Development - Dr Maraschin Paediatrician

Selective Food Phases in Toddlers: When Picky Eating Is Normal

Digital_Briefcase — Wed, 23 Sep 2026 07:52:07 +0000

Your toddler devoured sweet potato yesterday. Today they won’t touch it. My own son ate papino for a solid week at age two, then refused it until he was five. Welcome to selective food phases, the phase that tests parental patience like nothing else. As a paediatrician in Johannesburg, I reassure parents constantly: this frustration is usually developmental, not a discipline problem. Your child isn’t being difficult; they’re learning. Understanding the difference between normal pickiness and genuine feeding problems changes how you respond.

Developmental Selectivity: What’s Normal

Between 18 months and four years, selective food phases are completely expected. Your child is doing important developmental work:

Testing boundaries. Food is one of the few places toddlers control their world. “I won’t eat that” feels powerful when so much else is decided for them. This is healthy independence, not defiance.

Food jags. Your child fixates on a particular food, wants it every meal, then suddenly refuses it. This might last days or weeks. They’re developing sensory awareness, adjusting to textures, or exerting control. It passes.

Neophobia. Your toddler is learning what’s safe and what’s scary. Food selectivity mirrors stranger danger; wariness keeps them from danger evolutionarily. Of course your home-cooked dinner isn’t poisonous, but their instincts don’t know that yet.

These phases are normal. If your child grows well, explores a variety of foods over a five-day period, and follows their growth curve, they’re learning exactly what they should be.

When Selectivity Becomes Clinical

Sometimes picky eating signals something that needs professional attention. Look for these red flags:

Shrinking variety. By 18 months, children should eat at least 20 foods. If your child’s list is getting smaller instead of larger, this warrants assessment.

Distress at mealtimes. We’re not talking about refusing a vegetable. I mean real anxiety, gagging at the sight of food, panic around eating. This impacts both nutrition and mental wellbeing.

Missing entire food groups. Protein, grains, dairy, vegetables, and fruit each provide essential nutrients. Omitting one creates nutritional gaps.

Weight or height dropping. Your Road to Health book tracks growth percentiles. A downward trend over time needs investigation; it could signal reflux, allergies, or failure to thrive.

Not progressing with textures. Eating involves 30 coordinated steps. If your child can’t move from smooth to lumpy foods or struggles to chew, they may have a mechanical problem affecting speech development too.

How to Navigate This Phase

Stay patient. Mealtimes should feel safe and positive, not like battlegrounds.

Offer variety. Different textures, colours, and smells expose your child to possibilities.

Model eating. Eat the foods you want them to try; kids learn by watching.

Don’t force it. Pressure creates anxiety around food. Let them touch, smell, or lick first.

Skip the alternatives. Offer one dinner. Don’t turn it into a game where they command the family menu. Remember, they’re testing boundaries.

Monitor your anxiety. Children associate your stress with food itself. Stay calm, and they’ll stay curious.

The Bottom Line

Eating requires skill development, just like walking or talking. Some pickiness is developmental; some signals real problems. The key is knowing your child’s individual growth pattern and noticing trends over time.

Most selective food phases pass. But if you’re concerned, don’t wait. Early intervention prevents lasting eating difficulties.

Worried about your toddler’s eating? Book a consultation at my Johannesburg practice. I’ll review your child’s growth, discuss whether this is a phase or something we need to address, and help make mealtimes enjoyable again.

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Is Your Child’s Walking Pattern Normal?

Digital_Briefcase — Thu, 28 May 2026 11:17:04 +0000

During routine developmental checks in my Johannesburg practice, I always watch how children walk. A child’s walking pattern, or gait, tells me so much about muscle development, bone alignment, and neurological health. When parents ask, “Should I worry that my toddler is pigeon-toed?” or “Is duck walking normal?”, I reassure them that most gait differences resolve naturally. But knowing when to intervene can prevent pain, coordination issues, and confidence problems down the line.

Let me walk you through the most common gait patterns I see and when they need attention.

Understanding Your Child’s Gait: Three Common Patterns

In-Toeing (Pigeon-Toed)

This is one of the most frequent concerns parents bring to my office. A pigeon-toed child walks with feet turning inward, and the cause changes with age:

Under 1 year: Feet turn inward at the midfoot
Ages 1-3: Appears bow-legged due to shinbone rotation
Ages 3-6: Thigh bone turns inward from the hip (often genetic)

Here’s the good news: 95% of cases self-correct without treatment. I recommend assessment only if the in-toeing worsens, causes pain or persists past age 6. Conservative treatments like orthotics and muscle-strengthening exercises usually work well. Surgery is rare and reserved for cases affecting daily function.

Out-Toeing (Duck Walking)

That adorable waddle when toddlers first walk? That’s out-toeing, feet pointing outward as they gain balance. Most children outgrow this between ages 2 and 6. Children with flat feet may also walk this way.

When to assess a duck walking child:

Pain or limping occurs
Frequent tripping
Affects only one leg
Continues past age 3

If out-toeing persists at age 10, intervention is recommended because the unusual foot position stresses knee joints. Weight management becomes critical too, obesity significantly increases arthritis risk in these children.

Treatment typically involves physiotherapy or shoe inserts, though many cases need no intervention at all.

Toe-Walking

New walkers often go up on tiptoes or the balls of their feet. It’s cute initially, but persistent toe-walking after age 2 risks shortening leg muscles, creating balance issues, and causing pain after extended walking.

Most children toe-walk out of habit. Gentle reminders to drop their heels usually work if development is otherwise normal. However, toe-walking can signal autism spectrum disorder, cerebral palsy, or muscular dystrophy, especially when coupled with other developmental concerns.

Treatment progression:

Physiotherapy (stretching calf and foot muscles)
Leg braces or splints for moderate cases
Serial casting if needed
Botox injections to relax calf muscles
Surgery to lengthen muscles/tendons (last resort)

If toe-walking relates to an underlying condition, treatment addresses the whole picture, not just the gait.

Red Flags: When to See a Paediatrician

While most gait differences resolve naturally, certain milestones shouldn’t be missed:

By 12 months:

Not pulling up to stand
Not cruising along furniture
Stiff or floppy legs

15-18 months:

Not walking independently
Walking on toes consistently without flat steps
Uneven movements (favouring one leg)
Frequent falling

2 years:

Still not walking or only walking with support
Difficulty standing from floor without help
Unable to manage stairs without holding on

3 years and beyond:

Uncoordinated or unsteady walking
Tripping more than peers
Difficulty running, jumping, or climbing

Long-Term Consequences of Untreated Gait Issues

If gait problems haven’t been corrected by ages 6-8, life-long consequences may follow:

In-toeing causes joints to wear unevenly in hips, knees, and ankles. Children trip more frequently, risking injury and teasing that leads to exercise avoidance.

Out-toeing accelerates osteoarthritis onset and creates foot deformities like bunions and hammertoes. Weak calf and glute muscles affect balance and coordination.

Toe-walking permanently alters foot structure, shortens calf muscles, and increases fall risk. The social stigma and teasing can devastate a child’s self-confidence.

The Bottom Line

As Dr Maraschin, I tell parents that watching those first wobbly steps is magical. As muscles, bones, and joints mature, most gait quirks disappear naturally. But physical exercise, peer acceptance, and self-confidence all depend on pain-free, coordinated movement.

Trust your instincts. If walking seems delayed or increasingly different from peers, early intervention prevents unnecessary complications.

Concerned about your child’s walking pattern? Book a consultation at my Johannesburg practice. Together we’ll assess your child’s gait, discuss normal development, and create a plan if intervention is needed.

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Understanding Separation Anxiety in Children

Digital_Briefcase — Tue, 24 Feb 2026 11:22:17 +0000

When goodbyes feel impossible. The school gate tears. The creche drop-off meltdown. The clinging when you try to leave for work. If this sounds familiar, you’re witnessing separation anxiety, one of the most common concerns I hear about in my Johannesburg paediatric practice. While these goodbyes can break your heart, understanding what’s happening helps both you and your child navigate this normal developmental phase.

What Is Separation Anxiety?

Remember playing peekaboo with your baby? Those delighted shrieks aren’t just cute, they’re learning moments. You’re teaching “object permanence,” the understanding that things exist even when out of sight. This same concept explains why your little one panics when you leave: they’re learning that you still exist when you’re gone, and yes, you’ll come back.

Infant separation anxiety typically starts around 8 months and peaks between 10 and 18 months. Your baby is beginning to understand they’re separate from you but hasn’t quite grasped that you’re returning. By age two or three, this intense anxiety usually fades as confidence builds.

But here’s what catches parents off guard: separation anxiety can resurface during transitions, new schools, house moves, or the arrival of a sibling. These episodes are usually brief once your child feels secure again.

Signs of Separation Anxiety by Age

8-18 Months:

Hysterical crying when you leave the room
Raising arms desperately to be picked up
Refusing to be put down

Toddlers and Preschoolers (2-5 Years):

Difficult drop-offs at school or playdates
Clinginess before anticipated separations
Changes in sleep routines
Quick settling once distracted

School-Age Children (5-12 Years):

Reluctance about camps or sleepovers
Sunday night tummy aches or headaches
Fear that something bad will happen to the family
Difficulty concentrating at school

Practical Strategies That Actually Work

As Dr Maraschin, I’ve guided countless families through these tearful transitions. Here’s what makes the difference:

Manage Your Own Emotions. Your guilt about working or leaving doesn’t make you a bad parent; it makes you human. But children pick up on hesitation. Trust your childcare choices, and your child will too. Save the tears for the car.
Keep Goodbyes Short and Confident. Teachers handle meltdowns daily. Lingering sends confusing messages. Say goodbye and leave. Your child is safe, and you know it.
Create a Quick Ritual. Unpack the bag, spot a friend already playing, give a big squeeze, and say, “Have a fun day.” Repeat this every single time. Consistency creates security.
Use the Distraction Technique. Psychology calls this the 3-3-3 rule. Ask your child to name three friends at school or three activities they’ll do today. You’re shifting focus from worry to something manageable.
Tie Your Return to Their Routine. “I’ll be back right after nap time” works better than “I’ll be back at 2pm.” Small children don’t understand clock time, but they understand routines perfectly.
Never Sneak Out. Despite what grannies suggest, don’t disappear while your child isn’t looking. They need to learn that you leave and you return. Sneaking breaks trust.

When to Worry: Separation Anxiety Disorder

Most separation anxiety is completely normal. But sometimes the intensity crosses into concerning territory. Watch for:

Refusal to attend playdates or school for weeks
Constant messaging or phone calls
Physical symptoms (headaches, stomach pain) that persist
Inability to concentrate due to worry
Intense fear that harm will come to the family

If reassurance and routine don’t help after several weeks, book a consultation. Separation Anxiety Disorder (SAD) is treatable with cognitive behavioural therapy and family interventions. Early support makes all the difference.

The Bottom Line

Separation anxiety is rarely a problem; it’s proof that your child is attached and developing normally. Acknowledge their feelings while staying consistent with routines. Hold your side of the bargain: say goodbye, leave confidently, return when promised.

Most children adapt within days or weeks once they trust the pattern. And remember, this phase passes. Your child will grow into someone who confidently waves goodbye and runs toward their next adventure.

Struggling with persistent separation anxiety? Book a consultation with our Johannesburg practice. As a paediatrician, I’ll help you determine whether what you’re seeing is typical or needs additional support.

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The Real Value of Educational Toys

Sabina — Tue, 15 Jul 2025 09:34:10 +0000

Not all toys are created equal. Some toys simply entertain. Others open doors to creativity, connection, and critical learning. That’s the real value of educational toys. They take something as natural as play and turn it into something deeply meaningful.

I want to speak directly to you, as a paediatrician and as a parent, about why these kinds of toys matter. Let’s unpack what happens when a child plays, and how we can support that kind of learning without needing anything fancy, loud, or battery-powered.

Why play is essential for child development

In 2018, a landmark article highlighted just how important play is in a child’s development. In fact, it recommended that healthcare practitioners actively encourage play when assessing children. That paper was reaffirmed in January 2025, with this line standing out to me:

“Play is not frivolous: it enhances brain structure and function and promotes executive function (i.e. the process of learning, rather than the content), which allows us to pursue goals and ignore distractions.”

I’ve always believed that one of my roles as a doctor is to help parents raise children who can reach their full potential. And that’s why I talk about play so often. It’s not something we fit in between real life — it is real life, especially for small children.

Play helps kids:

Manage stress
Build life skills
Explore emotions
Practice problem solving
Develop language and focus

But I want to move beyond academic terms like “executive functioning” or “cognitive processing.” Let me show you what this looks like in real life.

A Wendy house and a world of learning

In my garden stands a little wooden Wendy house. It’s been there since my daughter was small. Inside are toy pots, pans, plates, a pram, a scruffy doll and a little blanket. There’s even a dressing table with wooden brushes and bottles.

Years ago, it was her world. Now, I watch with joy as my granddaughter, just 22 months old, steps inside and fills it with activity. Any willing adult is quickly roped into the scene.

At this age, she plays by imitating what she sees. And through that, she’s learning more than we often realise.

What children learn through play

1. Language

Each item in the Wendy house has a name. I’ll hear:
“You’ve got a pot and a spoon — are you going to cook for baby?”
She’s absorbing language, responding to it, and using it to make decisions.

2. Organisation and memory

She doesn’t like mess. If the plates are on the floor, she’ll say “away” and put them back. She’s not just tidying, she’s using her memory and visual perception to recreate order.

3. Problem solving

She’ll try different lids on pots until one fits. That’s matching, spatial reasoning, fine motor control, and perseverance.

4. Empathy

She wraps the doll gently in a blanket, offers a bottle, and even rocks it when she pretends it’s crying. She’s practising care and learning to recognise emotion.

5. Self-awareness

At the mirror, she giggles at her reflection, makes faces, and points at her eyes or nose. This is where social-emotional learning begins. She’s building confidence and identifying herself as her own person.

6. Interpersonal skills

The time we spend in that Wendy house is sacred. No screens. No distractions. It’s just her and me, bonding through shared attention. That’s the kind of play that builds language, focus, and trust.

So, which toys should we choose?

Here’s the good news: toys don’t have to be expensive or flashy to be educational.

In fact, many of the toys that light up and sing actually reduce the child’s chance to speak, imagine, or explore. If the toy does all the talking, the child doesn’t have to. And when a screen replaces a parent or sibling, it takes away the emotional back-and-forth that builds language and empathy.

Here’s what I recommend:

Blocks and puzzles

These help with:

Fine motor control
Spatial reasoning
Visual perception
Problem solving

A puzzle on a screen might teach one or two of those skills, but the real thing engages the whole child, not just their eyes.

Balls and large toys

They develop:

Balance
Coordination
Strength
Body awareness

Sedentary play, especially when overused, can lead to issues like poor muscle tone and childhood obesity.

Dolls, cars, farm animals

These classics:

Spark imagination
Encourage storytelling
Help children act out real-world scenarios
Support emotional growth and social learning

They let children take the lead, rather than reacting to what a toy says or does.

Choosing toys that are safe and age-appropriate

Just a quick note here: always check that toys are:

Non-toxic
Free of sharp edges
Too big to be a choking hazard

The best toys are the ones you can hand over without worry, knowing they’ll be used in a hundred different ways.

Final thoughts from Dr Rico

Any toy can be “educational”, if it creates space for play, connection, and imagination. You don’t need batteries or Bluetooth. You need time, attention, and a little room to explore.

A cardboard box becomes a spaceship. A jungle gym becomes the Amazon. That’s how children learn, by living inside their own imagination, with the support of someone they love.

By offering these opportunities, we’re preparing them not just for school, but for life. Problem-solving, creativity, resilience and empathy — these are the real gifts of play.

References

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What’s on Santa’s Sleigh? A Toy Guide for Parents

Sabina — Sun, 15 Dec 2024 16:48:31 +0000

It’s that time of year when children are dreaming of toys under the Christmas tree. As parents, selecting the best toys for child development can feel overwhelming. The choices are endless, and not all toys provide the same benefits for your child’s growth and learning.

Why Toys Matter

The American Academy of Pediatrics (AAP) highlights the importance of toys:
“Play is essential to optimal child development because it contributes to the cognitive, physical, social, and emotional well-being of children and youth. It also offers an ideal and significant opportunity for parents and caregivers to engage fully with children using toys as instruments of play and interaction.”

But why should we prioritise toys over apps or electronic devices? Here’s why:

Toys Promote Interaction: Toys foster interpersonal skills and bonding between children and adults. In contrast, electronic devices isolate children, reducing opportunities for language and cognitive development.
Hands-On Learning: Toys like blocks or puzzles encourage problem-solving and exploration, helping children develop motor skills, visual perception, and spatial awareness. Digital puzzles, on the other hand, provide only a two-dimensional experience.
Active Play Encourages Health: Toys that encourage movement, like balls or climbing sets, help develop gross motor skills, coordination, and agility. Sedentary electronic toys contribute to low muscle tone and even obesity.
Affordable and Versatile: The best toys encourage rich language and fun caregiver interactions. Everyday items like Tupperware lids or cardboard boxes can spark imagination and teach life skills, while electronic toys are often expensive and limited in use.

The Screen Time Dilemma

Limiting screen time is crucial for children’s development. The AAP strongly advises:

No screen time for children under 18 months.
High-quality programming only for 18 months to 2 years, and for less than an hour a day.

Excessive screen time can lead to behavioural issues and developmental delays. In my experience, children addicted to YouTube often exhibit difficult behaviour when not in front of a screen. Removing screen time often leads to dramatic improvements in these cases.

What Toys Should Santa Bring?

When choosing toys, it’s essential they are:
1️⃣ Age-appropriate.
2️⃣ Safe for use.
3️⃣ Able to promote positive caregiving and child development.

Here’s a helpful guide by age group:

Birth to 6 Months

Skills: Turning towards sounds, tummy time, reaching for objects.
Toys: Rattles, unbreakable mirrors, sensory mats, textured balls, vinyl books.

7 to 12 Months

Skills: Crawling, pulling to stand, packing and unpacking.
Toys: Large balls, push/pull toys, blocks, shape-sorting buckets, peg puzzles.

1 Year

Skills: Kicking or throwing a ball, pincer grip, identifying body parts.
Toys: Balls, colouring books, pretend cooking sets, sandpit tools, nursery rhyme recordings.

2 Years

Skills: Running, sorting colours/shapes, make-believe play.
Toys: Jungle gyms, finger paints, shape sorters, dolls’ houses, garages.

3 Years

Skills: Skipping, pedalling, understanding size differences.
Toys: Tricycles, puzzles, storybooks, baking tools, chalkboards.

4 Years

Skills: Balancing, catching balls, making friends.
Toys: Swingball sets, Lego, dress-up clothes, pool toys.

5 Years

Skills: Naming colours, cutting shapes, tying shoelaces.
Toys: Art kits, outdoor cricket sets, skipping ropes, colour-by-number books.

6 Years

Skills: Cause and effect, basic reading, empathy.
Toys: Stencils, insect collection kits, human body puzzles, musical instruments.

The Good News About Toys

Toys don’t need to be expensive to be valuable. Everyday household items like cardboard boxes or bottle caps can inspire imaginative play, stimulating creativity and development. A cardboard box can transform into a house, a ship, or even a treasure chest, while plastic caps can be repurposed into pretend money or wheels.

While smart devices have their place in children’s lives, they should not replace human interaction. A phone or tablet may keep your child entertained, but it cannot teach them the essential skills of communication and social etiquette.

Final Thoughts

The toys we choose for our children, whether for Christmas or any celebration, should encourage interaction, support emotional and social growth, and promote cognitive development. Who knew a simple toy could play such a significant role in your child’s overall well-being?

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Obesity Busters: Top Tips for Encouraging Healthy Eating in Children

Sabina — Wed, 04 Sep 2024 13:05:37 +0000

September marks “Childhood Obesity Awareness” month, making it the perfect time to focus on our children’s well-being. Parents and caregivers constantly hear about the importance of healthy eating. However, achieving this can be challenging, especially with long workdays and the convenience of fast food.

The American Academy of Paediatrics recently published guidelines for managing paediatric obesity, highlighting a significant concern: “The current and long-term health of 14.4 million children and adolescents is affected by obesity, making it one of the most common paediatric chronic diseases.”

Considering these alarming statistics, I spoke with Zhan Otto, a dietitian I have collaborated with for many years. She shared her top 10 tips for encouraging children to eat healthy foods. Here are her valuable insights:

Top 10 Tips for Promoting Healthy Eating in Children

1. Don’t Just Tell Them, Show Them

Children learn by observing adults, especially their parents. Demonstrating healthy eating behaviours is far more effective than simply giving verbal instructions.

2. Make Healthy Food Choices Fun

Create a “cake” using watermelon slices for dessert. Layer with low-fat frozen yoghurt and top with fresh cherries. This approach makes healthy eating enjoyable and visually appealing.

3. Use Animals as Physical Trainers

Young dogs love playing in the garden or park. Children will run around with them until they’re tired, often without even realising they’re exercising.

4. Limit Portions of Snacks and Processed Foods

Snack foods often have intense flavours that encourage overeating. They are also packed with calories. For example, one small box of Astro’s contains 822 kJ, which is the same as a small banana and 100g of natural low-fat yoghurt.

5. Create a ‘Favourites’ List

Teach each child to select one treat they enjoy and buy it in a small portion. Treats should be special and ideally saved for weekends. For example, choose a small Häagen-Dazs ice cream or a packet of crisps.

6. Make Food Fun with Colours, Shapes, and Textures

Prepare a large platter with a variety of colourful, healthy foods. Include raw vegetables, fruit slices, popcorn, chicken kebabs, baby potatoes, avocado dip, and small cubes of mozzarella. This variety makes meals more engaging for children.

7. Start Early: The Golden Window of Opportunity (6-24 Months)

Introduce a wide range of healthy, fresh, natural foods from the start of weaning. This approach gives children the best chance to grow up healthy, slim, and well-adjusted.

8. Create a Colour Competition Chart

Encourage each family member to track the number of different colours of plant foods they eat each day. Each portion should be at least ¼ cup. At the end of the week, the person with the most variety wins a non-food prize.

9. Avoid Using Snacks as Rewards

Instead of rewarding with food, consider activities or toys that promote learning or physical activity. For example, buy a stimulating game or fly a kite together. Frame these as “special treats” for weekends.

10. Fabulous Fibre: The Fat-Fighting Friend

Natural fibre-rich foods help maintain a healthy weight and promote overall well-being. Fibre controls blood glucose, creates a sense of fullness, regulates appetite, maintains gut health, and supports healthy colon function. Some high-fibre foods include apples or pears with skin, raw and cooked carrots, butter beans, lentils, brown rice, rolled oats, peas, cabbage, and broccoli.

Conclusion

Whenever I refer a patient to Zhan for weight management, I see children become more enthusiastic about healthy eating. They start to model their favourite sports stars and get involved in the kitchen. Zhan teaches both children and parents that healthy eating is not only vital for health but can also be fun.

About Zhan Otto

Zhan Otto is a registered dietitian with 25 years of experience in private practice. She works with both young and older patients in hospitals and at her office at Rochester Place. She enjoys yoga and cycling with her soon-to-be husband, Mike. Zhan practices what she preaches by leading a healthy lifestyle. She believes natural foods provide “divine design nutrients,” essential for the healthy growth and development of all children. She is dedicated to helping parents and caregivers make good nutrition practices a priority in the home. Introducing excellent nutrition habits to toddlers between 6 and 24 months offers a “golden window of opportunity” to set children on a path to a healthy, active lifestyle.

Zhan Otto
BSc (Dietetics) and Postgraduate Diploma in Hospital Dietetics (University of Pretoria)

Reference

American Academy of Paediatrics: Clinical Practice Guideline for the Evaluation of Paediatric Obesity

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Growth stunting and its effect on children

Sabina — Fri, 07 Jun 2024 11:39:14 +0000

Reading Time: 7 minutes

The World Health Organization (WHO) defines stunting as “the impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation.” BYY expert, paediatrician Dr. Maraschin, examines various scenarios where stunting could occur, its long-term effects, and measures to protect children from stunting.

Key Factors Contributing to Stunting

Impaired Growth

This occurs when a child’s height is significantly below the average for their age.

Impaired Development

This happens when a child fails to achieve developmental milestones like rolling over, sitting, and walking. It also includes delayed mental and social skills.

Poor Nutrition

Essential nutrients like protein, vitamins, and minerals are crucial for brain development, especially between weeks 24 to 42 of pregnancy and the first two years of life. Malnutrition can lead to long-term developmental issues. Factors like smoking during pregnancy also affect growth. After birth, rapid brain growth in the first two years makes proper nutrition critical.

Repeated Infection

Chronic illnesses such as asthma, diabetes, cystic fibrosis, coeliac disease, and heart disease can lead to stunting if poorly managed. Ill children may not eat well or absorb necessary nutrients.

Inadequate Psychosocial Stimulation

Physical, sensory, and emotional stimulation is vital, especially in the first 1,000 days. Children in neglectful environments, such as overcrowded orphanages, may not develop at the same rate as those receiving ample stimulation.

Child Growth Standards

Your child’s growth is monitored using the “Road to Health” book, which includes graphs for weight, height, and head circumference. Healthcare professionals plot your child’s growth against these standards at each visit. A stunted child will typically fall below the 3rd percentile.

Scenarios of Stunting

Baby A

At 18 months, Baby A was extremely small for her age, with weight and height below the 3rd percentile. Delayed introduction to solids led to severe malnutrition. With the help of an occupational therapist, dietician, and physiotherapist, Baby A improved significantly over six months.

Baby B

At 7 months, Baby B was the size of a newborn, suffering from severe vomiting due to Gastric Volvulus. After surgery and PEG feeding, Baby B showed slow but steady progress, although he had developmental delays due to early malnutrition.

Child C

At age 3, Child C experienced frequent diarrhoea, a sore tummy, and low energy levels. Tests confirmed coeliac disease. After eliminating gluten from her diet and working with a dietician, Child C’s symptoms improved, but she might not reach her full growth potential due to late diagnosis.

The Importance of Addressing Stunting

Stunting is a complex issue with many causes, including intrauterine growth restriction, growth hormone deficiencies, syndromes, and chromosomal abnormalities. Children with stunted growth can face lifelong consequences, including anxiety, low self-esteem, learning difficulties, and higher risks of chronic diseases. Early intervention and proper nutrition are crucial for reversing some effects of

stunting and helping children reach their full potential.

Conclusion

If you’re concerned about your child’s growth, trust your instincts. Proper nutrition and early intervention are key to ensuring your child’s healthy development. Remember, each child’s growth journey is unique, and providing the best support during pregnancy and childhood helps them achieve their potential.

References

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Mental health in children

Sabina — Thu, 04 Apr 2024 06:35:35 +0000

A young mind has the potential to develop into a masterpiece because of the experiences their significant adults provide. This would include love, reassurance, encouragement, and security etc. Today we’re talking about mental health in children.

In an article published by Harvard University’s Centre on the Developing Child, I came across this statement: “As early experiences shape the architecture of the developing brain, they also lay the foundations of sound mental health”. Wow! What an incredible picture this statement paints.

The American Association of Psychology explains that a child’s mental well-being is an essential part of a child’s overall health. Just like physical health, mental health will affect how your child thinks, feels, interacts and learns. Our precious children have personalities of their own. Some are shy and withdrawn, others are confident and boisterous, but each one of them will experience fear, anxiety and stress at certain times.

What is important is that we recognise what is age-appropriate and normal and how best to support the child when these feelings arise. The outcome of this insight will help support the architecture of the brain and improve mental well-being through adolescence and into adulthood.

Why do children experience anxiety?

Heightened levels of perceived danger: Fear and anxiety are part of a human’s defence mechanism. We have all heard of the “flight or fight “reaction when we perceive danger. This is a good thing as it often gets us out of difficult situations. In some people, however, this sense is extreme.

For example, one child may spot a spider in their room and simply ask someone to remove it before going to bed. An anxious child may scream and perform while the spider is being removed and then spend the night wide-eyed and terrified that the creature will return and cause serious harm.

Circumstances: Other times, circumstances may lead a child to develop anxiety. We saw a lot of this during COVID. Children were taught a lot about COVID, parents listened to devastating reports on the news, they heard of or may have even experienced a loss, and many families suffered financial difficulties. Any one of these factors, even outside of a pandemic, will cause anxiety and trauma in a young child.
Genetics: Research shows that children with a parent who suffers from an anxiety disorder are seven times more likely to have anxiety. An anxious parent is more likely to be overprotective and generate fear in children over certain activities. They may also model these behaviours in front of the child, and the child mimics the behaviour.

My mother was the overprotective type. In her world, I would fall out, break my neck and die. Needless to say, I never went near a tree for fear of death. Now, I believe that climbing a tree is a fabulous activity for a child to develop gross motor skills and motor planning and to get kids away from screens!

Social media: Social media is also a major cause of anxiety and depression among children. It is concerning that social platforms have an age restriction of 13 years. Yet, American statistics show that 40% of children 8 to 12 years old are on social media. Brain development is a critical factor to consider when handing a child a cell phone. Social media has been associated with changes in the amygdala, the part of the brain which is crucial for emotional learning and behaviour.

The prefrontal cortex is also affected. Its function is necessary for impulse control, social regulation and moderating behaviour. This means that your pre-teen and teen will be exposed to messages that may increase risk-taking, cause them to experience greater fluctuations in emotions than normal, and cause them to be negatively affected by information, thus damaging their self-worth.

Children aged 10 to 19 are undergoing a highly sensitive period of brain development. It is a time when mental health issues emerge, including depression. And as with anything, social media has both positive and negative aspects. It is up to parents to monitor usage and to recognise when their child is isolating themself from real social interaction.

Learning difficulties: Learning difficulties are also a major cause of anxiety. Children suffering from a learning difficulty or neurodiverse condition like ADHD or autism will develop anxiety if they do not receive the correct support.
Bullying: Please never underestimate the effects of bullying on a child’s anxiety level. It is hard for us to imagine having to go into a situation where we are likely to be physically or emotionally hurt. A child may have to go to school day after day and be confronted with a bully at each break. If bullying continues, it will affect a child into adulthood.

What is considered normal in terms of fears and anxiety?

Between the ages of six months and around three years, it’s widespread for a child to experience separation anxiety. I call this “Mommylitis”. The child becomes clingy and cries when they need to separate from the parent or carers. It’s a very normal stage of a child’s development and usually stops around 2 to 3 years of age.
Pre-schoolers may develop specific fears or phobias, like certain animals; the neighbour’s dog, thunder, blood, the dark, insects, water and the doctor are all common. These fears gradually improve on their own with the reassurance of adults and maturity.
As children get older, their anxiety and fears shift. A toddler may be terrified of the noise the toilet makes when it flushes for fear that a monster is in the tank. An older child begins to worry about real-life issues like natural disasters, not making friends, death or illness. This kind of anxiety spikes around the age of 7 or 8 when children begin to understand their world better and realise that many things cannot be controlled.

My own daughter had just such an experience. While away on a school camp, one of her classmates lost a sibling. For her, going to school camp became a massive issue in case something happened to a family member while she was away. We couldn’t tell her it wouldn’t happen. She had seen that it could happen. It was out of her control. She had to attend camp, with the understanding of the teachers about her anxiety and be allowed to make contact with us, if necessary, to overcome her fear.

How can I tell if my child is suffering from anxiety?

Young children are not able to verbalise how they are feeling, and this makes it difficult for adults to identify anxiety. Generally, these children will display feelings through behaviour. These behaviours often include:

Irritability
Being tearful or clingy
Increased difficulty with separating
Outbursts or tantrums
Aggression
Difficulty falling asleep or frequently waking
Night terrors
Bedwetting

Anxiety in older children presents slightly differently. These signs include:

Tummy ache
Nausea and vomiting
Headaches
Fingerpicking
Concentration issues (often diagnosed as ADHD)
Sleeping or eating problems
Reluctance to try new things
Negative thoughts
Fatigue
Avoiding social activities like parties, play dates and so on
Frequent visits to the school nurse with complaints of illness

How can I help my child with anxiety?

There are some dos and don’ts that will help a child who is suffering from an acceptable amount of anxiety:

Your aim isn’t to remove the anxiety but rather to teach your child to manage their response – nobody likes to see our children anxious, but we can’t remove all triggers. Instead, we help the child tolerate the anxiety and function as well as they can.

My daughter was timid and really struggled to be among strangers. On a Thursday, the librarian at Sandton Library used to read stories to children. My daughter loved the stories, but the minute she arrived at the library, she would want to leave because of the sea of new faces. Initially, my wife would sit on the carpet with her but, over time, could retreat to the chairs at the back of the room along with the other parents. My daughter has fond memories of those afternoons.

Don’t avoid situations that make your child anxious – if you allow them to avoid things that make them anxious, it may help in the short term. But, over time, it will reinforce the anxiety. They will learn that the only coping mechanism for anxiety is running away, and we, as adults, know that we can’t always avoid situations that cause us stress. My daughter learned that just like her, the other children were eager to hear the stories at the library, and actually sitting with new friends was such fun.
Think about the language you use. As a paediatrician, I unfortunately have to do things that children don’t like and create anxiety. Checking their throats, putting up a drip or taking blood are very unpleasant. The most important thing is for me to develop trust with my patients.

I need to talk to the child, interact with them, and let them know I am helping. The language I use and that the parent uses is really important. It is what we call focus language. I tell the child, “Dr Rico needs to look in your throat. I know you don’t like the stick, but Mommy can hold you, and I will look to see what is making you sore, or if you prefer, you can lie down on the cushion”.

The language needs to be age-appropriate; if the carer reiterates what I have said, the child accepts it, and we get the job done quickly. The child knows what I am doing and also has a choice in how. The carer doesn’t play down the feelings or force the child; they reassure.

Express your belief in them managing difficult situations. “I know you are a little scared about show and tell, but I am sure the other children will be very interested. Once you start telling them, you won’t feel so scared anymore.” Discussions like this don’t deny that your child is anxious, but lets them know you believe in them and know they can manage.
Don’t fuel the anxiety but respect the feeling. You do need to understand your child’s anxiety, but it doesn’t mean you have to agree: “I hear you; you don’t want to go swimming, but swimming is something all children need to learn. The teacher will be in the pool with you, and I will also be with you”.
Engage in activities that reduce stress. Mindfulness (3 3 3 rule for anxiety. Tell me 3 things you can see; tell me 3 things you can hear; tell me 3 things you can feel), breathing exercises, meditation, visualisation, creativity, journaling, physical activity, and talking about feelings are all activities and tools that you can do with your child in order to teach new skills when anxiety strikes. Once the child is distracted from the anxiety, he or she will feel better. Your child will learn how to control the feelings for themselves.

If I have tried all these techniques and nothing helps, what then?

As we have said, it is normal for children to have little fears, but in most cases, the anxiety fades with positive experiences and maturity. However, for around 9% of children aged 3 to 17 years, regardless of the parenting and positive experience, the anxiety intensifies. These children most probably suffer from an anxiety disorder.

There are several disorders. These are the most common:

Generalised anxiety disorder (GAD) – Children with this disorder worry excessively about everyday things and often talk themselves into a worst-case scenario situation.
Social anxiety disorder – These children have a fear of meeting people or having to talk to people. They usually worry about embarrassing themselves or being judged negatively. They may try to avoid school or social situations and, when forced, are likely to throw a tantrum.
Selective mutism – A child with this condition may happily speak at home but cannot talk to peers, teachers or other people in authority. The condition creates terrible anxiety as the child won’t be able to ask for simple things like going to the bathroom.
Separation anxiety disorder – We have all experienced those awful days when your child literally needs to be peeled off you to go to class. When you call 10 minutes later, the child has forgotten all about you and is having loads of fun. There are other children where the anxiety continues, and they believe that something dreadful has happened. They cannot be cared for by adults other than a parent.
Obsessive Compulsive Disorder (OCD) – These children tend to perform repetitive rituals in an attempt to control their anxiety and make it go away. These children may wash their hands repetitively, lock and unlock doors, ask the same question repeatedly, and often try to get the carer to participate in their ritual.

All of these conditions require medical intervention to help control the anxiety and to teach the child new coping skills. There are so many things which can be done for the anxious child. However, if anxiety goes untreated, it will affect the child’s schooling, result in your child missing important experiences, and place your child at a higher risk for substance abuse. No parent ever wants this for their child.

Please note that your child can also be excessively anxious but could disguise it so it may not be obvious to you. If you suspect anxiety exists, please consult a mental health professional for an assessment.

Anxiety in children is one of the most treatable disorders in psychology. This is excellent news for us all. What I would like to stress is that you, as the parent, have to see anxiety in the same way as you would an ear infection. If your child is tugging at the ear, crying, or complaining of ear pain, you take the child to the doctor for treatment. The same goes for anxiety. Don’t be afraid of the diagnosis. Denial will not make things better.

Parents may find it difficult to accept the possibility of some mental disorder. We need to get past this stigma if we are to build a strong, resilient child. The architecture needs to be sound so that the child can flourish in a stressful world. If you were worried enough to seek advice, you most likely have read the signs already. Be it anxiety, ADHD, autism or any other mental health issue, remember that there is so much help available if you are open to it. Be the gateway to your child’s psychological and physical well-being.

References:

https://www.cdc.gov/childrensmentalhealth/depression.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9650927/
https://www.cdc.gov/childrensmentalhealth/features/anxiety-depression-children.html
https://www.jaacap.org/article/S0890-8567(20)30280-X/fulltext
https://www.thecarlatreport.com/articles/3678-treating-anxiety-disorders-in-children-the-new-aacap-clinical-practice-guideline
https://wohum.org/understanding-anxiety-in-children-signs-and-symptoms
https://www.apa.org/topics/children/mental-health
https://www.youngminds.org.uk/parent/parents-a-z-mental-health-guide/anxiety/

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When baby should start wearing shoes

Sabina — Mon, 11 Mar 2024 06:11:42 +0000

Reading Time: 5 minutes

“When should my baby start wearing shoes?” This question has popped up in many consultations recently and so let’s address when your baby should start wearing shoes and which are best?

My children loved the book Two Shoes, New Shoes by Shirley Hughes. There are certainly some significant considerations when deciding on shoes. These go beyond cuteness and fashion.

The importance of barefoot

I have to say that there is absolutely nothing more adorable than those little, fat feet that demand kisses. Over and above the cuteness factor, these little feet contain a considerable number of nerves. These nerves send critical messages from the environment to the brain.

Babies learn to walk from about 9 months to 18 months. From early on, they experience movement when they crawl, shuffle on their bottoms, pull themselves to standing and start cruising around the furniture. In doing so, they begin to experience different pressure under their feet. The pressure and movement strengthen the muscles and ligaments, giving the baby greater stability on their feet.

This pressure felt under the foot spreads across the soles of the feet and activates the nerves that feed information to the brain. These nerve endings are called proprioceptors and send signals to the brain and allow your baby to be aware of motion and their position in relation to the space around them. Proprioception is part of the sensory system.

The vestibular system also forms part of the sensory system and is responsible for balance and coordination. The development of these senses is hugely influenced by the sensory input your baby receives through their feet. This is especially true during the first couple of years of life, from birth to childhood.

By now, I am sure you are seeing where this is going. Babies need to feel the pressure under their feet to achieve this significant milestone. Shoes may interfere with muscle development and the experience of pressure under the feet, thereby negatively affecting walking and other essential cognitive development.

Being barefoot has many benefits over and above the ones mentioned above. These include:

Improved motor skills – A child with good proprioception and vestibular sense will have greater confidence in their body, impacting physical, emotional and learning skills. These systems ensure good balance, eye-hand coordination and muscle tone. These are essential for both gross and fine motor skills.
Good gait – Gait refers to the way we walk. Going barefoot allows the ligaments and muscles in the foot to strengthen and distribute body weight evenly through both feet. This ensures that your child is able to walk correctly.
Prevents injury – Children allowed to go barefoot develop a strong sense of awareness through their feet. A bare foot will easily detect a sharp object that could cut or a slippery surface that may cause the child to fall. Being barefoot engages the arch of the foot.

This strengthens the ankles and leg muscles, making injuries like a twisted ankle less likely. Children that go barefoot tend to develop wider feet and strong muscles. This helps with the stability of many joints, including knees, hips and ankles, making injuries later in life less of an issue.

A time and place for shoes

If you are concerned that your baby’s feet are getting cold, socks or babygrows with rubber grips keep the toes warm and protect the little feet without restricting any digits. All the research agrees that a child should not wear shoes before walking.

If shoes are required, then it is essential to remember that these little feet are very different from adult feet. Until 6 months, the feet are predominantly cartilage with 22 partially developed bones which ossify to become 26 bones in the adult foot. A little fat pad covers the arch of the foot, making the foot appear flat. This is absolutely normal up to the age of 18 months.

Some children may have flat feet up until the age of 6 years, and unless they are experiencing pain, no corrective shoes should be worn. The bones in the feet are soft and pliable and don’t harden until the child is about 5 years old. It is only around the age of 18 years that the foot is fully matured. Obviously, there will be plenty of times where a child simply has to wear shoes. If you are going into a space like a shop, a playground, a school or onto a hot road, shoes will be necessary.

Criteria for choosing shoes

To quote from a podiatry journal, “In generations past, podiatrists believed that the inflexible support of high-topped shoes helped kids’ feet maintain optimal position and stability. Over the years, though, children’s podiatry specialists began to recognize that the bones in baby feet are pliable and do not sufficiently harden until four to five years of age.

Wearing rigid shoes over extended periods before the bones are fully fortified can negatively impact your child’s development. Another concern is in the process of learning to walk. Baby shoes clearly add weight to the feet and increase the likelihood and frequency of tripping and falling. Yes, these shoes are cute, but the proper growth and development of the feet should be first priority.”

What you need to look for when buying child’s shoes:

Wide toe box

When you stand barefoot, your toes actually splay out. This means that shoes should have enough room so that the toes aren’t squashed together. Get your child to stand up and then check the distance from the toe to the end of the shoe. A good guide is that there should be about 1,25cm between the longest toe and end of the shoe. This is about a thumb width. There should be at least 5mm space between all toes and the rim of the shoe.
Closed toes

When the toes are open, your child is more likely to trip or stub their little toes.
Lightweight material

Heavy, chunky material makes the shoes heavy and may put strain on the growing muscles.
Protective flexible sole

The aim of the shoe is to protect your child’s feet from being hurt by objects in the environment. These include sticks, glass and stones. At the same time, the sole needs to be flexible enough for your child to feel any changes in the surface they are walking on. Remember how important it is for your child to receive signals through their soles. The feedback they receive is important for proprioception. It also teaches your child to walk differently on different surfaces and helps to strengthen the muscles of the feet and ankles.
Firm but flexible heel

The heel of your foot ensures that the foot is in the correct position for walking. A very flimsy heel doesn’t provide any support, but a rigid heel may lead to abnormal heel positioning. You are looking for a heel that can be compressed slightly when you pinch it.
Velcro or adjustable straps

We spoke about the little fat pad. This can mean your toddler’s feet are thinner or fatter than the next child’s. These straps allow you to adjust the shoe to fit your child’s foot. It also helps your child become more independent because they can open the straps easily and remove their shoes when necessary.

I love it when nature knows best, and this certainly goes for the advantages of going barefoot rather than wearing shoes. Thankfully, our South African climate allows lots of outdoor activity and opportunities to experience so much while barefoot.

The benefits are enormous, but a time and place does come for us to put those new shoes onto our toddler’s feet. When you do have to do this, remember that your child’s feet are critical to motor development and a host of other important functions. Forget fashion and do your homework on the shoes you choose. It really is an important decision.

References

https://pubmed.ncbi.nlm.nih.gov/32404124/
https://my.clevelandclinic.org/health/body/21597-foot-ligaments
https://acpodiatry.com.au/development-of-childrens-feet/#:~:text=Children’s%20feet%20differ%20from%20those,the%20bones%20have%20fully%20matured.
https://kidsplus.com/parent-resources/doctors-notes/flat-feet/
https://www.footdoc.org/blog/what-to-watch-for-when-your-baby-learns-to-walk.
https://www.researchgate.net/publication/366922136_What_Happens_to_Babies’_Feet_When_They_Are_Learning_to_Walk
https://www.attipas.com.au/pages/being-barefoot-benefits-brain-development-
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6487054/

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The power of protein

Sabina — Sat, 08 Jul 2023 09:29:46 +0000

Reading Time: 4 minutes

Proteins are critical for many functions in the body. Dr Enrico Marashin breaks down why it’s essential that we ensure our kids get enough of it and how to do it.

When we talk about proteins, people usually think of building muscles, but over and above this, proteins regulate many body processes, enable the body to repair tissue, balance fluids, help with immunity, provide energy and are the building blocks for hair, bones, enzymes, skin and blood. Children who do not get sufficient protein often present with issues such as fatigue, slowed growth, joint pain, delayed healing and poor immunity. Small changes to the diet can make a massive difference in the health of your child.

A colleague recently commented, “There is no such thing as junk food. There is only junk or food”. I hadn’t heard this phrase before, but I absolutely agree. At this stage, I can almost hear parents groaning and saying that the only protein their child will eat is a chicken nugget.

We, the adults, the gatekeepers to our children’s health, must change this. No, it’s not easy, and it will come with resistance, but if we keep in mind that proper nutrition impacts your child’s physical and cognitive development and directly affects your child’s ability to learn, then our efforts will be worth it. My own son was a very difficult eater with loads of sensory issues, so I am really not sitting in the judgement seat. It’s tough, but we have to get it right.

How do I know what the protein requirements are for my child?

While your baby is still small, they will get enough protein from milk. The struggle usually comes in with our two- to three-year-olds. Naturally, these little ones assert their independence and often do this with food. Over and above this, they are usually much too busy to sit down and chew a lump of meat. The trick is being creative with finger foods by using exciting shapes and textures. Meat products can be cumbersome for a toddler to chew, so meatballs, shredded meat done in a slow cooker, diced chicken or steamed fish are great options.

So how much is enough?

Baby’s 7 months to 1 year: approximately 11g’s per day (teeth are not a prerequisite for protein. Those little gums can chew on soft proteins)
Toddlers approximately: 13g’s per day
School going children: approximately 19g’s per day

How do these recommendations translate into food?

FOOD	SERVING SIZE	PROTEIN CONTENT
Milk	1 cup (240mls)	8 grams
Egg	1 whole	6 grams
Yoghurt	I cup	8 grams
Peanut butter	2 tablespoons	8 grams
Assorted nuts	½ cup	8 grams
Cottage Cheese	100g	11 grams
Chicken breast	100g	31 grams
Lean mince	100g	20.8 grams
Ostrich	100g	28 grams
Salmon	100g	22 grams
Hake	100g	17 grams
Lamb chop	100g	25 grams
Pork loin	100g	27 grams
Edamame beans	½ cup	9 grams
Lentils	½ cup	8 grams
Black beans	½ cup	8 grams
Cannellini Beans	½ cup	8 grams
Chickpeas	½ cup	7 grams
Green peas	½ cup	4 grams
Spinach	1 cup	6 grams

What would this look like on a child’s plate?

I like the tool “My plate”. You can Google this on myplate.gov. Once you click on the various items on the “plate”, you can explore food ideas and meal prep depending on the food category

MY PLATE

https://www.myplate.gov/eat-healthy/what-is-myplate

Your child will need two to three portions of protein throughout the day. This includes healthy snacks. If we understand this, getting our poppets to eat the recommended amount of protein shouldn’t be such a struggle. A teaspoon of (sugar-free) peanut butter added to porridge (2 grams protein), a mid-morning snack could be a cracker with some cottage cheese (about 3 grams). You see, we haven’t even eaten our main meal but have been able to include 5 grams of protein. This is just 8 grams of what a toddler needs for the day. Now, a little bit of cottage pie with some green peas or a thumb size piece of chicken equates to 8 grams of protein, and you’ve done it! I am sure you are more creative than I am, but you see how this can be achieved without a struggle at mealtimes.

What if we are vegetarian?

The table above shows that it is far easier to achieve protein requirements from meat. Many of my vegetarian patients do struggle with the protein element of the diet. We often note that these children fall on the lower percentiles for weight, especially amongst the Indian population group. From my understanding, Indian diets are cereal-based, making adequate protein difficult but not impossible. It is really important that milk, curds, cheese and eggs are included in the diet where possible. If these items do not form part of the diet, parents must pay particular attention to the pulses that provide adequate protein. These children may require an iron supplement as well.

I found an article written by the Cuddles Foundation in 2021. The Cuddle Foundation is a non-profit organisation in India that helps children fight cancer with holistic nutrition. The article reports that many Indian children are underweight and short in stature. I liked that the article provides some lovely ideas for enhancing traditional dishes with proteins. For example, just looking at the suggestions of adding chickpea hummus to a roti or pureed paneer to a sandwich sounds delicious and certainly boosts the protein content.

Our modern lifestyles and work demands make it challenging to go to war with a child that is resistant to variety. But, on the flip side, we need to be aware of the effects of poor nutrition on children. The consequences are severe and can be autoimmune diseases, immune deficiencies, joint issues, and the list goes on. So it really is worth persevering.

There are so many sites that make meal preparation a joy with wonderful ideas of how to use protein-rich foods in a delicious meal. If you’re struggling, consider consulting a dietician. If you find that your child avoids foods, occupational therapists can work with your child and make eating a more pleasant experience for the entire family. Protein is critical in your child’s diet, but the good news is your child doesn’t need a huge amount. Some minor adjustments and some creativity could change the health path of your child.

References:

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