Category: Development

Why is playing important for my child?

[mme_highlight]Play is essential for children, contributing to the cognitive, physical, social development as well as for their emotional and general well-being. Playing benefits are numerous: it develops creativity, motor skills, intelligence, helps build confidence and coping with challenges, allows group work, improves physical activity and general health.[/mme_highlight]

Play is essential for children, contributing to the cognitive, physical, social development as well as for their emotional and general well-being. The importance of playing for an optimal development children is reflected in the recognition by the United Nations High Commission for Human Rights of playing as a right of every child.
In addition, playing time is an invaluable opportunity for parents to engage with their children and take advantage of quality family moments. However, it seems that nowadays, free time “just” for playing is shortening and getting lost in the daily routine and highly driven schedule of activities some children have since young age.

What are the benefits of playing?

Develops creativity

While playing, children use their creativity and imagination which boosts cognitive achievement.

Develops motor skills

Fine motor skills and dexterity are needed and developed while playing.

Develops intelligence

Playing contributes to a healthy brain development, because through play children engage and interact with the world around them.

Helps build confidence and to cope with challenges.

Through play, children can explore a world they can master at their own pace, dealing with fears and challenges and enhancing confidence and resiliency.

Group work

When children play with peers, they have to integrate in a group, make decisions and follow rules, share, solve conflicts and defend their points of view.

Physical activity and health

It is also fundamental that parents and caregivers understand that passive entertainment has nothing to do with play. Play implies movement and, thus, helps building healthier chidren’s body. It has been suggested that encouraging children’s “free” (unstructured)  play may be a good  way to increase physical activity, which may be a part of the resolution of the obesity epidemic in children.

Way of expression

Children with more difficulties to express themselves verbally may find in play a way of expressing their views, experiences and fears. This gives parents a good opportunity to get to know these children better.

School readiness and integration

Playing helps the child to adjust to school and enhances children’s readiness to read as well as their problem-solving skills.

Note that it is ideal to find a balance between “free” children play and playing time controlled by adults. The latter is also important, but if the play time controlled by adults predominates, children follow adult rules and share their concerns and many of the above cited benefits get lost, particularly those related to skills of independent thinking and group work.

[mme_databox]

Playing vs. watching T.V. among children – weekly totals

	Playing	Watching TV
Weekly total	7h28m	13h37m
Percentage of week time	4.46%	8.04%

[/mme_databox]

Less time for play – what are the harms?

As stated above, children need time for free play, which has been markedly reduced in the past years due to lifestyle factors and excessive time devoted to academics or extra-school activities. A survey conducted by the National Association of Elementary School Principals found, in 1989, that 96% of schools had at least 1 recess period.
A decade later this percentage fell to 70%, including kindergarten, which is preoccupying. In fact, although many children excel with a highly driven schedule, for some such a hurried lifestyle can be a source of stress and anxiety and may even contribute to depression.

Future as an adult is many times being prepared at the cost of childhood development. Although one can understand parents’ worries in the competitive world of nowadays, less time to be a child can compromise the later adulthood.

Undoubtedly, the participation in organized activities enriches kids’ knowledge and promotes different skills; quantity has to be moderated, meaning that the majority of parent-child time should not be spent arranging activities and transporting children from one to another.

[mme_databox]

Playing – weekly totals in hours in different age groups (U.S. survey)

	5-11 years	12-14 years	15-18 years
0 hours	8%	36%	51%
0-5 hours	21%	17%	16%
5-10 hours	26%	32%	23%
10-15 hours	21%	6%	4%
15-20 hours	11%	4%	2%
>20 hours	13%	5%	4%

[/mme_databox]

Summary and Recommendations

• Play is essential for children, contributing to the cognitive, physical, social development as well as for their emotional and general well-being.
• The importance of playing is reflected in the recognition of playing by the United Nations High Commission for Human Rights as a right of every child.
• It is through play that much of early children’s learning is acquired.
• Playing benefits are numerous: it develops creativity, motor skills, intelligence, helps build confidence and coping with challenges, allows group work, improves physical activity and general health. Play can also be viewed as way of expression, particularly in less verbal children, and improves school readiness and integration.
• Nowadays, many children have schedules fulfilled with too many academic or organized activities leaving almost no time for playing since young age, which should be a motif of concern for parents, educators and health care providers.

[mme_references]
References

• Office of the United Nations High Commissioner for Human Rights. Convention on the Rights of the Child. General Assembly Resolution 44/25 of 20 November 1989
• Ginsburg KR; American Academy of Pediatrics Committee on Communications;  The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics. 2007 Jan;119(1):182-91.
• Mahoney JL, Harris AL, Eccles JS. Organized activity participation, positive youth development, and the over-scheduling hypothesis. Soc Policy Rep. 2006;20:1–31.
• Pellegrini AD. Recess: Its Role in Education and Development. Mahwah, NJ: Erlbaum Associates; 2005.

[/mme_references]

Why do kids enjoy playing?

[mme_highlight] Although social play is an amusing activity, its apparent lack of a goal other than having fun is actually fallacious. One of the most prominent characteristics of social play seems to be its high reward value. It seems to be consensual that social play, rather than other social behaviors unrelated to play, is regulated by opioid systems.  [/mme_highlight]

Play is essential for children, contributing to the cognitive, physical, social development as well as for their emotional and general well-being. The importance of playing for an optimal development children is reflected in the recognition by the United Nations High Commission for Human Rights of playing as a right of every child.

In short, social play is fun. But what explains why kids’ like so much playing? Most research in the subject has been done with animals. Like human children, most young mammals devote a significant amount of time and energy playing together. One of the most prominent characteristics of social play seems to be its high reward value.

What’s the point in playing?

In fact, although social play is an amusing activity, its apparent lack of a goal other than having fun is actually fallacious. Generally talking, playing has many benefits like developing creativity, motor skills and intelligence, helping build confidence and coping with challenges, allowing group work as well as improving physical activity and general health.

Play, being a pleasant activity, leads to the release of substances in the brain that convey a sensation of reward and happiness which is beneficial itself and also in the sense that it makes children take more advantages of the benefits of play for cognitive, motor and social development.
In fact, the neurotransmitter systems in brain implicated in the motivational, pleasurable and cognitive aspects of reward, such as opioids, endocannabinoids, dopamine and noradrenaline, modulate the performance of social play.

In addition, social play helps reduce stress and is a way of maintaining group cohesion.

How much do children enjoy playing?

With the goal to develop physical activity interventions to prevent the excess weight gain in children, a team of investigators, including Howe CA, developed a study to measure the energy expenditure and enjoyment of some children’s games. A list of 30 children’s games was created from previous intervention studies. Children’s enjoyment concerning each game was indicated by pointing to the appropriate facial expression on the Facial Affective Scale (FAS), a 9-point Likert scale of facial expressions ranging from happy to sad. Total medium scores are presented in the box below.

The 5 most appreciated playing games by the children included in the study were:

• Stop and Go: Two teams have their own end zone at opposite ends of the play area and the goal is that players pass the ball (either basketball or football) to reach the end zone, but they cannot move while they are in possession of the ball.
• Dragon’s Tail: Children have scarves in their back pocket (“dragon tail”) and have to steal other kids’ scarves while protecting theirs; if a scarf is they had to complete a task before returning to the game.
• Capture the Flag: The goal of this game is to avoid being tagged in the opposite team area while trying to find and capture their flag.
• Monkey in the middle: five children, one in the middle (“monkey”) and one ball. The goal is to prevent the monkey from intercepting a pass; when this happens, the monkey must switch places with the thrower.
• Sharks and Minnows: one or two sharks tag minnows while they attempt to cross the ocean; last minnow(s) becomes next shark(s).

[mme_databox]
Enjoyment by game (from higher to lower ratings, with standard deviation)

Game	Enjoyment (FAS score)
Stop and Go	8.4 +/- 0.6
Dragon’s Tail	8.3 +/- 0.6
Capture the Flag	8.2 +/- 0.6
Monkey in the middle	8.2 +/- 0.6
Sharks and Minnows	8.1 +/- 0.6
Pirate´s treasure	7.9 +/- 0.6
Can´t touch this	7.8 +/- 0.6
Crazy soccer	7.8 +/- 0.6
Fox and Hound	7.7 +/- 0.6
Hibernation	7.6 +/- 0.6
Couple Tag	7.5 +/- 0.6
Steal the bacon	7.5 +/- 0.6
Barker’s Hoopk	7.1 +/- 0.6
Clean your room	7.1 +/- 0.6
Fitness Tag	7.1 +/- 0.6
Treadmill	7.1 +/- 0.6
Crowns and Cranes	7.0 +/- 0.6
Eagles and Sparrows	7.0 +/- 0.6
Great escape	7.0 +/- 0.6
Hot spot	7.0 +/- 0.6
I’m a new skunk	7.0 +/- 0.6
Builders and Bulldozers	6.8 +/- 0.6
Computer virus	6.7 +/- 0.6
Mini kick ball	6.6 +/- 0.6
Dribblers and Strooters	6.5 +/- 0.6
Cardio course	6.4 +/- 0.6
Castles	6.3 +/- 0.6
Domino Relay	5.9 +/- 0.6
Race Day	5.7 +/- 0.6
Blob Relay	5.3 +/- 0.6
Pass the hat	4.2 +/- 0.6

[/mme_databox]

What happens in the brain during playing?

It is not easy to explain, and even the existing evidence needs further support from studies. As the majority of studies include animals, one has to assume the very likely similarity of humans regarding play behavior in order to interpret results. It seems to be consensual that social play, rather than other social behaviors unrelated to play, is regulated by opioid systems.

With the goal of understanding the brain sites at which opioids affect social play, Vanderschuren LJMJ and colleagues investigated the question with an in vivo autoradiographic procedure o measure changes in brain opioid receptor binding after social play behavior in rats. These changes, which occurred to the opioid receptor binding, are likely to be due to the release of endogenous opioids (produced by the brain).

Interesting significant results were found because of the effect of social playing mainly in two brain locations: the paraventricular nucleus, located in the hypothalamus (a region responsible by the release of many hormones and involved in the control of some behaviors.); the paratenial nucleus, located in the thalamus (region that relays informations to the cerebral cortex and also regulates consciousness).
As shown in the box below, when social play happened, binding to the receptors was increased in the paraventricular hypothalamic nucleus, irrespective of duration of social isolation preceding the test. In the paratenial thalamic nucleus, social play decreased opioid receptor binding, in line with other research and supporting an important role for this region concerning the regulation of social play behavior by opioids.

[mme_databox]

Effect of social play on opioid receptor binding in rat’s brain after social isolation   0h of social  isolation 3.5h of social isolation 24h of social isolation   Play No play Play No play Play No play Paraventricular Nucleus 74.5 +/-1.6 64.2 +/-3.0 73.6 +/-2.0 68.2 +/-3.0 68.8 +/-1.6 64.4 +/-3.4 Paratenial Nucleus 69.7 +/-0.9 72.3 +/-1.0 71.8 +/-1.4 69.8 +/-0.5 68.5 +/-1.3 73.8 +/-1.2

[/mme_databox]

Summary and Recommendations

• Play is essential for children, contributing to the cognitive, physical, social development as well as for their emotional and general well-being.
• Children do not play “just for fun”. It is known that reward mechanisms conveyed by neurotransmitters in brain are involved.
• The main neurotransmitters research has investigated are opioids, endocannabinoids and dopamine.
• Most research has been doing in mammals, since these, like human children, devote a significant amount of time and energy playing together. It is still intriguing what exactly happens in children’s brains while playing. More research is

[mme_references]
References

1. Office of the United Nations High Commissioner for Human Rights. Convention on the Rights of the Child. General Assembly Resolution 44/25 of 20 November 1989

• Ginsburg KR; American Academy of Pediatrics Committee on Communications;  The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics. 2007 Jan;119(1):182-91.
• Trezza V, Baarendse PJ, Vanderschuren LJ. Thepleasures of play: pharmacological insights into social reward mechanisms. Trends Pharmacol Sci. 2010 Oct;31(10):463-9.
• HoweCA, Freedson PS, Feldman HA, Osganian SK. Energy expenditure and enjoyment of common children’s games in a simulated free-play environment. J Pediatr. 2010 Dec;157(6):936-942.e1-2.

[/mme_references]

What should I know about Toilet Training?

[mme_highlight] Toilet training is a milestone in children development and for many parents it is a challenge. You should look for signs in your child which may indicate she/he is ready for toilet training. Do not push your child into potty training. Give positive reinforcement and rewards for each step completed in the process. [mme_highlight]

Toilet training is a milestone in children development and for many parents it is a challenge with difficulties in the way. Knowing if a child is ready to initiate toilet training and doing it with the required time and patience are not always easy to balance. The ultimate goal is a positive toilet training experience without punishment or too much pressure both for children and parents.

When should Toilet training be initiated?

There is no right or specific time to begin toilet training. However, there has been consensus that it the period between 18 months and 2.5 years seems the most adequate. There has been a major change in toilet training in the last 60 years.
The data shown below is from a population survey and indicates that the age at which toilet training began has been significantly postponed, suggesting more awareness and information on this subject among parents and caregivers.

[mme_databox]

Population Survey on Toilet Training

“When did you begin toilet training (TT) your child?”
Respondents were divided into groups by age:
Group 1: > 60 years of age; Group 2: 40 to 60 years of age; Group 3: < 40 years of age.

	Group 1	Group 2	Group 3
Daytime TT < 18 months	88%	50%	22%
Nightime TT < 18 months	43%	13%	5%

(Belgium Survey – 812 replies completed by 320 people)
[/mme_databox]

How do I know if my child is ready for toilet training?

To know if your child is ready to begin toilet training, the best option is to seek medical advice. Your health care provider will help you understand this, according to the achievements of your child regarding the other developmental milestones.

You should look for signs in your child which may indicate she/he is ready for toilet training:

• If your child walks confidently;
• If your child tries to imitate other people’s behavior;
• If your child starts trying to express the need to go to the bathroom;
• If your child is able to pull down and pull up pants and clothes;
• If your child starts being more independent;
• If your child shows direct interest in toilet training.

Parents have their role in influencing their children’s readiness for toilet training, not forcing or pushing their children directly into it, but giving encouragement and positive reinforcement. In addition, parents should find the right time both for them and children. Moments of changes or new milestones in life are not recommended to initiate toilet training (eg., moving into a new house, enrolling a new school, having a sibling).

What can I do to make toilet training easier?

Articulation between parents and caregivers

First of all, toilet training should be a commitment, not only for parents but also integrating the other caregivers or family members with whom children stays during the day. It is important that everyone is on the same page regarding potty training.

A pleasant moment

Parents should try to transform the moment for toilet training into a pleasant experience. If you can, let your child choose the potty in the store and make all the efforts so that she/he feels the potty is her/his propriety.
The color of it should be appealing and you may let your child put some stickers on it as a reward after that moment of toilet training is finished, as a reward for being on potty, even if there is not urine or stools in it.
You may put the potty wherever the child feels more comfortable in the house. Another tip is to put the potty next to you when you are using the bathroom, which can motivate your child to imitate you.

The correct time

Try to do toilet training at times with higher probability of bowel movements: when the child awakes or after meals.

The sequence matters

Try to make clear to your child that toilet training obeys a sequence, which you too should demonstrate: going to the toilet, undressing, wiping, dressing, flushing and, finally, washing hands. Note also that the flushing sound may frighten some children; make a joke of it, like saying “bye bye”.

The appropriate diet

During toilet training, you should pay closer attention to your child’s diet, which should be high in fiber. This will help soften stools. Hard stools are generally painful and difficult to pass, which can be a step backwards in toilet training.

Take your time

You can start toilet training with the child sitting in the potty dressed; parents can then put the stools from the diaper to the potty, to show children where it should be. Progressively, put your child undressed in the potty.

In addition, if pressure rises for both sides, it is wise to stop potty training for a while, like 2 to 3 months.

When will toilet training be completed?

Each child is different, but generally boys take longer. By 36 months the majority of children present daytime continence.

[mme_databox]

Achievement of Continence by Children (United States)

• 26% achieve daytime continence by 24 months
• 85% achieve daytime continence by 30 months
• 98% achieve daytime continence by 36 months

[/mme_databox]

Summary and Recommendations

• Toilet training is an important developmental milestone.
• Before starting toilet training, assess your child’s readiness; your doctor may help you in this.
• Do not push your child into potty training. Give positive reinforcement and rewards for each step completed in the process.
• The success of toilet training is not related with your child’s intelligence or character (do not think your child is lazy just because she/he is taking a while to learn toilet training).
• If your child is older than 7 years old and has not achieved continence, seek for medical help.

[mme_references]
References

1. American Academy of Pediatrics.Toilet Training. Guidelines for Parents. Elk Grove Village, Il: AAP; 1998.
2. Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics. Pediatrics 1999;103:1359-61.
3. Brazelton TB. A child-oriented approach to toilet training. 1962;29:121–128.
4. Bakker E, Wyndaele JJ. Changes in the toilet training of children during the last 60 years: the cause of an increase in lower urinary tract dysfunction? BJU Int 2000; 86:248.
5. Horn IB, Brenner R, Rao M, Cheng TL. Beliefs about the appropriate age for initiating toilet training: are there racial and socioeconomic differences? J Pediatr 2006; 149:165.
6. Parker, S, Sices, L. Toilet training. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn, M, Zuckerman, B, Caronna, EB (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.393.

[/mme_references]

What should I know about children daytime wetting?

[mme_highlight] Daytime wetting is generally self-limited and in most cases benign. It should be considered a problem in a child who is over the age of 4 years. One of the main reasons to treat daytime wetting is to help minimize children’s embarrassment and parents’ frustration. [/mme_highlight]

Daytime wetting is also named daytime urinary incontinence. The medical definition for daytime wetting is, as listed in Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), an involuntary voiding of urine during the day, with a severity of at least twice a week, in children >5 years of age in the absence of congenital or acquired defects of the central nervous system.
This situation is generally self-limited and in most cases benign (not related to any medical condition).

How common is daytime wetting?

The prevalence of daytime wetting varies with age and sex. Generally speaking, it has been estimated to be approximately 3% to 4% of children between the ages of 4 and 12 years, affecting more girls than boys – oppositely to nocturnal enuresis, which is more prevalent among boys. More detailed statistical data is listed below.

[mme_databox]

	Prevalence of Daytime Wetting Study Population: 1192 people from 1.5 to 27 years of age   –        Overall prevalence: 10% –        ≤2 years old: 64% –        2 -3 years old: 29% –        3 -4 years old: 13% –        4 -5 years old: 7% –        5 -6 years old: 10

OR – Odds Ratio; CI – Confidence Interval
Prevalence – The total number of cases of a disease in a given population at a specific time.
[/mme_databox]

[mme_databox]

	Prevalence comparison between girls and boys regarding Daytime Wetting 1)      Study Population: 5386 children – 6 year old (Scotland) –        Prevalence among girls: 4.1% –        Prevalence among boys: 1.8%   2)      Study Population: 3556 children – 7 year old (Sweden) –        Prevalence among girls: 6% –        Prevalence among boys: 3.8%

OR – Odds Ratio; CI – Confidence Interval
Prevalence – The total number of cases of a disease in a given population at a specific time.
[/mme_databox]

Is daytime wetting normal?

Yes, it can be normal. Generally, by 4 years of age, children are able to control their bladder and stay dry during the day. Children between 2 and 5 years old can generally stay dry during the day, although at this stage wetting accidents may happen and are not considered a problem.

What are the causes of daytime wetting?

If children are very active, they can try to hold urine too much time and wait too long before going to the toilet. Constipation may also be a cause of incontinence for children. Urinary tract infections cause incontinence and sometimes pain when urinating. Nervous system conditions are rarer causes.

What can be the impact of daytime wetting for children?

Especially when children enroll in school, daytime wetting can be a source of embarrassment leading to ridicule by peers. In fact, it was rated as the third out of 20 most stressful life events for children at school age.
Some studies have suggested an association between daytime wetting and psychological problems. A study reported a higher rate of attention-deficit/hyperactivity disorder in children with daytime wetting.

[mme_databox]

Psychological Problems in children with daytime wetting  (8000 children, only statistical significantly results shown) – Separation Anxiety: 1.77 times more risk in those with daytime wetting (OR 1.77 [95% CI, 1.36–2.30]) – Attention problems: 2.06 times more risk in those with daytime wetting (OR 2.06 [95% CI, 1.70–2.50]) – Oppositional Behavior: 1.98 times more risk in those with daytime wetting (OR 1.98 [95% CI, 1.52–2.59]) – Conduct problems: 2.02 times more risk in those with daytime wetting (OR 2.02 [95% CI, 1.56–2.62])

OR – Odds Ratio; CI – Confidence Interval
[mme_databox]

How can I help my child?

• Put your child to urinate every 2 to 3 hours.
• Give a positive reinforcement when children stay dry during the day; on the other hand, do not punish your child if she/he wets the pants.
• Explain your child she/he should not hold urine too much time.
• Be careful with the use soap in the genital area, as it can be irritating.
• Remember that the cause for daytime wetting can be constipation.

What treatments are available?

The general measures stated above are successful and sufficient in most cases. If the cause is a urinary tract infection, an antibiotic may be prescribed. Children with constipation may need a high-fiber diet, enema or laxative to help evacuate.

When should I be worried?

Daytime wetting should be considered a problem in a child after the age of 4 years. However, regardless of the child’s age, your concern is reason enough to seek for medical help. It is always an alarm sign in a child who was previously continent.

Summary and Recommendations

• Daytime wetting is an involuntary voiding of urine during the day in children >5 years of age.
• It is a common problem, but generally benign and self-limited.
• Common causes are behavioral, constipation and urinary tract infections.
• Daytime wetting is a source of embarrassment for children and frustration for parents, which is the main cause to treat it.
• In most cases general measures to help toilet training of the child are sufficient.
• If a child who was previously continent is wetting during the day, seek medical help.

[mme_references]
References

• 1. Robson WL, Leung AK, Bloom DA. Daytime wetting in childhood. Clin Pediatr (Phila). 1996 Feb;35(2):91-8.
• 2. Joinson C, Heron J, von Gontard A. Psychological problems in children with daytime wetting. Pediatrics. 2006 Nov;118(5):1985-93.
• 3. Hellström AL, Hanson E, Hansson S, Hjälmås K, Jodal U. Micturition habits and incontinence in 7-year-old Swedish school entrants. Eur J Pediatr. 1990 Mar;149(6):434-7.
• 4. Ollendick TH, King NJ, Frary RB. Fears in children and adolescents: reliability and generalizability across gender, age and nationality. Behav Res Ther. 1989;27:19–26.
• 5. Kodman-Jones C, Hawkins L, Schulman SL. Behavioral characteristics of children with daytime wetting. J Urol. 2001 Dec;166(6):2392-5.

[/mme_references]

What should I know about Bedwetting in children?

[mme_highlight] Despite being a common situation among children, enuresis is associated with embarrassment and a significant emotional impact for affected children and families. Most of bedwetting cases are not related with a medical condition and resolve by themselves. [mme_highlight]

The medical term for bedwetting is enuresis, which can be defined as wetting in small portions while asleep, in children older than 4 years of age. Despite being a common situation among children, enuresis is associated with embarrassment and a significant emotional impact for affected children and families. 
Many people do not know that this is a treatable condition, in consequence some families prefer to keep enuresis a secret, waiting for a spontaneous resolution, rather than seeking for medical help.

How common is enuresis?

Enuresis is a very common problem among children, with surprisingly high prevalence in population, as shown in the table below.

[mme_databox]

Prevalence of Enuresis

• By 6 years of age: 10% to 16%
• By 10 years of age: 5%
• Teenagers/young adults: 0.5-1 %

(Estimated for a wetting frequency of more than one “wet night” per month)
Prevalence – The total number of cases of a disease in a given population at a specific time.
[/mme_databox]

Is enuresis normal?

Yes, it can be, depending on each case. However, generally, enuresis is considered abnormal in children aged ≥5 years. Although most children older than 4 years are able to control their bladder while awake, they can take longer to control it during night.

What are the causes of enuresis?

Most of bedwetting cases are not related with a medical condition and resolve by themselves.  Some possible causes for enuresis are listed below:

• A bladder that takes more time than usual to mature;
• A bladder that holds a quantity of urine below the normal.
• Genetics: children whose parents have had enuresis have highest odds to have enuresis too.
• Decreased quantity of vasopressin: leads to increase in urine production.
• Physical or emotional problems are rare causes of bedwetting.
• Medical conditions: Diabetes, urinary tract infections, kidney failure, seizures, sleep apnea, constipation.

What can be the impact of enuresis for children?

Enuresis can have a negative impact on children’s lives in different ways, which can thus justify a proactive intervention:

• Source of distress both for child and family;
• Difficulty of “sleeping over” on holiday or at friends’ houses;
• Reduced self-esteem;
• Potential disturbance of the child’s and the parents’ sleep that may have an impact on daytime functioning;
• Untreated enuresis (especially if severe) can persist to adulthood, in 2 to 3% of cases.

How can I help my child?

• Do not punish your child for bedwetting, because it does not happen voluntarily, so it is not her/his fault.
• Put your child to pee frequently during the day and before bed.
• Avoid giving your child drinks with sugar or caffeine, especially at night.
• Try to give your child the majority of fluids during morning and afternoon.
• Put night lights in the alleyway to help your child find the way to bathroom easily during night.
• Ask your child to help you clean and set the bed.
• Do not allow siblings or other relatives to tease a child for bedwetting.
• Use a rewards system to motivate your young children.

What treatments are available?

There are some information you must have with you when you seek for a doctor, like a record of diary urine losses, the frequency of bedwetting episodes, family history of enuresis, if your child snores and impact of the problem for your child.

The first line treatment option is desmopressin, a hormone which reduces the volume of urine produced overnight to within normal range. It is particularly indicated for children with nocturnal polyuria (NP, meaning these children urinate many times per night), but whose maximum voided volume is not reduced compared to the normal for their age. This is further explained in the table below.

An enuresis alarm is recommended for children who have a reduced maximum voided volume but normal nighttime urine output. The alarm should be worn every night. The alarm is triggered when a sensor in sheets becomes wet – the alarm wakes the child, who stops voiding and arises to go to the bathroom.
Parents must help children to wake when the alarm is activated; otherwise, children can turn it off and continue sleeping. Note that response is not immediate and treatment should be continued for 2 to 3 months or until the child stays dry for 14 consecutive nights.

Combination therapy with desmopressin and an alarm can be considered in some cases.

[mme_databox]

Expected age-related bladder capacity and voided volumes

Age (years)	Expected Bladder Capacity (mL)	Maximum Voided Volume (mL)	Total Voided Volume (mL)
5	180	117	234
6	210	137	273
7	240	156	312
8	240	176	351
9	300	195	390
10	330	195	429
11	360	234	468
12	390	254	468

A reduced maximum voided bladder suggests a reduced bladder capacity, a situation in which alarms can be beneficial. A total voided volume under the listed value suggests that the child urinates many times during night – nocturnal polyuria – so treatment with desmopressin should be considered.

[/mme_databox]

When should I be worried?

Each case is different. When a child who was formerly able to control sphincters during night is no longer capable of it, this is definitely an alarm sign. On the other hand, a 6-year-old child with enuresis whose father had enuresis too, may not bring great concern. In addition, if bedwetting is interfering in children’s social life, then it is a motif to worry too.

Summary

• Enuresis is a common situation among children: approximately 16% of 5 year old children.
• Enuresis, the medical term for bedwetting, can have a negative impact in children’s and families’ lives.
• Most cases of enuresis resolve by themselves. If you are worried or if your child was formerly able to control sphincters and has loose this capacity you should seek a doctor.
• The most recommended treatments available are desmopressin and enuresis alarms.

[mme_references]
References

1. Vande Walle J, Rittig S, Bauer S et al. Practicalconsensus guidelines for the management of enuresis. Eur J Pediatr. 2012 Jun;171(6):971-83.
2. De Jonge DA (1973) Epidemiology of enuresis: a survey of the literature. In: Kolvin I, MacKeith RC, Meadow R (eds) Bladder control and enuresis. Heinemann Medical Books, London
3. Sit FKY, Yeung CK, Sihoe JDY, Liu JWH (2003) Self-esteem before and after treatment in Chinese children with nocturnal enuresis and urinary incontinence: a qualitative approach. ICCS Abstracts 40
4. Tekgul S, Nijman R, Hoebeke P, Canning D, Bower W, von Gontard A (2009) Diagnosis and management of urinary incontinence in childhood. Report from the 4th International Consultation on Incontinence. Health Publication Ltd.
5. Vande Walle J, Vande Walle C, Van SP et al (2007) Nocturnal polyuria is related to 24-hour diuresis and osmotic excretion in an enuresis population referred to a tertiary center. J Urol 178 (6):2630–
6. Von Gontard A (2009) Psychological aspects of urinary incontinence, enuresis and faecal incontinence. In: Abrams P, Cardozo L, Khoury S, Wein A (eds). Report from the 4th International Consultation on Incontinence. 4th edition. Health Publication Ltd, p. 760–

[/mme_references]

What factors influence my child’s ability to learn?

[mme_highlight] The way a child experiences learning, particularly in early years, can influence the child’s global health and ability for further learning, as well as confidence, motivation and self-esteem. Factors such as a low socio-economical status, male gender, low maternal education, speech defects and low birth weight were found to raise the likelihood for grade retention.  [/mme_highlight]

Children are constantly learning, however they may have different ways and rhythms to incorporate knowledge and there are many factors which may affect a child’s ability to learn in the complex interplay between child, family, environment, educators and community. Entering kindergarten is an important developmental milestone not only for the child, but for the family as a whole.
The way a child experiences learning, particularly in early years, can influence the child’s global health and ability for further learning, as well as confidence, motivation and self-esteem. It is estimated that about 32 to 50% of children entering kindergarten have at least one risk factor to further experience difficulty in learning and approximately 15% have more than one risk factor.

What are the risk factors that can impair the ability to learn?

School readiness is a common worry among parents. However, little is known about what are the associations between children health and environment with school success and failure.  An interesting study tried to investigate health and social factors associated with early grade retention in a nationally representative sample of children in the United States, revealing that approximately 8 percent of children repeat kindergarten or first grade.
Results obtained after logistic regression analysis are shown in the table below. In this study, factors such as a low socioeconomical status, male gender, low maternal education, speech defects, low birth weight, enuresis and exposure to smoking were found to raise the likelihood for grade retention.

[mme_databox]

Factors independently associated with increased risk of grade retention (logistic regression analysis) (Study design: study conducted to investigate health and social factors associated with early grade retention in a nationally representative sample of 10000 children in the United States.) ·        Poverty: 1.7 times more risk for grade retention (OR 1.7 – 95% CI 1.4-2.1) ·        Male gender: 1.5 times more risk for grade retention (OR 1.5 – 95% CI 1.3-1.9) ·        Low maternal education: 1.4 times more risk for grade retention (OR 1.4 – 95% CI 1.1-1.8) ·        Speech defects: 1.7 times more risk for grade retention (OR 1.7 – 95% CI 1.1-2.6) ·        Low birth weight: 1.6 times more risk for grade retention (OR 1.6 – 95% CI 1.2-2.2) ·        Enuresis: 1.6 times more risk for grade retention (OR 1.6 – 95% – CI 1.1-2.2) ·        Exposure to household smoking: 1.4 times more risk for grade retention (OR 1.4 – 95% CI 1.1-1.7)

OR – Odds Ratio; CI – Confidence Interval
[/mme_databox]

What are the factors that enhance the ability to learn?

It is consensual that a good learning environment as well as positive early learning experiences enhance a child’s ability to learn. In fact, such learning opportunities at an early age establish a solid basis for future academic success and general well-being. School readiness is thus a result of interactions between health and social, language, emotional, cognitive and social development. The study described above found that factors such as a high maternal education and living with both biological parents decrease the likelihood for grade retention.

[mme_databox]

Factors independently associated with decreased risk of grade retention (logistic regression analysis) (Study design: study conducted to investigate health and social factors associated with early grade retention in a nationally representative sample of 10000 children in the United States.) ·        High maternal education: decreases the risk for grade retention by 40% (OR 0.6 – CI 0.4, 0.9) ·        Residence with both biological parents at age 6 years: 1 decreases the risk for grade retention by 30% (OR 0.7, CI 0.6, 0.9)

OR – Odds Ratio; CI – Confidence Interval
[/mme_databox]

Getting the whole picture…

Child development is a major determinant of health throughout life. Risk and protective factors play an important role influencing the ability of a child to learn, however the cumulative experience of buffers or burdens is a more powerful determinant than any of these factors alone.

Summary and Recommendations

• A child’s ability to learn can be influenced by different factors in the interplay between child, family, environment, educators and community.
• Approximately 8 percent of children repeat kindergarten or first grade.
• A good learning environment as well as learning experiences at an early age enhance a child’s ability to learn; studies have shown that factors such as a high maternal education and living with both biological parents decrease the likelihood for grade retention.
• Poverty, male gender, low maternal education, speech defects, low birth weight, enuresis and exposure to smoking were found to be independently linked to a higher likelihood for grade retention.
• The cumulative experience is a more powerful determinant for learning than any risk or protective factor alone.

[mme_references]
References

• Byrd RS, Weitzman ML. Predictors of early grade retention among children in the United States. Pediatrics. 1994 Mar;93(3):481-7.
• Raver CC, Knitzer J. Ready to Enter: What Research Tells Policymakers about Strategies to Promote Social and Emotional School Readiness Among Three- and Four-Year-Old Children, National Center for Children in Poverty, New York 2002.
• Anderson LM, Shinn C, Fullilove MT, et al. The effectiveness of early childhood development programs. A systematic review. Am J Prev Med 2003; 24:32.

[/mme_references]

Why do babies fight sleep?

[mme_highlight] Spontaneous waking up in babies or their resistance to be put to bed is considered as fighting sleep. Studies have reported that about 30% of infants fight sleep. A consistent bedtime routine helps the babies to calm down and relax before sleeping.  [mme_highlight]

Studies have shown that there are striking changes during the first postnatal months of life in the duration of the maximum continuous period of sleep. The two most common problems associated with a child’s sleep in the early years of life are the difficulty in putting the baby to sleep and the waking up of the baby in the night.

Research studies have reported that standard norms for infant sleep or wake patterns during the first two years of life include an increase in the length of maximum sleep from about 4-5 to 8-10 hours by 4 months of age. The total duration of sleep in 24 hours is 13 to 15 hours, decreasing slightly during the first two years. Reports suggest that only 20% to 30% of infants wake regularly at night during the second year.

What is the normal sleep pattern of infants?

Studies reported that there is a relatively small decrease in the total amount of sleep per day with increase in age in babies. In the first week, infants have equal amount of sleep during the day and night which in the sixteenth week of life tends to change, with double the amount of sleep at night as compared to the daytime sleeping.  The sleeping period is generally longer at night. Infants younger than 3 months old slept on average to 5-12 hours a day, whereas those over 9 months slept 13-14 hours per day.

[mme_databox]
Average sleeping duration among newborns
(Source: study including 75 full term newborn babies)

– first day of life: 17 hours
– second day of life: 16.5 hours
–  third day of life: 16.2 hours.
[/mme_databox]

[mme_databox]
Duration of continous sleep
– < 3 months of age: 35% of infants showed continuous sleep  for at least 6 hours
–  9-12 months: 72% of infants showed continuous sleep for at least 6 hours
[/mme_databox]

Why do babies fight sleep?

Studies have reported that about 30% of infants fight sleep. 83% of the validation sample in a study has shown sleep resistance due to reasons such as accidents or illness in the family, separation anxiety from the mother, depressed mood of the mother and maternal attitude of ambivalence towards the child.

In fact, there are many physiological and developmental reasons which can influence the waking and sleeping patterns of babies. Spontaneous waking up in babies or their resistance to be put to bed is considered as fighting sleep. Below are some of the commonest reasons:

Active sleep

Most of the time, babies wake up and cry as soon as they are put down because they were in the light REM (rapid eye movement) sleep and not fully asleep. After an initial 20 minutes of REM sleep, babies enter the deep sleep, when a transition in their sleeping place can be made. In later months, some babies can enter the deep sleep directly bypassing the light REM sleep. Soon parents will learn to recognize the stage of their baby’s sleep.

Shorter sleep cycles

Another reason is that babies have shorter sleep cycles than adults. Within one hour of deep sleep, a baby makes a transition to the phase of light sleep and if there is any upsetting or uncomfortable stimulus (such as hunger) at this time, the baby will wake up and cry. If the baby is not disturbed, then she/he will reenter the deep sleep phase. This sleep cycle is longer in adults lasting for an average of 90 minutes while in the sleep cycle of infants it lasts for about 50 to 60 minutes. Babies seem to fight sleep because they experience this vulnerable period of night waking around every hour or even less.

Sleep rhythms

Babies do not sleep as deeply as adults. They take much longer to fall asleep, with more vulnerable periods of light sleep and on top of this they have twice as much active or light sleep as adults.

Development of the brain

Sleep researchers believe that brain develops during active or light REM sleep. The blood flow to the brain almost doubles during REM sleep. During this active sleep, the production of nerve proteins increases in the brain. In fact, premature babies spend almost 90% of their time in active sleep to accelerate their brain growth.

An overtired baby

A baby who is resisting sleep or is not ready to go to bed may be actually overtired. A cranky or hyperactive baby is generally a common sign of overtiredness.

Still resisting sleep

Even though it is known that babies achieve sleep maturity sometimes in the second half of the first year, some babies still fight sleep. There may be many reasons for this such as painful stimuli (cold or teething pain). Major developmental milestones (like sitting, crawling, walking) can drive babies to practice their newly achieved skill.  Separation anxiety and nightmares are also reasons for a baby to fight sleep.

What to do?

There are many daily routine practices which can be inculcated in your day to day life to ensure that your baby goes to sleep easily and sleeps peacefully.

After you have nursed and rocked your baby to sleep, make sure that she/he has transitioned from the light or active sleep to deep sleep (indicated by regular and shallow breaths, completely relaxed muscles and weightlessly dangling arms and limbs) before putting him in his crib or bed.

Know your baby’s sleep stages. While in the light sleep, comfort your baby by patting his back, singing a soothing lullaby, nurse him through close physical contact or simply staying next to him.

Follow a bed time routine religiously. Follow a relaxing routine such as oil massage, warm bath, brushing teeth, reading a book, singing and prayer. A consistent bedtime routine helps the babies to calm down and relax before sleeping.

Studies have also recommended a program involving promotion of infant self –settling by the use of a controlled crying technique, together with wrapping, cessation of night feeds and establishment of day time routine to help babies of 8-12 months to sleep.

Breastfeeding and sleep fighting

It has been studied that the fact that whether an infant was still nursing or had been weaned is strongly related with baby fighting sleep. Breastfeeding babies sleep in shorter bouts than their weaned counterparts and overall slept less.

Co-sleeping and sleep fighting

Babies sleeping with their mothers showed a strong association with sleep or wake patterns. Those infants who slept with their mothers slept in shorter bouts than those who slept alone. But the babies who slept with their mother reached out for their mother’s breast, suckled and went back to sleeping.

Summary and Recommendations

• Spontaneous waking up in babies or their resistance to be put to bed is considered as fighting sleep.
• Studies have reported that about 30% of infants fight sleep.
• Babies have shorter sleep cycles than those of the adults; as babies experience a transition from light to deep sleep every 60 minutes, they can wake up and cry if there is any a stimulus or discomfort in this period.
• Other reasons for a baby to fight sleep can be: separation anxiety, nightmares, achievement of major milestones, painful stimuli or ambivalent attitude from the mother.
• The most important tips to improve sleep in babies is to have a knowledge of your baby’s sleep patterns and provide relaxed as well as strict bedtime routines.

[mme_references]
References

• Infant Sleep Patterns: From Birth to 16 Weeks of Age. (1964). The Journal of Pediatrics, 576-582.
• Ball, H. L. (2003). Breastfeeding, Bed sharing and Infant Sleep. Birth: Issues in Pre Natal Care, 181-188.
British Medical Journal, 1177-1179.
• Elias, M. F. (1986). Sleep/Wake Patterns of Infants in the First Two Years of Life. Pediatrics, 77, 322-329.
• Leeson, R. e. (1994). Management of Infant Sleep Problems in a Residential Unit. Child:Health, Care and Development, 89-100.
• Lozoff, B. e. (1984). Sleep Problems Seen in Pediatric Practice. Pediatrics.
• Michelsson, K. e. (1990). Crying, feeding and Sleeping Patterns in 1 to 12 Month Old Infants. Child:Health, Care and Development, 99-111.
• Parmelee, A. H. (1961). Sleep Patterns of the Newborn. The Journal of Pediatrics, 241-250.
• Sears. (2013). Baby Fighting Sleep. Retrieved from The Sleep Sense Program.

[7mme_references]

When do Babies start Walking?

[mme_highlight] Most children can walk well by 15 months. In the weeks prior to independent walking parents can observe their child showing transient upright skills. When infants start their first steps, being without shoes can help refine the coordination and balance. Walkers should be avoided as they can be at harmful. [/mme_highlight]

In the weeks prior to independent walking parents can observe their child showing transient upright skills: children hold to furniture to acquire and sustain an upright position and hold parents’ hand or to furniture to make steps forward. Note that furniture or parents compensate for the missing levels of leg strength and balance control.

The main milestones in infant’s motor development are:

• Sitting, at approximately 6 months.
• Hands and Knees Crawling, at 8,5 months.
• Walking, at 12 months.

From Cruising to Walking

Cruising is a term used to describe the sideways movement when babies hold to furniture. This “pre-walking” way of locomotion is important because helps strengthen legs and create a notion of balance and coordination, also improving the security for the further achievement of independent walking. Researchers assume that there is a functional continuous from cruising to walking, since both involve locomotion in an upright posture.
There is consensus implying that there are two major factors essential for walking in children: acquisition of leg strength and control of balance. It is easy to understand that infants cannot walk before they can sustain body weight and keep the balance on one leg while the other goes forward to make a step.

Learning from falling?

Yes, walkers fall. Investigations estimate that, on average, 14-month-olds can fall 0 to 12 times in only 16 min of free play and 0 to 14 times during a short walk around a city block. However, most of these falls are not serious enough to need medical assistance, despite being one of the leading causes for accidental injury in children under five years.
Do not worry, because researchers think that learning from falling can be an impetus to control locomotion. It is believed that the experience of falling or of the near falls instigates awareness and can serve as a stimulus for adaptative avoidance.

What can I do to help my child walk?

You can stimulate your child by positioning in front of him with your arms open and encourage him to walk in your direction. When infants start their first steps, being without shoes can help refine the coordination and balance.

Walkers should be avoided as they can be at harmful various levels: they can impair legs muscles from strengthen and they can turn leading to a fall that may be dangerous.

When should I be worried?

There is a normal variation within the above milestones, but in the end most children can walk well by 15 months, while some children walk later, at around 18 months. You can expect a 3-year-old to walk, stand, run and jump but some actions like standing on tiptoes or only on one leg can take longer to refine.
The evaluation and surveillance of the motor development and the gait is part of the routine of the general practice doctor or pediatrician. Yet, if you think you have concerns in this field, do not hesitate in searching for medical assistance. Bear in mind that sudden alterations in gait, coordination and balance or if your children looses any already acquired motor skill you should seek medical advice.

Summary and Recommendations

• Cruising is considered as a pre-walking phase in which children walk holding to furniture.
• If your child has recently started walking, falls will occur. Specialists believe that minor falls can indeed be a stimulus for confident walk.
• Parents should encourage children to walk by positioning in front of them. In the first walking attempts, children should be without shoes.
• Walkers should not be used, as they impair muscle development and can result in dangerous falls.
• Most children walk well by months of age.

[mme_references]
References

• Karen EA, Sarah EB, Andrew JL. Developmental Continuity? Crawling, Cruising, and Walking. Dev Sci. 2011 March ; 14(2): 306–318.
• Frankenburg, WK.; Dodds, J.; Archer, P.; Bresnick, B.; Maschka, P.; Edelman, N., et al. Denver II Sceening Manual. Denver Developmental Materials, Inc.; Denver, CO: 1992.
• Amy SJ, Karen EA. Learning from falling. Child Development, January/February 2006, Volume 77, Number 1, Pages 89 – 102.
• National Center for Injury Prevention and Control, C. D. C. (2003). Web-based Injury Statistics Query and Reporting System (WISQARS).

[/mme_references]

When do Babies start teething?

[mme_highlight] Generally, the primary teeth appear between 6 and 8 months with a tendency to emerge first in girls. The first to erupt are usually the four front teeth. there is probably an association between teething and irritability, diarrhea, increased salivation, slight rise in temperature and sleep disturbance. [mme_highlight]

Teething is a natural process that can be defined as the migration of tooth from its intraosseous position in the jaw to erupt in the oral cavity.

When do teeth start to erupt?

Generally, the primary teeth appear between 6 and 8 months with a tendency to emerge first in girls. The first to erupt are usually the four front teeth. Usually between 2^1/2 and 3 years of age the full set of 20 temporary teeth are already in the oral cavity. As the child’s jaws continue to grow, they become prepared for the eruption of the first permanent teeth between 5 and 7 years of age.
The permanent teeth can be up to 32, if the third molars erupt, which does not happen always. The chart below helps understand the estimated chronology of the eruption of the first teeth, the central incisor being in the midline of the jaw and the other being situated lateral to it, in the order shown.

[mme_databox]

	Upper Jaw	Lower Jaw
Central Incisor	8-12 months	6-10 months
Lateral Incisor	9-13 months	10-16 months
Canine	16-22 months	17-23 months
First Molar	13-19 months	14-18 months
Second Molar	25-33 months	23-31 months

[/mme_databox]

What symptoms can be linked to teething?

Tooth eruption is believed to be linked to a variety of symptoms in children, but there is not a consensus yet, because the association of the time of teething and the onset of symptoms may simply coincide. The latest evidence from studies points that there is probably an association between teething and irritability, diarrhea, increased salivation, slight rise in temperature and sleep disturbance; these associations shown to be significant on the day of eruption and  one day after eruption.
Keep in mind that teething is not associated with severe signs or symptoms.

Early Teeth

Natal teeth (when a baby is born with teeth) or neonatal teeth (teeth that develop during the first 28 days of life) are a rare occurrence, although the first situation occurs more frequently than the latter in the proportion of 3:1. The estimated prevalence of early teeth varies between 1:1000 and 1:30.000.
In approximately 85% of cases, these teeth are located in the region of the mandibular central incisors (i.e. central position in the lower jaw). This early appearance of teeth can cause concern among parents and in many cultures this is a poorly understood subject that can lead to superstitions. In addition, the early teeth can cause pain on suckling, refusal to feed and traumatic ulceration both in the mother’s breast and in the baby’s mouth.
The cause of this premature appearance remains to be proved, but probably it can be due to a conjugation of various causes, such as hereditary, endocrine disturbances, infections, nutritional deficiencies, superficial position of the tooth gem and genetics.
If this is the case, the baby should be observed by a pediatrician as there is risk of inhalation, ulceration or feeding difficulties.  The pediatric dentist will evaluate the teeth and will decide the best treatment option, which can range from “attentive follow-up”, in most cases where the teeth is of normal dentition, to the extraction.

Taking care of baby’s teeth

0 to 6 months

• clean your baby’s gums with a moist gauze or towel
• do not put sugar in the nursing nipple

6-18 months

• introduce cups with a mouthpiece (the baby bottles increase the incidence of caries).
• introduce tooth brushing.
• The first visit to the dentist around 12 months.

Summary and Recommendations

• Primary teeth appear between 6 and 8 months.
• The first teeth to appear are the four front teeth.
• Permanent dentition starts appearing by 6 years.
• It has not been proven that teething is associated with symptoms, but it is believed that irritability, slight rise in body temperature and diarrhea can occur with teething.
• Natal teeth (when a baby is born with teeth) is more frequent than neonatal teeth (teeth that appear during the first 28 days of life), but both conditions are rare. As there is a risk of inhalation, ulceration and feeding problems, the child should be observed by a doctor.
• Teeth your child’s teeth with a gauze from birth to 6 months and then introduce the toothbrushing.

[mme_references]
References

• Wake M, Hesketh K, Lucas J. Teething and tooth eruption in infants: A cohort study. Pediatrics. 2000; 106:1374-9.
• Maheswari NU, Kumar BP, Karunakaran, Kumaran ST. Early baby teeth: folklore and facts. J Pharm Bioallied Sci. 2012 Aug;4(Suppl 2):S329-33.
• Joana Ramos-Jorge, Isabela A. Pordeus, Maria L. Ramos-Jorge and Saul M. Paiva. Prospective Longitudinal Study of Signs and Symptoms Associated With Primary Tooth Eruption. Pediatrics 2011; 128;471.

[/mme_references]

When do Babies start Talking?

[mme_highlight] A baby shows surprising speech processing skills since birth. Lexical acquisition starts at the second half of the first year of life, before children uttering their first words. Learning the meaning of words requires advanced abilities, which starts at 14 months.[mme_highlight]

Language is a uniquely human capacity. Interestingly, research has shown that the functional organization of a newborn brain in terms of language processing is similar to the adult brain. A baby shows surprising speech processing skills since birth. Studies have proved what the daily life shows: babies prefer their mother’s voice over other female voices and their native language over foreign languages. Surprisingly, newborns are able to distinguish most sound contrasts used in language.

How is the language development during the first year of life?

During the first year of life, however, this ability is somewhat narrowed because babies usually only listen to their native language, but at the same time this ability is increased to discriminate sound contrasts of their own native language.
Nevertheless, some babies learn more than one language: how do they distinguish? Scientists believe the answer is in the babies’ sensitivity to language rhythm – this discrimination ability emerges as early as at 4 months of age.
Also surprising, lexical acquisition starts at the second half of the first year of life, before children uttering their first words. At 8 months, before start learning the major amount of words, babies discriminate a minimal pair of words and can associate them with two different objects. In fact, learning the meaning of words requires advanced abilities, which starts at 14 months.

What are the major language milestones?

The major milestones are listed in the table below. Expressive language refers to the ability of using language, while receptive language is the ability to understand it. Note that these milestones are based on the 50^th percentile and, thus, they are merely indicative and intended for general developmental surveillance by primary care assistance.

[mme_databox]

Age	Expressive Language	Receptive Language
Birth - 2 months	cry	Turns toward sound
2- 4 months	Open vowel sounds: “ooh”; “ahh”	Social smile Attention to faces
6 months	Repetitive combinations: “bababa”	Responds to name
12 months	First word. Repeats sounds to get attention	Responds to “no” Follows simple verbal commands if made with gesture
15- 18 months	Points to body parts when named	Follows simple verbal commands (one-step commands)
18-24 months	Two-word sentences (e.g., “daddy water”)
24- 36 months	Answers simple questions	Follows two-step verbal commands
36- 48 months	Sentences with 4-5 words; pronouns; plural	Understands placement in space
48- 72 months	Complete sentences with grammar markings	Follows three-step verbal commands

Adapted from: Sices, L. Use of developmental milestones in pediatric residency training and practice: time to rethink the meaning of the mean. J Dev Behav Pediatr 2007; 28:47.
[/mme_databox]

When should parents be worried?

Language learning is frequently viewed by parents and society with anxiety and there are a lot of associated myths. There is a significant variability in the normal range of development of language in young children. There are some identified risk factors that can contribute for language delays: poverty, if the parents’ level of education is low, prematurity and low weight at birth, family history of language delays, maternal depression and male sex.

As part of the general development surveillance, your family doctor can use screening validated tools at the main milestones and refer the child for further evaluation if considered necessary. Note that approximately 10 to 15% of the 2-year olds have language delay, but this delays remains only in 4 to 5% of children after three years.

Can I help my baby learn words?

Sure! Studies show that the quantity and quality of the language babies hear from their parents or caregivers influences the early lexical development. This implies that babies who are exposed to richer language may interpret words better and thus be able to learn more words.

Summary and Recommendations

• At 6 months starts the lexicon acquisition, as well as babbling using repetitive combinations; the baby respondes to name.
• The first words are said at 12 months in 50% of babies. Babies understand the meaning of certain words at around 14 months.
• Expect 2 word sentences from your baby by 18 to 24 months.
• Between the age of 2 and 3, your baby answers simple questions.
• Complete sentences with complex grammar are expected between 48 and 72 months.
• Note that 10 to 12% of 2-year-olds present language delay.

[mme_references]
References

• Mehler J, Gervain J. Speech Perception and Language Acquisition in the First Year of Life. Rev. Psychol. 2010. 61:191–218
• Swingley D. 2009. Contributions of infant word learning to language development. Trans. Royal Soc.
• Nereyda H, Virginia A M, Anne F. Does input influence uptake? Links between maternal talk, processing speed and vocabulary size in Spanish-learning children. Dev Sci. 2008 November ; 11(6): F31–F39.
• Sices, L. Use of developmental milestones in pediatric residency training and practice: time to rethink the meaning of the mean. J Dev Behav Pediatr 2007; 28:47.
• van Noort-van der Spek IL, Franken MC, Weisglas-Kuperus N. Language functions in preterm-born children: a systematic review and meta-analysis. Pediatrics 2012; 129:745.

[/mme_references]