, also known as the Moro reflex, is a primitive reflex that normally disappears by four months of age, but can persist until as late as six months before she outgrows it. You don’t need to do anything about the reflex at this stage, but if it persists beyond six months, do visit your doctor for a checkup. One final reassurance is that your daughter’s brain development will not be affected by her current sleep issues. This is a common problem in infancy which your daughter should eventually outgrow. Thank you. Dr. Michael Lim Consultant Division of Paediatric Pulmonary and Sleep National University Hospital

Q. Dear Doctor, it takes me about an hour to coax my 5 week old to sleep and it’s very frustrating. She seems to be angry no matter if I carry her or put her down. She doesn’t really seem to like the pacifier either. How can I make her fall asleep sooner?

A. Establishing a bedtime routine is important in the process of training a child to fall asleep. Set a time for bed and start the routine 30 to 45 minutes earlier to prepare the child by winding down of activities, bathing and/or changing her clothes to bedwear. You can read stories or tell stories and then dim the lights and quieten the room. Once the child is sleepy, place the infant into bed and allow the child to fall asleep herself. Do not carry or rock the baby till she falls asleep. Do not watch TV or have any exciting or stimulating activities. This is part of the process of training the child to self-sooth which also enables the child to return to sleep spontaneously when she awakens in the night (without need for an external intervention). With a consistent bedtime routine, the child will soon learn to fall asleep with less fuss and certainly no frustration. The routine need not be elaborate – keep it simple but most importantly be consistent. Don’t despair, what you are facing is not uncommon but it should not be left to continue but with proper ‘training’ the child should be able to fall asleep with less problems. By Dr Daniel Goh

Q. My girl is going 9 months and ever since I started going back to work, she keeps waking up at least 4 times a night. Initially was to suckle awhile and fell asleep and 2 hrs later wakes up again. Also she needs to latch on before she can sleep. Needed some advice how I can change that. She will scream and cry if I give her bottle before bed time.

A. It appears your child is using the breast to sooth herself to sleep. She needs to latch on to the breast to sooth herself to sleep. This is an example of inability to self-sooth. The bottle will not be able to replace the breast as feeding is not the main agenda but just familiarity and association of the breast with sleep onset. Self-soothing in a child can be encouraged through the following strategies:

1. Establish a consistent bedtime routine. Preparation for bedtime with soothing activities (e.g. bath, massage, stories) helps to set the tone and mood for sleep. It is also important to avoid stimulating or exciting or noisy activities just before the child’s bedtime. This enables the child to fall asleep him/herself without external intervention and hence the child will be trained to do likewise when he/she arouses in the middle of the night.

2. Exercise restraint in responding to the child’s demands whether fussing or crying. Avoid responding immediately to the baby’s movement, sounds or even cries - sometimes parental interventions can contribute to a prolonged arousal. This is essential in the process of ‘training’ the child to self-sooth. Some of the techniques include ‘Extinction’ i.e. putting the child to bed and systematically ignoring the child till a set time the next morning; ‘Graduated Extinction’ i.e. waiting progressively longer periods of time, usually in 5-minute increments before checking on the child and avoiding picking up the child; ‘Fading of adult intervention’ i.e. this is a proactive plan with gradual withdrawal of parental intervention in steps, usually working with the doctor or therapist.

3. Avoid night time feeds. After the baby turns six months, do not persist with night time feeds (otherwise known as middle of the night feedings). There is no evidence that night feedings improve sleep in the child. Night feeding can become a learned behavior which can lead to more frequent and prolonged night waking and hence disrupted sleep.

4. Do not rock or pat the baby till he falls asleep. Rocking and patting the baby till he is asleep will propagate his/her dependence on parental intervention. It does not allow him to develop self-soothing techniques resulting in the same needs when he/she is aroused in the night. By A/Prof Daniel Goh

Q. Hi, I am a new mother and my son is turning 3 months in a few days' time and he has not been a very good sleeper and always wants to be carried. He sleeps in our arms and only when we walk around with him in our arms and then wakes up almost immediately when we leave him back into his cot. It has become such a tiresome period as we are all working and my mother who is the main caregiver is getting on age. I heard about letting the baby cry to sleep and was curious to find out if it would impair the child's social and emotional development in the long run. What other methods can I adopt to help him tune in to a better sleeping pattern for good?

A. Infants sleep goes in cycles of about 90 to 110mins,or shorter in younger babies. Brief arousals normally occur at the end of each sleep cycle, hence it can occur about four to six times a night. Babies who are able to self-soothe get back to sleep rapidly without interruption. However, babies who are unable to do so may wake up and cry and require parents to carry, pat, rock or feed them before they can fall back to sleep. Self-soothing in a child can be encouraged through the following strategies:

1. Establish a consistent bedtime routine. Preparation for bedtime with soothing activities (e.g. bath, massage, stories) helps to set the tone and mood for sleep. It is also important to avoid stimulating or exciting or noisy activities just before the child’s bedtime. This enables the child to fall asleep him/herself without external intervention and hence the child will be trained to do likewise when he/she arouses in the middle of the night.

2. Exercise restraint in responding to the child’s demands whether fussing or crying. Avoid responding immediately to the baby’s movement, sounds or even cries - sometimes parental interventions can contribute to a prolonged arousal. This is essential in the process of ‘training’ the child to self-sooth. Some of the techniques include ‘Extinction’ i.e. putting the child to bed and systematically ignoring the child till a set time the next morning; ‘Graduated Extinction’ i.e. waiting progressively longer periods of time, usually in 5-minute increments before checking on the child and avoiding picking up the child; ‘Fading of adult intervention’ i.e. this is a proactive plan with gradual withdrawal of parental intervention in steps, usually working with the doctor or therapist.

3. Avoid night time feeds. After the baby turns six months, do not persist with night time feeds (otherwise known as middle of the night feedings). There is no evidence that night feedings improve sleep in the child. Night feeding can become a learned behavior which can lead to more frequent and prolonged night waking and hence disrupted sleep.

4. Do not rock or pat the baby till he falls asleep. Rocking and patting the baby till he is asleep will propagate his/her dependence on parental intervention. It does not allow him to develop self-soothing techniques resulting in the same needs when he/she is aroused in the night. By A/Prof Daniel Goh

Q. My two-year-old wakes up in the middle of the night and makes his way into our bedroom on his own. How do I break this habit of his?

A. This problem is commonly encountered in toddlers after 2 year of age after they are moved to their own room. There are 2 main pillars to achieve positive change: 1) consistent parenting, 2) positive reinforcement to encourage the desired behaviour (staying in his own bed). If your child comes into your room, stay calm but firm. Immediately return him into this room firmly, ignoring all protests. For some children, simply returning them to bed multiple times may work after a period of time. If your child keeps coming into your room, you may want to try the following strategy. When he comes into your room, take him back and close his bedroom door for one minute. Open the door when he has been quiet for one minute. If he gets out of bed again, close the bedroom door for 2 minutes. The time can be increased by 1 minute for each successive time out of bed. Soon your child will learn that it is better to stay in his room with the door open rather than closed. Remember that it is important for both parents to be persistent and consistent for this to work. If you give in to your child occasionally (i.e. allow him to sleep with you), you may actually make it more difficult to modify the behaviour, because he may learn that he will occasionally get what he wants if he tries his chances frequently enough. Use positive reinforcement to reward desired behaviours, e.g. sticker charts and reward systems. You should give rewards first thing in the morning. Larger rewards can be given for continued good behaviour, such as 3 nights of staying in his own bed. Take note to avoid punishment as this has been shown not to be an effective way to change a child’s behaviour. By A/Prof Daniel Goh

Q. My girl is going 9 months and ever since I started going back to work, she keeps waking up at least 4 times a night. Initially was to suckle awhile and fell asleep and 2 hrs later wakes up again. Also she needs to latch on before she can sleeps. Needed some advice how I can change that. She will scream and cry if I give her bottle before bed time.

A. It seems that your daughter has developed a sleep association with breastfeeding. This means that she has formed a habit of falling asleep only when breastfed. I recommend that you try to tackle this issue on a few fronts. Have you been weaning your child to a solid diet? At 9-10 months, she should be getting 3 main meals of finely chopped consistency. An example would be thick porridge with finely chopped meats, finely chopped soft vegetables and small pieces of soft fruits. Reliance on main meals will decrease hunger sensations at night and nightwakings. In addition, management of her nightwakings should also include a consistent nightly bedtime and a consistent bedtime routine. I recommend that you set a consistent bedtime routine of about 30 min in duration, which includes 3 soothing activities (e.g. bath, changing to pajamas, singing to her). These have been shown to reduce nightwakings. It is normal for infants to have brief awakenings several times a night (almost every hour), but the baby should be able to go back to sleep herself. This requires the ability to self-soothe to sleep. Your child has associated falling asleep with breastfeeding, which she cannot provide herself independent of her mother, hence she is unable to go back to sleep herself without mom breastfeeding her. In order to remove this association, she would need to learn to fall asleep independently should she have brief awakenings at night. Also, be careful not to rock your child to sleep, as this is another association that your child will not be able to provide herself independently. I recommend that you follow your preset bedtime routines, avoid breastfeeding or rocking your child to sleep, and place her in bed drowsy but not fully asleep. These changes may be challenging to institute initially, and may require more advanced techniques to remove her sleep association over a period of time such as planned ignoring (without breastfeeding) for a pre-agreed time limit but these are best discussed in detail with a sleep specialist. By A/Prof Daniel Goh

Q. My girl is 2 years and 4 months old. Till now she still wakes up 2-3 times a night for feeds. She is super active and regardless how early or late she sleeps, she still wakes up at night. In the day, it is hard to get her eat proper meals (like rice, noodles or porridge) and we have to feed her with milk. On an average, she can consumer 5 times of milk (125oz per feed) a day. My second baby due in April, what can we do to solve this issue?

A. It seems that there are 2 main concerns here. Firstly, your child may have mealtime problems; and secondly, she has excessive nightwakings. Both issues may be related but can be addressed separately. At this age, your child should have a set routine at mealtimes and be able to take three main meals a day with 2 snacks in mid-morning and mid-afternoon plus supper before bedtime. She should be less dependent on milk for nutrition. I recommend that you set up a daily mealtime routine with 3 main meals and a morning and afternoon snack at regular times of the day. Explain to her that she will be allowed food at these times, with a 30 minute limit. Mealtimes should be incorporated into the family routine with everyone in the family sitting at the dining table, and with minimal distractions especially TV. Plan ahead how you would reward and praise your child if she follows the routine; also plan how you would deal with any problem behaviour. Within this routine you can include a bit of “creative touch” with the food content, e.g. having an interesting food display, including foods that she likes, using a variety of foods etc. It may take a while for her to accept the routine but as long as she is growing well and active, there should not be any concerns. With regard to her frequent nightwakings, it seems that she has developed an association between going to sleep and milk feeds. This means that she has formed a habit of falling asleep only when fed milk. Part of the strategy to manage this would be to increase her intake of main meals as described above, because this will decrease her sensation of hunger at night. In addition, management of her nightwakings should also include a consistent nightly bedtime and a consistent bedtime routine. I recommend that you set a consistent bedtime routine of about 30 min in duration, which includes 3 soothing activities (e.g. bath, changing to pajamas, bedtime stories). These have been shown to reduce nightwakings. In order to remove her sleep association with milk feeds, you may want to try a substitute (e.g. stuffed toy, blanket) so that she falls asleep with the substitute item instead. There are more advanced techniques to remove her sleep association such as planned ignoring (without milk feeds) for a pre-planned time limit but these are best discussed in detail with a sleep specialist. By A/Prof Daniel Goh

Q. How many hours should my son of 18mths sleep a day? I read that inadequate sleep is damaging to the overall development of a kid. How many hours is considered good enough?

A. Infants: birth to 2 months need 12-18 hours 3-11 months need 14-15 hours Toddlers/ children : 1-3 years need 12-14 hours 3-5 years need 11-13 hours 5-10 years need 10-11 hours Adolescents 10-17 years need 8.5-9.5 hours It is true insufficient sleep is associated with mood and behavioral changes as well as disease For some children setting a good routine and sleep training is needed to help them settle down. - By Dr Tan Siew Pin

Emotional & Mental Well-Being

Q. Hi recently my girl had been very fearful of growing up. She will be going to primary 1 next year and she will suddenly cry and tell me she don't want to go primary one and that she don't want to grow up to be an adult. Just yesterday, as she was preparing to sleep, she suddenly sit up and cry and said that she don't want to go to Jesus there when she grow old. I am really very worry. How can I help her overcome this fear? I check with her school teacher and no one mentioned any topic about growing up or getting old. Is she stress out?

A. "It is not uncommon for young children below the age of 8 to be terrified by the uncertainties of their future. This is due to their lack of maturity in their psychological and cognitive development. Also, your daughter may also be experiencing separation anxiety now that she has to enter primary school. Going to school means she is growing up and she has to separate from key attachment figures such as parents and other significant caregivers. This can cause intense anxiety and perpetuate a reluctance to go to school. Irrational fears and phobias are common in children at this age. Also, due to their egocentricity and concrete thinking, young children may misinterpret major life events and think that bad things would befall upon them, or misattribute adverse incidents to themselves thus causing them to blame themselves for their occurrences. For example, a young child may feel guilty after reading about or after watching a TV program depicting a disaster because he had been disobedient toward his parents earlier. Children with anxious temperament or who are worrisome and insecure tend to present with anxiety issues. Anxiety, besides presenting as an emotional symptom, can also manifest itself in sleep disturbances and behavioral changes. Be aware that children often mirror their parents in emotions and behaviors. So it is important for parents to remain clam and provide the necessary reassurance. Do explain that events may not be what they seem to be from newspapers or from TV. Acknowledge your daughter's feelings without dismissing them as the anxiety and fear is very real to her. You can ask gently where she got her ideas from and correct her misconceptions gently. You can describe the many positive things that could arise from going to school such as doing fun things and making new friends. Go through the school activities and rehearse or role play them at home. You may also wish to communicate her difficulties to the school counselor or teacher so that they could help reassure her and monitor her in school. Pairing her up with a buddy could help. Be sure that you are there when she expects you to be r when you have promised her so. This is so that you do not further evoke anxiety and fear in her. In addition, you could share with her what adults do everyday so that she has a better understanding of what her parents do at work and that both of you are constantly and readily available for her. Let her know that you may be out working but you will always return home to care and provide for her. Should your daughter continues in this distressing behavior and experiencing intense anxiety despite your interventions, it is recommended that she be seen by a professional such as a child psychologist or child psychiatrist for thorough assessment, management and treatment." - By Dr Ong Say How

Q. My children are bickering the whole day long. The four-year-old and the two-year-old just don't see eye-to-eye. They fight over toys, or the elder one will irritate the younger one by chanting phrases that get him upset. I need some advice please!

A. Sibling bickering and rivalry is normal in children especially when they both desire the same things, e.g. toys, games and affection from adults. Older siblings might feel that the parents favour the younger ones and do not love them as much anymore. Young siblings may feel that parents are unfair as their older siblings could enjoy more privileges. Bullying can be a very real problem among siblings and it is important to look out for it. According to normal childhood psychosocial development, children between ages 3 and 4 need to begin asserting control and power over the environment. Siblings may hence see each other as a "threat". Success in asserting oneself leads to a sense of purpose. However, children who try to exert too much power may experience disapproval by adults, possibly resulting in a sense of guilt. So make sure you even the game for them. Be clear about the reasons why the older sibling could have something and the younger one can't, and why the parents are expecting the older sibling to be a good role model for the younger one. It is paramount to remain impartial and fair in managing squabbling siblings. Setting basic house rules (e.g. no shouting, hitting) from the very beginning. Emphasize the importance of playing nice and playing fair. If they are unable to agree in getting along, they can choose to stop at anytime. Set a personal space for each of them at different corners of the house or room which they could use as a sanctuary if they want some time-out to feel better. When it is difficult to establish who is right and who is wrong over an argument, both could be dismissed to their own quiet corners. Only allow them to play together when they have decided to play nicely and cooperatively. Remember to provide 1-1 private quality time to each of the siblings so that they enjoy the same amount of attention from the parents. The fundamentals of using positive reinforcement (e.g. verbal praise, rewards etc.) to encourage good behaviour and implementing consequences (e.g. withdrawal of privileges, time-out etc.) to discourage negative behaviour would continue to apply. By Dr Ong Say How

Q. I have a two year old who is so into throwing everything, including his shoes from his cars eat to me at the driver's seat. Can you suggest how to correct his behavior?

A. When your child is 2 year old, he may attempt certain behaviour to determine what the outcome is. He may have developed an interest in certain items associated with a particular colour, texture or sound it produces, and hence is reaching out to them, including throwing them to see what happens. He might also be throwing items to get your attention and if it has worked previously, he would very well be doing so again! Be sure that your child is not in any way distressed or feeling uncomfortable as he may not have developed the language to say so. Check whether he is sensitive to excessive traffic noise or to the heat and glare sitting by the car window. If there is no discomfort, usually gentle guidance in the right direction with appropriate reinforcement of desired behaviour would help him understand what is expected of him (i.e. no throwing) and how to get what he wants (e.g. make a request for something). Position yourself at his eye level and speak to him in a firm but calm voice that what he did was unacceptable. Set 1-2 ground rules before travelling in the car and revise them with him every time before boarding the car. If you have to, stop the car if he throws again. This would indicate that you are serious about abiding by the rules in the car and due to his negative behaviour, you have to stop the car and he is unable to get to his destination. Continue to drive only if he calmly agrees to follow the rules. This will take some effort on the parent's part. Provide an alternative distraction if he is bored in the car by using a toy or storybook. If he is indeed seeking your attention, give him your attention when he is cooperative and especially when he is not throwing things. By giving him attention, even if it is a negative one, is still attention. If you are able to give him ample positive attention when he is in his good behaviour, he may not need to do the reverse to get your attention any more. By Dr Ong Say How

Q. My son, who is five, told me he's scared of the dark, how do I overcome his fear?

A. Simple phobias such as fear of the dark is very common in young children. Phobia is an irrational fear of something or a situation even though there may not be any imminent threat or danger. Simple phobias in children normally improve with age and maturity. However in some cases, they can be very debilitating. Children afraid of the dark might ask parents to sleep with them, or request the lights be turned on throughout the night. They might become distressed and exhibit acting out behavior before bedtime. Each child may have his or her own driving theory behind the phobia. Is it a fear of the absence of light itself or a fear that there could there be a monster lurking in the dark? Understanding the background behind the fear would be a very good start. After understanding where the fear originates from, parents are encouraged to validate the child's feelings and his sense of helplessness about the situation without judgment. Reassuring the child frequently and distracting the child with storybooks and other soothing activities are likely to help. Consistent bedtime routines and rituals could also enhance his sense of familiarity and security. You might consider leaving a bedside lamp on at night to alleviate his fear if necessary until such time he is more comfortable with darkness. If the parent is still sleeping with the child at night, it would be advisable to wean off this sleeping arrangement gradually over time so that the child learns to sleep by himself during bedtime. After some initial resistance (which could last for several weeks), the child is likely to accept the reality and begin to get used to sleeping in his own bedroom without his parents accompanying him. The use of positive reinforcement like compliments and rewards for sleeping alone can help increase motivation to sleep independently. Children often mirror the emotions of their parents, so it is extremely important that the adults remain calm and reassuring during the whole time. Parents who persevere on with concerted efforts would aid the child to eventually overcome his phobia. By Dr Ong Say How

Q. My son is 22 months old. He is at a stage of throwing things down my balcony. When I try to read to him, he snatches the book away. When we are outside, he runs around non-stop. We are very worried he could be attention deficit.

A. Your concern is very valid. Young children often have very short attention span and require adults to frequently remind them to stay focused or simply follow through with a task. By keeping direct eye contact and calling him by his name, your child would immediately understand that his attention is required. Do keep your instructions short and concise so that he does not get distracted or drift away. For example, say “after we finish reading together, we can have your favourite ice cream”. Repeat instructions before stepping out of the house on what are the things he can do or cannot do if he goes out with you. Praise him when he carries out your instructions right. Though professionals usually refrain from diagnosing children under the age of 7 years to have Attention Deficit Hyperactivity Disorder (ADHD), preschoolers can certainly suffer from it. What must be established is whether he has some special needs that adults are not aware of and whether they are met. Children with sensory problems can be overly sensitive to certain stimuli like noise, smell, taste, touch and colours. So your son might be resenting the items you give to him or the activity he is suppose to participate in. Sensory problems can occur in both normal children and also in children with Autism but to different degree, with autistic children reacting more strongly to the stimuli as they feel overwhelmed. Given your son’s young age, I would recommend that he get a consultation with a doctor who specializes in developmental paediatrics to assess the nature of his problems. If he is indeed ADHD or having sensory issues, there are interventions that could help him such as behavioural modification techniques, attentional training and sensory modulation. By Dr Ong Say How

Q. My child was scratched very badly on his face by a classmate. He said that the child pounced on him because my child was sitting in his seat. How do I approach this to prevent something like this from happening again? What should I advise my child to react when he faces such bullying incidents again?

A. In such trying situations when the other party could be aggressive and violent, it is best to give in to him or her rather than trying to stand up for oneself. This is to prevent anyone from getting injured. Giving way does not mean one is cowardly. Instead, it takes great courage to let others have their way. Having said that, the aggressor’s behaviour should not go uncorrected. You could alert the situation to the teacher and let the school handle this rather you approach the other child’s parents yourself. Many parents remain fiercely protective of their children and approaching them on your own might make the situation worse or create a misunderstanding. For general bullying without aggression or any threat of violence, your child could consider ignoring a bully as the latter is attempting to invite him to react in a certain way, which could potentially create further problems to your child. For example, the teacher may reprimand your child for shouting at the bully without realizing that someone else had just aggravated him. If ignoring does not work, your child should calmly but firmly tell the bully to stop as it bothers him. If the bullying continues, I would advise he report this to the teacher or school counsellor. Teachers often do notice problems among children, so your child’s bringing the bullying incident up would provide opportunity for them to intervene. Schools generally have anti-bullying policies and protocols. Other ways would include keeping close to his friends who could support him in standing up against the bully. In such situations, strength in numbers helps. By Dr Ong Say How

Q. My daughter, who is four this year has a fiery temper. She screams, shouts, defiantly ignores us when she doesn't get her way. Nothing seems to work, not even the cane. We are getting exasperated.

A. Children this age may exhibit angry temper outbursts because they have yet to learn how to manage their emotions. For some children, they are unable to identify and express feelings in words understandable to adults. So helping them label those feelings and validating them can be helpful, i.e. they learn how to tell you they are angry instead of shouting or hitting the next time they feel that way. Remember that children tend to mirror the adults in emotional expressions. So do look at ourselves when we are angry or upset. Stay calm and in control. What you could do is to ignore these “bad” behaviours even if you feel you need to attend to them. By giving your undivided attention when they throw a temper tantrum, you might inadvertently be drawn into giving them too much attention. This is called negative attention. Children sometimes want attention, even if it is negative like when you are scolding them. Instead, walk away from tantrums and give them attention after when they have calmed down. Praise them when they do that. Similarly, shower them with attention when they behave well and let them know how much you appreciate their asking for things nicely or doing something you would approve of. This is called positive attention. They may then learn to ask for things nicely and in return get what they want faster rather then getting into a tug of war with you. Managing angry tantrums need not be a battlefield. On the other had, if such behaviour escalates or persists despite using the right strategies, consulting a professional to exclude possible emotional, developmental or psychological conditions would be the right thing to do. By Dr Ong Say How

Q. My son is 20 months old and he very shy. He refuses to let other people carry him, not even his grandparents. How can I get my son to open up and be more sociable.

A. It is not uncommon for toddlers and children to be shy in the presence of strangers and sometimes even with family members whom they do not get to see everyday. This could be due to their lacking in security to separate from their parents, their inherent shy temperament or simply just a lack of familiarity with the person you were trying to introduce him to. Many a times, a period of exposure time to the other person is required for a child to warm up to others from outside the immediate family. I suggest getting his grandparents to be around him more so that he can get acquainted with them. You may also involve them in his games and activities. Once he feels a better sense of who they are and that there is nothing to be afraid of, he might begin to open up to them. If he has another sibling, you could get this sibling to interact with the grandparents in the form of role modelling. Do not scold or show disapproval of him as this might heighten his sense of anxiety and further aggravate his shyness. You might also consider enrolling him into a play group to build up his confidence during play with other toddlers. Some children are known to be socially inhibited and would naturally take a long time to warm up with others. A number of such children could have autistic tendencies. If there are other signs of social communication difficulties such as lack of eye contact and lack of reciprocity during conversations, delayed speech development and preoccupation with certain objects that are normally not of interest to other children his age, you should seek a professional consult with the pediatrician or child psychiatrist. - By Dr Ong Say How.

Q. How to handle a temper tantrum from my son who is only 21 months old?

A. A 21-month-old child should be able to understand in a simple way the concept of reinforcements and consequences. If these measures are carried out consistently and immediately after the child has presented with a specific behaviour, the child will soon learn by association his parent's responses to his behaviour, and understand that what behaviour is welcomed by parents and what behaviour is not. Normally, a child who is throwing a temper tantrum is ignored for a couple of minutes so that he could calm down to talk the problem through with the parent to achieve a solution. The temper tantrums are just that and nothing more. If the child is unable to calm down in the stupulated time, the time could be extended by another ten to fifteen minutes until the child does so. The parent must at all times remain calm and be assertive in order to carry this out with good effect. The message is that you shall only attend to him or her when they calm down. If this happens in a public place like shopping mall, remove yourselves to a quiet corner so that the child does not have the advantage of getting the eyes of the public to pressure you into giving in to him. If the child runs the risk of endangering himself during a tantrum, remove any dangerous items around him. You could hold him with both your arms from behind as if you were hugging him from behind him. Apply light pressure while grabbing or holding onto his wrists in order to prevent potential injury to himself or yourself. Count down with him from ten to zero slowly while encouraging him constantly to breathe in and out slowly to relax. Only when you perceive he has relaxed sufficiently, you could then slowly let him go. Continue to hold him if he persists and repeat the cycle. This "holding" technique however may not be suitable for all occasions, and may not be suitable for older, bigger sized or physically aggressive children. When he has cool down eventually, praise him for picking the right choice and how much you appreciate him doing that. - By Dr Ong Say How.

Q. At what age should I start disciplining my child? How should I go about doing it without cane?

A. There is no age limit to disciplining your child. Instead, one should consider why a parent has to discipline a child in the first place. Is it to correct a negative or disruptive behaviour, or simply because one is at a loss over the situation that the child has created? It is important to not let anger get to you as discipline might become too excessive or punitive, thus doing more harm than good. Most children, no matter how young they are, are able to appreciate the actions by their parents. So if discipline is carried out effectively and properly, the child would learn what is right and wrong and what is expected of them. The use of discipline is based on the prinicple of Operant Conditioning in that behaviour could be shaped using reinforcements (to increase good or desired behaviour) or using natural consequences (to reduce bad or undesired behaviour). There are two types of reinforcements -positive reinforcement like praising, giving a reward or privilege in order to encourage more of the desired behaviour, and negative reinforcement like the removal of an averse stimulus such as removing a chore which the child does not like to do if he is able to finish his homework. The same principle applies to consequences - it could be positive or negative as well. Examples of positive consequences are meting out of punishments such as spanking or issuing penalties for bad behaviour, while negative consequences involve removal of a certain privilege if the child does not perform a specific task. Generally, a good balance of reinforcement and consequence methods work best to encourage desired behaviour and reduce negative behaviour. Caning a child is no longer considered appropriate in this day and age because there is a risk that if a punishment is meted out of anger, it could become abusive. In addition, the child might become resentful of the parent and pose more challenging behaviour later in life, or the child might suffer from post-traumatic stress symptoms. So caning is reserved for the most severe of behaviour and only when other methods of correcting the child's behaviour did not work. Should caning be done, it should be targeted on the fleshy parts of the body such as the buttocks. - By Dr Ong Say How.

Dental

Q. How do I prevent tooth decay in my children and is tooth decay a common problem?

A. 40% of all children in Singapore have a form of tooth decay known as Severe Early Childhood Caries, or SECC. The main cause of this is dietary sugars, usually in the form of milk (formula, breast-milk) or sugary foods such as sweets. There are many ways to prevent SECC in young children, such as through the promotion of good oral hygiene, use of fluoride toothpaste and fostering of good dietary habits. A chief example of the latter is to not put your child to bed at night with a bottle of milk or sweetened liquid. More tips on decay prevention can be found on our facebook page at facebook.com/PaediatricdentistryNDC - By: Dr Terry Teo - Registrar, Paediatric Dentistry, National Dental Centre Singapore

Q. When should I start caring for my baby’s teeth and how do I go about doing it? At what age should I start using tooth brush and tooth paste?

A. Good infant oral health starts from birth. Before the eruption of your baby’s first primary tooth at around 6 months of age, you should regularly wipe your child’s gums with wet wipes or a soft cloth especially after feeding to keep the mouth clean. Upon eruption of your child’s first teeth, the use of a soft, small-headed children’s toothbrush is encouraged twice a day, once in the morning but more importantly once at night before bed. At age 1, bring your child to a paediatric dentist who will advise on use of toothpaste based on your child’s risk factors. - By: Dr Terry Teo - Registrar, Paediatric Dentistry, National Dental Centre Singapore

Dietary

Question: Do nutrients I take in during pregnancy all get passed on to the foetus? What key nutrients should I consume?

A. Yes, the nutrients that you eat get passed to your foetus. However, the specific nutrients and the amount of such nutrients taken up by your foetus is self-regulated, according to your foetus' biological requirement. In another word, your foetus will imbibe as much as it needs for growth and development. Unfortunately, there are situations when mother's metabolic disorders may override her foetus's self-regulation. For instance, if the mother has type 2 diabetes, excessive maternal glucose may cross over and harm her foetus. The foetus may develop insulin resistance and presents with obesity. in this case, the mother's diabetic condition must be carefully managed to minimise the impact on her foetus.

Every mother must observe the following guidelines :

• Eat a nutrient-rich diet to ensure balanced nutrients for the foetus.
• Avoid excessive calorie intake to minimise gestational diabetes. This is particularly important if mother is obese or has type-2 diabetes.
• Avoid using processed vegetable cooking oils that normally contain rancid fats and trans-fats. Rancid fats and trans-fats are toxic to both mother and foetus. For the same reason, avoid eating processed foods that use such oils and margarine. Instead use virgin coconut oil or butter from pasture-fed cows.
• Make sure you eat adequate smart brain foods that provide smart brain fats for your foetus's rapidly developing brain and nervous system. These include wild fish and free-range chicken eggs. If you have difficulty getting good quality foods, take supplements like fish oils, krill oil or fish liver oils.
• Avoid eating excessive protein. Choose only complete protein from meat and fish.
• Try to eat as much organic food as you can manage.

Dr Ang Poon Liat Paediatrician MBBS (NUS) | Master of Medicine (Paediatrics, NUS) | MRCP – PAEDS (UK) FAMS | MD (Singapore) Thomson Paediatric Centre 339 Thomson Road #03-06 Singapore 307677 Tel: 6258 3353 Website: http://www.thomsonpaediatriccentre.com

Question: Is it common for pregnant women to have digestion issues and what can we do to improve digestive health during pregnancy?

A. During pregnancy, there are hormonal and physical changes that can cause gastric reflux and the feeling of indigestion. Hence, it is common for pregnant women to frequently feel bloated and experience heartburn. As the pregnancy advances, the growing baby occupies more space and pushes the intestines and stomach upwards, and symptoms may worsen. However, after the baby is born, these symptoms will usually disappear.

During pregnancy, to reduce the discomfort, these can be done:

1) Diet and lifestyle changes • Have smaller but more frequent meals. Try to avoid very spicy or high fat dishes. Alcohol and coffee can also worsen symptoms. • Stop smoking - it increases the likelihood of acid reflux and is harmful to the baby. • Avoid lying down after eating, try to stay in an upright position be it standing or sitting, at least an hour after meals. • If symptoms are worse at night, avoid supper; for better sleep, raise the head of the mattress slightly or lie on your side.

2) Medications • There are medications available to reduce acid reflux and provide symptom relief, which are safe for pregnancy. • See your doctor instead of buying over the counter medications to ensure that the medication is safe for pregnancy. Also the doctor can assess to exclude other possible rarer causes for your symptoms.

Dr Ong Xiaohui Obstetrician and Gynaecologist MBBS | MMed O&G MRCOG (UK) | FAMS Hsuan & Xiaohui OG Clinic 339 Thomson Road #05-04A Thomson Medical Centre Singapore 307677 Tel: 6250 7828 Website: http://www.hsuanxiaohuiclinic.com/index.html

Q. My son doesn't like to eat meat, from pork to chicken even fish! Is there a reason why he is refusing to eat them or just being fussy? He likes vegetable though!

A. It could be due to the following reasons: 1. adverse experience of eating meat, chicken and fish such as choking 2. sensory - dislikes the texture of meat, chicken and fish 3. swallowing issue 4. food preference/being picky. Alternative sources of protein for the child: egg, dairy products, tofu, taukwa, legumes (red beans, green beans). Please consult pediatrician if the child does not like any kind of protein foods. By Dr For Wei Chek

Q. My son who is one and a half year old refuses to eat any fruit. What other food I can give him that have the same nutritional value as fruits?

A. Fruits are an essential food group of a well balanced diet, there is no other food which can be used to substitute fruits completely. However, there are several ways to encourage your child to eat fruits: (i) to blend the fruits into fresh fruit juices with pulp (no added sugar) (ii) to make ice blended fruit juices with pulp (no added sugar) (iii) to blend fruits into ice cream texture or sorbet texture by using a special fruit blender (iii) to blend fruits with low fat milk and make it into milk shake such as banana milk shake (iv) to cut fruits into smaller pieces (cubes form) and mix variety of cut fruits on a plate to serve colourful fruits (v) to cook fruits into dishes such as stewed chicken with pineapple cube; fried pineapple rice (vi) to make fruit jelly By: Mr For Wei Chek, Senior Consultant Dietician at Mount Alvernia Hospital

Traditional Chinese Medicine (TCM)

Q. My child constantly have running nose. This is inspite of the flu vaccinations we have given him. How can TCM make a difference?

A. Having frequent runny nose reflects a weak Lung function. TCM can help alleviate this symptom by first strengthening a child’s Lung function, thereby boosting his/her protective energy. This in turn reduces the frequency of a flu attack and shorten the recovery process. By Ms Seah Ai Wei

Q. What are the childhood aliments that TCM can help with?

A. TCM helps with most common childhood ailments. They include: 1) Respiratory concerns like common flu, cough and asthma. 2) Digestive irregularities such as constipation, diarrhea, colic and poor appetite 3) Poor sleep patterns 4) Weak immune system 5) Eye care 6) General Wellness. By Ms Seah Ai Wei

Q. What is the youngest age that you will accept as a patient for TCM?

A. We accept patients 6 months and above. By Ms Seah Ai Wei

Q. My 28-month child still doesn't sleep through the night. Is TCM able to help him sleep better?

A. TCM believes that disturbed sleep in children is usually related to the Heart-fire, where the child may exhibit high energy levels in the day. Tuina is found to have marked improvement on children’s sleep patterns. Stimulation of certain acupoints and meridians helps to remove excessive heat and tame the hyperactive mind. Certain Chinese Herbs may also help calm the mind and aid in sleep. By Ms Seah Ai Wei

Q. My son of 21 months old have been having regular loose stool since birth. We have put him on different milk powder including lactose free milk powder like Pediasure but it doesn't help. Does this indicate that he has digestive problem and how can TCM help?

A. From the symptoms described, your son seems to have a weak digestive system. From TCM’s perspective, weak digestive system is generally related to weak Spleen and Stomach function. This could stem from either weak body constitution since birth or improper feeding. Regular Tuina therapy may improve the Spleen and Stomach function by gentle stimulation of selected acupoints. Chinese Medicine may also be prescribed to help to boost the Spleen and Stomach function. By Ms Seah Ai Wei

Q. I had severe gastric reflux when I was pregnant with my first child. My morning sickness last till 24 weeks plus. Would I likely to have the same symptoms for my second pregnancy?

A. Every pregnancy is different and it is likely that you may not suffer the same symptoms in your second pregnancy. From a TCM perspective, mummies who have a strong digestive system are less likely to suffer severe morning sickness and other gastrointestinal discomfort during pregnancy. By Ms Seah Ai Wei

Q. How can a new mother best look after herself during confinement? What kind of food should a new mother eat and are there any specific restrictions to follow?

A. Confinement period is an important time for new mothers to recuperate and regain their energy and pre-pregnancy vitality. In the first 2 weeks, plenty of bed rest is recommended and new mothers should rest in a well-ventilated environment, keeping away from “wind” and “dampness” factors (such as direct exposure to fan and air-con) that may aggravate water retention and painful joints. Apart from physical rest, it is just as important to stay happy and relaxed. Having someone whom you can entrust your newborn to will alleviate much of the anxieties of a first time mother. Traditional Chinese customs place much emphasis on the use of ginger, sesame oil and rice wine – to keep the body warm and assist blood circulation for new mothers whose bodies are deemed to be “cold” and weak after delivery. Cold drinks and “cooling” food are avoided during this time and these include vegetables like bak choi, kang kong, radish, cabbage, bitter gourd and cucumber; as well as fruits like starfruit, watermelon, kiwi, pineapple and water chestnut. By Ms Seah Ai Wei

Dermatology

Q. I'm pregnant with my second child. On some nights, I get all these raised patches on my limbs. They are itchy, but bearable. They go away completely after an hour. What could these rashes be and would they affect the pregnancy?

A. It sounds like you may have acute urticaria. Urticaria, or hives, appears as red itchy swollen bumps on the skin. Each urticarial lesion may last for a few hours, and resolve on its own without leaving any scars or marks. However, new lesions may keep appearing over a period of time. Urticaria may be caused by medication, food, a viral infection or physical triggers such as heat, cold and pressure. In pregnancy, a condition known as pruritic urticarial papules and plaques of pregnancy (PUPPP) presents with lesions that resemble urticaria. PUPPP occurs mostly in the first pregnancy, and in the third trimester of pregnancy. Although the rash may resemble urticaria, it is usually persistent and intensely itchy. If your rash disappears after an hour, you probably have acute urticaria. You may like to consider if there are any medication or food triggers. If you also had some viral symptoms recently, such as a sore throat, runny nose, cough or fever, it could be an acute viral infection causing the urticaria. Oral anti-histamines can help alleviate itch and hasten resolution of urticaria. You should ask your doctor for advice on which anti-histamines are appropriate and safe for you during your pregnancy. By Dr Audrey Tan.

Q. My newborn has all these acne spots on his face. My friend said that it's baby pimples. Do babies have pimples and what can I do about it?

A. Your baby probably has erythema toxicum neonatorum (ETN), which is also known as toxic erythema of the newborn. Although the name of the condition sounds rather frightening, it is a common and benign occurrence in newborn babies. ETN may appear in around half of all newborns who are carried to term. The spots appear 1 to 2 days after birth and resolve on their own in 1 to 2 weeks. They consist of red small bumps with a central yellowish or white spot, and are usually found on the face, chest, arms or legs. The cause is not known, but the condition is harmless. No treatment is required as the spots resolve spontaneously. By Dr Audrey Tan

Q. My son has eczema and has been prescribed mild steroids. What are the side effect of applying steroids on a baby less than 2 years old and what are other effective cures other than steroids.

A. It is safe to use a topical steroid on your son's skin as long as the steroid is of the potency appropriate for the degree of skin inflammation, and it is applied only on affected skin. In general, a lower potency topical steroid is usually preferred for young children, unless the rash is severe. Prolonged application of a potent topical steroid can result in thinning of the skin at the site of application, and if used over large areas, can be absorbed into the blood. It is essential that you moisturize your son's skin frequently every day, especially after baths. Restoring the oil and water content of the skin on a regular daily basis is one of the key steps in managing eczema. The topical calcineurin inhibitors (pimecrolimus and tacrolimus) are steroid-free anti-inflammatory agents that have also been demonstrated to be effective in the treatment of eczema, but are indicated only for children older than 2 years. - By Dr Audrey Tan.

Q. What kind of baby products should I use on my baby who has mild eczema problem? Are there any special ingredient I should look out for or avoid when buying products? Can my baby continue with swimming since swimming will dry out the skin?

A. Applying a moisturizer is an important part of the daily skin care routine for your baby with mild eczema. There are many moisturizers to choose from, and ingredients used in these moisturizers vary from one product to another. Some of these ingredients include glycerin, ceramides, squalene, lanolin, paraffin and shea butter. Moisturizers should be applied at least twice each day, especially after your baby's bath. Avoid using harsh soaps on your baby's skin. Choose a soap substitute instead for bathing your baby. You may want to avoid products with fragrance. If your baby's skin improves with the frequent use of moisturizers and with switching to soap-free products, you may continue swimming and see if there's any worsening of the skin after a swim. You may want to limit the duration spent soaking in swimming pool water. Bathe your baby immediately after a swim, and follow this with a generous application of moisturizers over the body, limbs and face. - By Dr Audrey Tan.




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