Clinical Frequently Asked Questions

1. How do I submit a medical question phone call to my child’s pediatrician?

Most questions are best handled during regular office hours when your child’s chart is available. All calls regarding routine childrearing or school issues should be made during hours when your primary physician is in the office. Phone calls during office hours are returned in the order received. If you have a call of an urgent nature, please state this clearly to the receptionist when you call and your call will be handled separately. When you call, you will be asked for the child’s name, date of birth and the name of the responsible adult (a.k.a. “billing name”). This helps us identify the proper chart, as there may be several patients in the practice with the same name. You will also be asked for a phone number where you can be reached. If convenient, you may leave multiple phone numbers along with the times up until 5 p.m., when you will be at each number. If at all possible, please try NOT to leave a pager number. The delay in the page going through and then waiting for the call to be returned makes this a very cumbersome way to reach you, especially when the doctor is trying to reach you during the day between patient appointments. Also, please disable your Caller ID Privacy Manager. If your Privacy Manager blocks our call, we will not be able to reach you. Have paper and pencil handy to make notes, and have ready the phone number of the pharmacy you use. If you have not heard back within three hours of placing your call, please call the office back to make sure that we have the correct phone number or that we have not had other trouble reaching you.

2. How do I contact a pediatrician when the office is closed?

After-hours (when the office is closed) call the office number and the number will be transferred to our qualified trained nurses who will answer your call. In the case of life-threatening emergencies, call 911 or go directly to the Emergency Room. Again, do not leave a pager number for a call back number and disable your Caller ID Privacy Manager. If you prefer not to speak with a nurse from Carelink nurses, please tell the operator on the Exchange and the on-call doctor will be paged. If your call has not been returned within one hour, please call back. There may have been a problem reaching you. After regular office hours, neither the exchange nor the on-call doctor can schedule appointments.

3. How do I request a refill for my child’s medication?

Refills of prescription medications should only be requested during regular hours when charts are available. Do not wait until you are out of medication to call. Controlled substances (e.g. Ritalin, Adderall) are required by law to be prescribed in written form only, in which an appointment is required for reevaluation. We will call in the prescription to your preferred pharmacy, or you may pick it up at the office, whichever method you have arranged with your pediatrician. When it is time for a refill, call the office at least one week before you need the prescription. Federal law only allows a one month supply of these medications to be dispensed and prohibits refills of these medications if they are lost or stolen. To keep the lines open for true emergencies, please do not call after hours for non-urgent issues accept for an appointment. Have paper and pencil ready to take notes and have ready the number of a pharmacy that is open at the time you have called. If a prescription needs to be called in, it is your responsibility to know which pharmacy in your area is open. If you pharmacy is closed, a prescription cannot be called in.

4. Are Vaccines Safe?

The simple answer is YES. Vaccines contain either pieces of bacteria or viruses or weakened versions. They trick your body into thinking it is seeing an illness and alerts the immune system. This creates a memory of that illness, so should you come across the real organism, your body’s immune system can fight it off more effectively. Vaccines are carefully tested and given to millions of children and adults worldwide each year. Vaccines do not cause autism – they prevent diseases and save lives.

5. Will an antibiotic help my child’s cold?

The majority of colds, or upper respiratory infections (URI’s) are caused by viruses. They can have symptoms like a cough, fever, nasal congestion, nasal drainage or sore throat. Antibiotics are medications that can kill bacteria, not viruses. Therefore most colds will not respond to an antibiotic. Ask your doctor about ways to help the symptoms.

6. What is considered a fever?

A temperature of 100.4 or greater taken orally, under the arm, or rectally. Fever is the body’s way of fighting off a bacteria/virus. It is important to consider the child’s symptoms along with the temperature.

NEW BORNS

Colic

Reviewed 6/24/2011  By Daniel Feiten MD Greenwood Pediatrics

Colic can be one of the major stresses in child rearing. The colicky infant usually cries for at least several hours a day, more often in the late afternoon and early evening hours. It begins in the first few weeks of life, peaks in the fourth to sixth week, and then typically resolves by the third or fourth month of life. Your child may display sudden and intense crying which is accompanied by stiffening, drawing up of the legs, and passing of gas.

Cause

The cause of colic is unknown. Although many people assume that it is a result of intestinal pain, the cause seems to vary with each infant. Air swallowing, immaturity of the intestinal tract, immaturity of the nervous system, a hypersensitivity to a protein in cow’s milk, a sensitivity to environmental stimuli, and low progesterone have all been suggested as possible factors.

What to do about Colic

Don’t Blame Yourself. It is natural to become frustrated and angry over a child who won’t stop crying. Some parents will begin to question their parenting skills, thinking that ” I must be doing something wrong !” Try to relax. Fortunately, colic usually resolves by itself over time.

Never Shake your Baby! Anxiety and frustration have led parents to shake their baby in an attempt to make them stop crying. Shaking can lead to bleeding in the brain and it must be avoided at all times! Call us immediately if you have just shaken your newborn or if you feel the urge to harm your infant.

Feed your Baby Calmly. Feedings should be quiet and not hurried. Handle your baby gently. Avoid distractions by discouraging telephone calls and well-meaning visitors, especially during the peak periods of colic.

Try a Variety of Calming Methods. Each baby responds to these methods differently. Try to find the right one for your child: gently rocking or walking, swaddling, “shooshing”, an infant swing, soft music, “white noise” from the TV/radio, taped uterine sounds, auto rides, and pacifiers. A child carrier (eg. “Snuggly”) has been shown to be of benefit when used consistently. Try bathing your baby or simply undressing her. Some parents have found success with putting their child in a car seat and putting it on top of the dryer when it is running. (Be sure to hold on !)

Minimize Air Swallowing. Use frequent burping and proper bottle position. If your baby is bottle-fed, make sure that the hole in the nipple is big enough. If your baby tends to pass a lot of gas, you may try Mylicon drops, an over-the-counter remedy which is harmless.

Avoid Cows Milk. A few studies have shown that a small percentage of infants are sensitive to a protein found in cow’s milk.If you are bottle feeding, try changing from a cow’s milk -based formula to a soy-based formula or a lactose-free formula. For nursing mothers, it may be necessary to avoid all milk products for one week to see if your child’s colic diminishes. Some doctors will also recommend avoidance of other types of food such as chocolate, spicy foods, and “gassy vegetables” like cucumbers and broccoli. If these don’t help, call us during office hours to consider further formula changes.

Plan Ahead. If your child is fussy during dinner time, prepare the meal earlier in the day so that you can devote all of your time to your baby. Housework may have to wait.

Take a Break. Many people feel reluctant and guilty about giving their child to another to take care of. Spouses, partners, friends and relatives can each take their turn with a colicky child. Don’t try to do it alone!

Consider Probiotics A recent study in Italy evaluated 50 babies with colic…some were given Lactobacillus Reuteri while others received a placebo. The infants who received the probiotic had a significant reduction in crying. This study needs to be repeated in other centers. Keep in mind that the FDA does not regulate OTC probiotics and so the quantity of bacteria may vary among OTC products.

Feeding Your Baby

Reviewed 6/24/2011 By Daniel Feiten MD Greenwood Pediatrics

Breast milk is good for your baby. It is superior to any alternative form of infant formula and is uniquely designed to meet the nutritional needs of your infant. It contains antibodies which will help protect your baby against illness. Breastfeeding is easy, inexpensive, and convenient; there are no bottles to wash and no formula to prepare. Breast milk is easy to digest, and less allergenic, thus there are fewer problems with constipation and diarrhea. Breastfeeding provides a special bonding for baby and mother. It also helps mom get back into shape by contracting the uterus.

While breastfeeding may be the natural thing to do, it helps to know a little about how to do it. Here are a few steps to help you get started.

Wash hands with soap and water.
Hold your baby close to your breast and turn your baby so you are tummy to tummy.
Hold the breast in your hand and gently stroke the babies lips with the nipple until the baby opens wide. Your baby has a “rooting reflex” which will make him turn his mouth toward your touch.
Pull the baby onto your breast, helping him to take in as much of the brown area of the nipple as possible.
Nurse the baby on both breasts, about 10 minutes per side, burping in between.
To remove the baby from the breast, place your finger in the corner of his mouth to break the suction.
Proper positioning of the baby on the breast and using different positions to hold your baby while nursing is very important to reduce nipple soreness.

How do I know my baby is getting enough milk?

Your baby should have at least 6-8 wet diapers per day and frequent bowel movements. Call us if your newborn is stooling less then 4 times a day in the first two weeks of life.
Initially, your baby should nurse 8-14 times over 24 hours (every 1 1/2 to 3 hrs). In the first 2 weeks of life, you should wake your baby for feedings if she sleeps beyond 5 hours.
Your breast should feel full before feeding and softer after your baby has nursed.
In general, your baby should seem satisfied and content after feeding. If you are concerned, you should call us. We may want to have the baby weighed.

Collecting and Storing Breast Milk

Situations arise where you may need to be separated from your baby; school, work or an evening out. When this occurs, you may wish to pump and store your milk ahead of time. There are a number of different breast pumps available and you will need to find the one that fits your needs.

Breast milk may be stored in the refrigerator for 48 hours. To freeze breast milk, first cool it in the refrigerator, and then put it into the freezer. Frozen breast milk should be used within 3 months if it is stored in the freezer compartment of a refrigerator. Milk stored in a deep freezer is good for 6 months. Remember to label the breast milk with the date that you pumped it. Thaw milk in the refrigerator or in warm water just before feeding. Thawed milk must be used within 24 hours. Note: freezing breast milk destroys some of its antibodies.

You may introduce a bottle of breast milk or formula at 2-3 weeks of age (2-3 times/week). This is enough to get your baby used to a bottle, but not so much that it will compromise your breast milk supply.

When a Nursing Mother is Ill and Needs to Take Medications

When a mother becomes ill, she should not interrupt breastfeeding for fear that she may make her baby sick. Breast milk passes immunity to the baby in many circumstances. Frequent hand washing will also decrease the risk of contagiousness.

If you are nursing while ill, it is generally best to avoid most medications. If you wish to take medicine, the following medicines may be taken safely (at the recommended dose) without risk to your baby:

For fever: Acetaminophen, Ibuprofen

For colds: nasal sprays (eg. Afrin, Neosynephrin); Benadryl (Other antihistamines may be given, but there may be a slight decrease in mother’s milk supply)

For pain: Acetaminophen, Ibuprofen, Codeine, Naprosyn

For infection: Antibiotics do not usually produce adverse effects in breast-fed infants.

You may take: Penicillins (eg. Amoxicillin), Cefzil, Suprax, Keflex, Augmentin

For weight reduction

After your child reaches one month of age, you may take products with Aspartame(Nutrasweet) or saccharin. Mothers who carry the gene for phenylketonuria should consult us before taking Aspartame.

If you are taking a medicine which is not listed here, please call and speak with one of our providers or phone nurse.

Bottle Feeding

If you decide to bottle feed your baby, rest assured in knowing that formulas will provide your baby with all the nutrients she needs to grow and be healthy. An advantage in bottle feeding is that it’s easy for dad and others to feed the baby when mom needs a break.

There are basically two kinds of formula which you may choose to use: cows milk protein or soy protein. Formulas are labeled “with Iron” or “low Iron”. Formula “with Iron” is recommended so your baby won’t become anemic. Most babies will do fine on cows milk-based formula and it is recommended unless you have a family history of milk allergy or your baby is having problems with cows milk formula. In that case, you may want to try a cow’s milk-based formula that does not contain lactose, or a soy-based formula.

Bottle Preparation

There is no need to boil water for formula or sterilize bottles and nipples if you live in a city with sanitized water. To avoid bacterial infection you should thoroughly wash the bottles and nipples in hot soapy water using a bottle brush. Most bottles may be placed in the dishwasher. Always rinse your infant’s bottle after it is empty to avoid bacterial growth; it is very hard to remove dried milk after it hardens.

When preparing formula, you should always start with clean hands. Here are some general guidelines for mixing formula:

Ready to Feed: No Mixing required. Pour directly into bottle.

Concentrated Liquid: This must be mixed in a 1 : 1 ratio with water. If you make a 4 ounce bottle, add two ounces of concentrated liquid to two ounces of tap water.

Powdered: Add one scoop of formula to every two ounces of water. Measure the water first and then add the formula and shake.

Breast milk or formula is recommended for your baby’s entire first year. Whole milk should not be given to infants under 12 months unless it is recommended by us.

Tip: Always hold your baby during feedings. Never prop the bottle and don’t give your baby a bottle in bed.

If your baby doesn’t finish his bottle, you may offer it up to one hour later. If refrigerated, you may keep it up to four hours. Bottles for nighttime feedings that are prepared in advance should not be left at room temperature. They should always be refrigerated.

Vitamins and Fluoride

Infant formulas and breast milk contain all the necessary vitamins so there is no need to give supplemental vitamins unless we have recommended vitamin D supplementation. Extra fluoride is not needed in any baby less than 6 months of age, regardless of whether they are formula-fed or breastfed. After 6 months of age, certain babies and children may require fluoride supplementation, but only if their primary water source has no or low fluoride content (well water, some bottled water). If you have concerns about the fluoride content in your water supply, discuss this with your pediatrician at the 6 month well baby visit.

Water

There is enough water in formula and breast milk to meet your babies needs, so no extra water is really needed. It may be offered during hot weather or when baby is ill. Once your baby starts eating solid foods, he may require more water.

Introducing Solids

When is your infant ready?

It is recommended that solids be started between 4 and 6 months of age. They are not necessary before this time because breast milk or formula provide all the nutrition and calories a baby needs. Feeding solids too soon may cause infant allergies and may increase their risk for later obesity. Solids do not help babies to sleep through the night.

Some signs which will help you recognize if your child is ready for solids are:

Baby can sit with some support and turn head away when full.
Baby is able to swallow food from a spoon.
Baby is drinking more than 36 ounces of formula per day.

How to Begin Solids

Start with plain iron fortified infant cereal, such as rice.
Mix 1-2 tablespoons of cereal with breast milk or formula until it develops a mustard-like consistency. Feed with a small spoon. Continue with cereal for 2 – 3 weeks, 1-2 times per day.
Next add plain vegetables, then fruit. Try one new food at a time, waiting 3 – 5 days between new foods. Squash, sweet potatoes and carrots are high in Vitamin A and are liked by most babies. Avoid wheat products, corn and berries until 9 months of age.
Around 9 months, slowly introduce finger breads, cereals, and strained meats. You may try other protein foods such as beans, yogurt and cottage cheese.
Avoid egg whites, fresh cow’s milk, shellfish, peanut butter, citrus, chocolate and honey until one year of age.

A cup should be introduced around 6 months of age. This is a good time to start juice, limiting the amount to 4 to 8 ounces per day. Don’t put juice in your baby’s bottle, help him learn to drink it from a cup.

Tip: If using jarred baby foods, mix single foods like chicken, with peas or peaches. These products are better for baby and cost less than combination or mixed dinners.

Healthy Eating for Your Child

Many parents have concerns about what, how much and how to get their child, to eat. Parents are responsible for selecting and buying food, making well-balanced meals, setting the timing of meals and snacks, presenting food in a form that the child can handle and setting standards of behavior at the table. The parent is not responsible for how much a child eats, whether he eats, or how his body turns out.

Newborn Characteristics

Reviewed 6/24/2011 By Daniel Feiten MD Greenwood Pediatrics

All babies are different. Here is a summary of some of the physical characteristics and newborn behavior that your baby may have. Each of them are normal findings. Take a minute to examine your baby, looking for some of these characteristics.

Soft spot: The anterior fontanel, a diamond-shaped soft area at the top of the skull. It’s okay to touch it! Don’t worry if it pulsates.It should close over between 6 to 18 months.

Caput/Cephalohematoma: Fluid-filled swellings on the top of the scalp. They’ll usually go away within a few days to months after birth.

Ears: A pit or dimple in front of the ear is not uncommon. Rarely, these may get infected, so call us if you see redness or swelling. Also, the ears may be soft and folded over, but will assume normal shape soon.

Eyes: Eyelids may be swollen for the first three days. The white of the eye may have a scarlet-colored hemorrhage on it. This will resolve within 6 weeks. Your infant’s eyes may occasionally look crossed in the first two months; call us if it persists.

Watery Eyes: This may be a blocked tear duct. Most of these open up by one year. Call us during office hours if there is a lot of mucus or yellow discharge.

Stuffy Noses: It is very common for infant’s noses to appear to be stuffy. Hold a mirror directly under each nostril. If mist appears on the mirror, the nostril is open. Try saline drops (one drop each nostril as often as needed) down each nostril. The stuffiness disappears as the nostrils get bigger (around 2 – 4 months).

Mouth with white spots: Epithelial pearls are found on the gum or hard palate and are about the size of a pinhead. They’ll go away by 2 months. Thrush consists of white patches on the tongue and inner cheeks. It can be confused with milk or formula (which easily wipes off.) Call and talk to our phone nurse of you think your child may have thrush.

Skin: Many babies get red blotches with a small white lump in the center (about the size of a pencil eraser head) all over their body. They’ll come and go for the first 1 – 2 weeks. It’s called erythema toxicum. Sounds and looks serious. It’s not.

Acne: Begins around 2 weeks of age and lasts until 4 to 6 months. Baby lotion may make it worse. Keep clean with soap and water.

Dry skin: Babies lose their outer layer of skin after they are born. You’ll see flaking. Especially around the ankles, feet, hands and extremities. Remember, they’ve been living inside a fluid environment for the past 9 months. Avoid using a lot of baby lotion. Just let it flake off.

White Bumps: On the face and chest are called milia. They look like pimples. They’ll go away in 2 months. Note: if your baby has blisters, call our office immediately.

Stork Bites: These are flat, pink/burgundy birthmarks found on the back of the neck, or above the nose and eyes. Most of the facial marks will go away by 18 months, 25% of the neck birthmarks will remain, but are covered by hair.

Breast enlargement: May occur in male and female newborns in the first few weeks of life and may last for 6 months to 1 year. It’s due to hormones that have been passed on by the mother before birth. You may even notice a drop of milk coming from the enlarged breast.

Umbilical cord: You’ll sometimes see some yellowish discharge underneath the dried cord. The cord should fall off between 10-30 days of age. There may be some oozing of blood for a few days as the cord separates. This is normal and you should continue cleaning the cord as you were instructed at the hospital. Don’t be afraid to lift up the dry part in order to apply rubbing alcohol to the moist part below. Call us immediately if there is red streaking, swelling or inflammation around the cord.

Genitals: Girls may have a white, sometimes blood-tinged discharge from their vagina in the first two weeks. No need to worry. 10% of girls will have a moist pink skin tag coming from the vagina: this will resolve over 1 to 2 months. Boys may have a fluid collection in their scrotum called a hydrocele. If it seems to change in size, call us during office hours.

Circumcision: You may see some yellowish skin on the head of the penis or at the end of the remaining foreskin. This will return to normal in 10 days. If your child has a plastic device after the circumcision (the Plastibell), this will fall off within two weeks. Keep the circumcision clean with water 3 times a day. Apply petroleum jelly (Vaseline) to the circumcision to avoid sticking to the diaper. If there is marked redness or swelling of the skin with streaks running toward the body, call our office.

Bowel Movements: Stools may vary in color and consistency, but are most often mustard yellow with a “cottage cheese” consistency. During the first few months, most babies strain when they stool. This occurs even when the stool is soft. Don’t worry about this unless your baby’s stool is hard or has a clay consistency. Call us if your breastfed newborn is stooling less than four times a day in the first two weeks of life.

DON’T WORRY ABOUT:

(the following behaviors are normal and should disappear within three months)

Hiccups
Sneezing
Yawning
Spitting up
Straining with bowel movements when stool is soft
Chin or lip quivering
Passing gas
Jitteriness of arms and legs when crying
Startling to noises with brief body stiffening (called the Moro reflex)

Mild congestion of the nostrils (very common in a dry climate!)

Sleeping

Reviewed 6/24/2011 By Daniel Feiten MD Greenwood Pediatrics

Newborns sleep a lot during the first month of life. Your child may sleep anywhere from 12 to 20 hours per day with an average of 16 hours per day. The duration of this sleep is variable, from 15 minutes to 5 or 6 hours.

Most newborns awaken 1 to 3 times during the night in the first 3 months of life and the majority of infants can be expected to sleep through the night by 4 to 6 months of age. Many parents (and grandparents!) assume that these nighttime awakenings are related to their infant’s need to eat. This may be part of the problem in the first 2 months, but there is much more to it.

Infants awaken several times during the night because they have an immature sleeping pattern. Two general patterns exist:

REM Sleep: This is an “active sleep” pattern in which babies display a lot of movement, restlessness, twitching, irregular breathing and brief awakenings. Infants may go through this pattern 2 – 4 times a night, resulting in a nighttime awakening at the end of each REM sleep pattern. Newborns have this pattern during 50% of their sleeping time (adults have 25%). No wonder babies wake up so much at night! Fortunately, this pattern decreases by age 3 – 4 months, allowing most children (and parents) to sleep through the night.
NON-REM Sleep: A “Quiet Sleep” pattern in which infants display less movement, a regular breathing pattern, and a deeper sleep in which it seems to be very difficult to awaken your baby.

Although most children learn to sleep through the night on their own, here are a few tips to follow to try to avoid future sleep problems:

Before 4 Months:

Keep ’em Cozy. Your newborn has been used to 9 months of close quarters while she was growing inside you. Keep her comfortable by swaddling her, using a small bassinet or crib, and keeping the room at about 68° to 72°F. Caution: don’t over bundle, and don’t use sheepskins, waterbeds or down comforters because of the risk of suffocation.
Give ’em their own space. Many parents prefer to have the child’s bassinet in their own room. While this may calm your fears, you will wake up to every movement when your baby is going through REM sleep. Try to move your baby to her own room by one month of age.
Put your baby in the crib while awake. Let your baby learn to fall asleep without you. Crying for 15 to 20 minutes is not unusual. If necessary, rock her, but put her in the crib before she falls asleep. Background noise may also help to signal nap times or bed time. Try a radio, air conditioner, a musical toy, tapes of uterine sounds, or the white noise that comes from an unoccupied TV channel or radio frequency. Try to wean the use of noises by 4 months of age.
Establish a routine. A consistent daytime and nighttime ritual for naps and bedtime is extremely important. If your hectic schedule does not permit this, try to always be home for the same nap time every day.
Hold your baby for fussy crying. Children under 4 months need to be soothed. Respond to your baby. You will not spoil her.
Be brief during nighttime feedings. Save the fun stuff (singing, playing etc.) for the daytime.

Don’t awaken your child during the night to change diapers. Wet diapers can be left until the morning, unless your child has a severe diaper rash.

Sleeping

Reviewed 6/24/2011 By Daniel Feiten MD Greenwood Pediatrics

Infants awaken several times during the night because they have an immature sleeping pattern. Two general patterns exist:

REM Sleep: This is an “active sleep” pattern in which babies display a lot of movement, restlessness, twitching, irregular breathing and brief awakenings. Infants may go through this pattern 2 – 4 times a night, resulting in a nighttime awakening at the end of each REM sleep pattern. Newborns have this pattern during 50% of their sleeping time (adults have 25%). No wonder babies wake up so much at night! Fortunately, this pattern decreases by age 3 – 4 months, allowing most children (and parents) to sleep through the night.
NON-REM Sleep: A “Quiet Sleep” pattern in which infants display less movement, a regular breathing pattern, and a deeper sleep in which it seems to be very difficult to awaken your baby.

Although most children learn to sleep through the night on their own, here are a few tips to follow to try to avoid future sleep problems:

Before 4 Months:

Keep ’em Cozy. Your newborn has been used to 9 months of close quarters while she was growing inside you. Keep her comfortable by swaddling her, using a small bassinet or crib, and keeping the room at about 68° to 72°F. Caution: don’t over bundle, and don’t use sheepskins, waterbeds or down comforters because of the risk of suffocation.
Give ’em their own space. Many parents prefer to have the child’s bassinet in their own room. While this may calm your fears, you will wake up to every movement when your baby is going through REM sleep. Try to move your baby to her own room by one month of age.
Put your baby in the crib while awake. Let your baby learn to fall asleep without you. Crying for 15 to 20 minutes is not unusual. If necessary, rock her, but put her in the crib before she falls asleep. Background noise may also help to signal nap times or bed time. Try a radio, air conditioner, a musical toy, tapes of uterine sounds, or the white noise that comes from an unoccupied TV channel or radio frequency. Try to wean the use of noises by 4 months of age.
Establish a routine. A consistent daytime and nighttime ritual for naps and bedtime is extremely important. If your hectic schedule does not permit this, try to always be home for the same nap time every day.
Hold your baby for fussy crying. Children under 4 months need to be soothed. Respond to your baby. You will not spoil her.
Be brief during nighttime feedings. Save the fun stuff (singing, playing etc.) for the daytime.

Don’t awaken your child during the night to change diapers. Wet diapers can be left until the morning, unless your child has a severe diaper rash.

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