Gastroenterology with Dr. Victoria Martin, MD, MPH

Season Intro and Guest Introduction 0:00

Hello, welcome to Season 5 of the Baby Manual Podcast. This season, I'm doing something a little different and I am speaking with pediatric subspecialists who are all experts in their field so they can tell you about the sort of things that they see in the office and reasons that you might be referred to a subspcialist and then some things you can do at home while you're waiting for your specialist visit. Today, I have the pleasure of speaking with Dr. Victoria Martin, who's an MD and an MPH, and she's just amazing.

She talks all about things like blood in the stool and milk protein allergies and other signs of food allergies in children. So I think you'll really enjoy it. Make sure you listen to the end. Welcome, Dr Martin. Tell me a little bit about yourself and how you got into gastroenterology. Thanks so much for having me. I'm really excited to be here. So like you knew very early on, I wanted to take care of kids and had a particular interest in babies. And then during my training I became really interested in things that happen in baby's intestines, particularly very on.

populate our infant gut starting out from what they get from breast milk and then ultimately the things that may or may not lead to kids having food allergies or fussiness or reflux. And so I do a lot of research trying to understand more about that.

How Pediatric GI Focuses on Infant Gut Health 1:28

That's really cool. I've heard it explained that like the gut is sort of like a second brain for the body that it really affects all kinds of things and not just it's not Just about eating and pooping. Right. Totally. And we're learning so much more about as we get older, the ways that our emotions and the way that we think actually translate into how our gut is feeling. And if you think about, you know, there are lots of expressions we have in many languages about like, trust your gut or listen to your guy.

I think there's lots, lots. Of ways in which we think those two things are really connected. Yeah. Even if. You think of like butterflies in your stomach. Totally. Cool. So what are some of the things that you see early on in babies as a pediatric gastroenterologist? One of the most common things that I see are babies that are fussy, and particularly that our fussy and spitting up. And sometimes I've seen babies where there's a question of whether that may be caused by a certain food, either an ingredient in their formula or something that their mom is eating.

So I'd say in my practice, that's one of things I think most commonly. Yeah. And where would you sort of draw the line between a normal amount of fussiness and spittiness versus we need to really see somebody about this? Yeah, it probably makes the most sense to separate them out. So a baby that's spitting up, so that some of their stomach contents from having recently fed coming up and either you can see it come up almost all the way but then they swallow it back down or actually come it all away and then spit it out.

Normal Reflux vs Concerning Spit-Up 3:03

We call that reflux and that's normal in babies. They're not quite great at keeping everything in their stomach until they get a bit older, get it a little stronger trunk, sit up more, things like that. And so if they're spitting up but it's relatively small volumes and it is not shooting across the room and they are not very fussy, then we don't do anything about that. That's considered normally called that physiologic reflex. On the other hand, if they're really unhappy, really uncomfortable, and it seems to be getting in the way of things that are important like sleeping and eating, then, we start to think about gastroesophageal reflux disease, which means exactly that, it's something that's causing a problem.

And that is when we started to thinking about doing more testing or intervening in some way. Cool. Is there anything that parents should try in the meantime while they're trying to decide like, you know, is my baby spitting up too much or how can I help them spit up less? I know I have a couple episodes in past about this with just sort of tricks, like keeping them upright for 20 or 30 minutes after eating and things. Yeah. I think the first thing when you're worried about something is to pay a little more attention to it and to write down some details.

You always get to that doctor's office and then they ask you questions about like, how many times did they poop yesterday? And you think like gosh, I wish I was writing that down. That doesn't mean we need to spend our whole lives writing everything our kids are doing down, in fact, it's probably much better if we're just present and enjoying them. But when there's something that we are worried, about it is helpful to keep track. Some parents have like an app on their phone or Some parents have a little notebook in their kitchen that is where they keep track of some symptoms.

What you could keep check of is how often this thing is happening. If you notice that it's a certain time of day, a time away from eating or drinking, and if it seems to be related to any particular foods that you, the mom, are eating if you're breastfeeding or if the child's old enough to eat other foods than certain foods you are giving them. Data gathering, I would say, would be the first thing you can do before you get to that appointment. And then, like you mentioned, holding kids upright for 20 minutes after feeds if you're worried about how much they're spitting up or maybe refluxing.

Burping is an interesting thing. Some people feel like it helps a lot and I think some babies really benefit from being burped. Other babies, it seems to make them less comfortable or they don't like being interrupted. And so there's some old studies actually about like frequent burping also leading to more reflux. So I think that's one that just sort of depends on the baby seeing what works for them, the timing of the burpping and how often you do it. And then there are some over-the-counter medicines that you've mentioned in your, I Think it was in Your Tummy Troubles episode, like semethicone, which is an over the counter medicine that parents can try.

Tracking Symptoms and Trying Simple Reflux Remedies 5:49

Those are sort the primary things that You could try and see if it makes a difference. Cool. Before you talk to your doctor. You had mentioned possibly foods that mom was eating if she's breastfeeding. How long would you say it takes foods to get into the breast milk after mom eats them? Because it's not immediate, I don't think. I perfectly, perfectly left that out because I worry that moms and parents eliminate foods from the diet when they're feeling particularly desperate. And I think years ago, not that many years, ago we thought that that was pretty harmless, right?

You take this thing out of someone's diet, moms or the babies, if the baby's eating solid foods yet, and they get better. So like, who cares, that's a great non-invasive intervention. The problem is that we've learned that having a really varied diet and particularly having early exposure to allergens, proteins that might be allergic someday, consistently in baby's diets is actually preventative against real life threatening food allergies later. So we're really trying to move back away from eliminating lots of foods from people's diet without really having a methodical approach with a doctor helping you decide if that's the right thing to do.

To answer your question though, when you take a food, an allergen out of a mother's who's breastfeeding. The data is really rangy. It can go anywhere from, you know, being out of the breast milk in 24 hours to maybe taking 72 or longer. And then it takes time for the baby's system to get less inflamed or less allergic if that was causing a problem. So we usually tell folks that they eliminate a food, milk, protein, cow's milk being the most common, that it really takes about four weeks to make a decision about whether you think it helped or not.

Yeah, and I know you have to be very strict about eliminating even traces of that from food for it to really be considered an elimination. Yeah. And we do have some parents who feel like when they just reduce the amount that that's helpful. Honestly, that might be less potentially harmful than total elimination from an allergy prevention perspective. Um, I think that's pretty harmless, but it's also really important that moms who are breastfeeding are getting a really healthy, robust diet and all the calories they need.

And so I. It's super important. That if that something you're thinking about that the mom or the lactating mother has the opportunity to see a nutritionist or talk to someone to make sure they're getting the nutrition that they.

Breastfeeding Diet, Elimination, and Food Triggers 8:10

Yeah, that's great advice. I always tell parents, don't cut anything out of your diet when you're breastfeeding. You should and can eat everything. The big variety is always better, because then babies are getting exposed to all those proteins of new foods. Yeah. That's right. And I think for the vast majority of people, That is definitely true. So for things like, there are some foods I feel like that can make reflux a little bit worse, or fussiness or gas. Things like caffeine, garlic, I've heard, maybe some cruciferous vegetables.

Is that something that does that really happen? And when do you see the effect of that? Yeah, as you know, things like this are really hard to study. And so these are the kinds of things that I talk about in a common sense way. If you notice when you're making that diary that every time you eat dark garlic, your baby seems uncomfortable. Stacking off the garlic might make sense. In large scale studies, any that have been done, I'm not aware of any of that give really compelling scientific evidence that removal of some versus others make a big difference.

But it's not harmful, like we said, to try and reduce or remove temporarily as long as we keep our diet pretty, pretty varied otherwise, and that we don't continue it if it didn't make big a difference, if didn t make positive change. One of the things that parents ask me a lot about is what the infant stool looks like. And sometimes they're really worried about thinking that there might be mucus in there or blood in their. Sometimes that can be a sign of allergic inflammation in the GI tract or this milk protein allergy or intolerance.

But also some amount of mucous is normal because bacteria make that in your baby's intestine and it's normal to have some So we talk about, again, this is where the innovation of phones and cameras that are easily accessible has changed a lot. My patients all come with an album full of pictures to show me, and we laugh about it, but it's actually really helpful. A picture is worth a thousand words. Sometimes parents who are really worried can be really relieved just to have sent a picture. Some of them have a patient portal they can upload to or a way that they bring it to their doctor visit, and that can really be helpful for us to take a look and see if anything is concerning to us.

Blood in the stool is almost always not normal, so if you see that, that's definitely something to call your doctor about and talk through, with the exception of a newborn baby girl in their first few days of life. Other than that that is not something normal to talk about. Right. And I also will sometimes suggest to parents to bring in diapers just in case they don't poop while they're in the office. If you have one at home that you think has blood in it, there's a lot of things that look like blood too.

Once they start doing solids, especially watermelon, I feel like is a big one because it just like compresses down to these little red strings. It really looks like lead though. Yeah. Um, you bring on the diaper, the doctor can always test it for blood. The common test that we use in the office is called a Guayac test. It's not perfect, and it has a lot of limitations. Both it can be fooled by certain foods, like you mentioned. But we also, in our research study, have noticed that even totally healthy babies with no symptoms, about 10% of them, if you test their stool,

Blood in Stool and Stool Testing 11:23

will be positive for a little bit of blood at that age, at like one to two month age. And so it may be that some amount of that is actually normal, and that's something we don't totally understand really well yet. But it is a test that, some doctors will use to kind of... It's really helpful if it's negative, I think, because then you know it not blood. I thinks if its positive, it sometimes gives us a little bit more thinking to do. Yeah. That's cool. Tell me more about cow's milk protein allergy and how that actually is diagnosed now.

Typically babies with cow's milk protein allergy or intolerance, and I should say, we need a new term for it because technically it's not an allergy the way that like a peanut allergy would be that you need an EpiPen for that's life-threatening. This is an entity that happens in little babies. It usually starts around one to two months of age and those babies present pretty fussy, sometimes very reflexy, so spitting up a lot. Um, and often with blood and or mucus in the stool. And so it's sort of a clinical diagnosis.

That means that your doctor can make the diagnosis just by listening to you and your story and looking at your baby, looking up pictures of stool, if you have them testing the store for blood, maybe if they think that that's helpful to confirm, um, And then taking milk out of their diet cows milk, either changing their formula. If they're on a cow's milk based formula or taking out the mom's diet, If she's breastfeeding. and seeing if the symptoms go away as part of the diagnosis, but actually internationally now there are guidelines that if that works, if you think that work, you have to put the milk protein back in the diet and prove that all the systems come back.

That's called an in-home challenge before you can technically make that diagnosis. And to be honest, most people have been skipping that for a long time. And now that we know what we talked about a little earlier about how important it is to probably keep these things in baby's diets, we're getting better at doing that challenge. What's so interesting is that there are so many babies that when you were sure they got better when they took it out, a month later when we give it back, they don't have those symptoms anymore.

So we don t know if that's because we were wrong the first time, or if it's just very transient, meaning something that their little GI tract figures out in just that month break, and then they can tolerate the food again. That's really cool. What I remember is that things like milk, soy and eggs are allergies that kids tend to outgrow as they get older, but things, like nut and fish allergies, don't really go away.

Cow's Milk Protein Allergy and Formula Changes 14:02

Yeah, some of that allergies kids outgrow. And we're learning a lot more about how we can speed that along. So there are both some newer medicines on the market that might help kids grow their food allergies. There are also tests we could do and then ways that we do desensitization, meaning giving tiny little bits of the food that they're allergic to to try to help them out grow it when they are at a safe level of allergy. But yeah, milk is often an allergy that's outgrown an egg as well. And so that is part of why we want to make sure that even if we make a diagnosis of cow's milk allergy early in life, that we're constantly questioning whether kids are still allergic.

That's when you would need an allergist or a gastroenterologist or your pediatrician to guide you. Cool. And if they are on a milk-based formula, do we still change them to a hydrolyzed formula? Yeah. So this cow's milk protein allergy or intolerance that I'm talking about is a non-IGE mediated food allergy. That means that it's not the kind of life-threatening allergy that we normally think of kids that have to go to an emergency room or have an EpiPen. There are kids who have that to milk, but it is much rarer in infancy.

And so for that entity, we often change formula if the baby's formula fed, and we change from a standard cow's milk-based formula to usually an extensively hydrolyzed formula. So that means that they take that milk protein and they put it in a processor that chews up all those proteins into tinier chunks called peptides that the immune system we think doesn't react to in the same way, or maybe the gut microbes don't interact to it the way. We don' actually know how this mechanism works. And most babies will get better on that formula.

Some babies need a fully hypoallergenic formula, and that's when they just, instead of having that protein in at all, they put in each individual amino acid, so those tiny building blocks that make up a protein. And kids often will better get on those formulas. The same principle applies that concept of a challenge even if they get much better on the new formula. It's recommended by all the international guidelines now that you actually switch back a month later to make sure that the symptoms really come back and you're really doing the right thing or that it's something that they still need before committing them to six or nine months of that formula before they turn one.

Wow. And that's just a month after starting that change. The symptoms get better. Yes. You start the change, the symptoms got better, and then two to four weeks after that, we feel like the systems are really convincingly better than that when both the DRACMA guidelines and the ESPAGAN guidelines, IMAP guidelines. These are all acronyms for big societies that got together and wrote these ideas down, recommend. That's really cool. Yeah. What other sort of things seem to come up in gastroenterology?

Yeah, so speaking of parents who love showing me pictures of diapers, constipation is another thing that parents often ask about. Many people don't realize that it can be totally normal for babies, particularly new babies to poop seven to even 10 times a day at that those first few weeks at home. But it's also just as normal For them to go seven or sometimes even ten days without pooping. And so that can Be distressing to parents and it Can also look distressed. on the baby. There's this thing called infant dyskisia, which is the medical term for babies looking really uncomfortable when they're pooping.

Squirming, scrunching, face turning all red. And it's actually just how they poop. I tell parents sometimes to think about how hard it would be to poop if you were laying down, Which is what babies are most often doing. You can't quite get into the right position, right? And so that's why they are so squirmy and turn red And so all of those things can be normal.

Constipation, Dyschezia, and Stool Patterns 17:58

We really define constipation by what the poop looks like. And if babies are really constapated, the poops will come out very hard. That can either be like little pellets, like almost like rabbit pellet, or if you've seen other animals that have those hard dried out pellete stools. Ones that if tried to squish in the diaper would be sort of hard to squash that hard, Or sometimes babies can have a big, hold on to a lot of stool and then have big big stool that's like a ball that is hard as a rock.

And that also can be a cause of blood in the stool, because if it's so big when it comes out, it can painful and cause what we call a little fissure, like a cut there. And so both of those would be reasons to talk to your pediatrician. In young infants, the first thing we often try is prune juice, not to drink out of a bottle, but as a medicine in small amounts. Yeah, exactly. And that's to announce of straight fringes per day. Exactly. Yeah. Then as kids get older, if they're eating solid foods, then we can preferentially offer things that start with P conveniently.

So prunes and pears can help a lot. Some families feel like mango helps a And so focusing on some of those foods and a little less on things like banana and dairy products that can be most constipating is really helpful. And this often comes up when kids are starting solid food introduction because their gut is getting exposed to all these different foods that are a bit harder to digest. Parents often say they went from pooping a few times a day and then they skipped three days and they're panicked because that seems like a different pattern, but that's really common as we're trying to introduce new foods.

Yeah. I also feel like around a month of age when they go through that phase of discordant stalling, which is the same as sort of the dyskesia, they're learning how to poop and then. They hold it for a really long time. And then when they finally do poop, it's like a huge explosion out the diaper, up the back, all that. Yeah, and usually when you have them in a nice white outfit and you're like in the middle of events or something is when do that, right? Exactly, or in their car seat. Right, always in my car seats, but yeah, It comes out soft.

So it is not actually constipation at that age, But it can be really alarming for your baby to go for several days without pooping. Totally, totally. I feel like everyone should have a Bristol stool chart in their house. The consistency of the poop and just know that like, yeah, in the middle is normal and then the two extremes is not. Exactly. And infant stools can be a lot more liquidy than even a five or a six on that Bristol Stool chart can normal in infancy. Then as they get older and eat more solid foods, it tends to firm up a bit, which makes sense based on what they're eating, right?

One of the other things that families ask me a lot is what I think about the introduction of allergenic foods and like what foods I recommend introducing early when babies are ready and when to start introducing complementary foods. And the American Academy of Pediatrics recommends introducing solid foods between four and six months and the WHO at six month. And some of this is a little complicated by the fact that we know that the earlier you introduce those allergens, at least peanut, the more likely you are to be able to prevent peanut allergy in kids who are at risk.

So like kids with eczema or other atopic disorders or allergic diseases. You should talk to your pediatrician about whether they think that your baby's ready. And some signs of that readiness are that they're watching you and seeming really interested when you're eating salad. So all of a sudden their like head turns, right? As you like trying to take a bite when they are sitting on your lap or they trying grab for your spoon or your food. That's one signal. Another is that their pretty sturdy in a high chair.

They don't have to be like totally perfect, but they shouldn't like, totally slump over to one side when their sitting in their highchair. We call that good truncal control and head and neck control. And when all those are met, then often it's time to start introducing solid foods. Most people start with something really smooth and soft, like a puree. Once a baby is able to take a few spoonfuls of that reliably, that's a good time introducing allergens and asking your pediatrician most of the time.

We recommend starting with peanut. which you can get in like a powder that can sprinkle onto foods, or once they're ready to start to chew and swallow a little bit, there are puffs that have peanut protein on them that help prevent peanut allergy. Those are called bomba. My kids love, my kids loved those. Yeah. They're not the healthiest otherwise, but they're good for this purpose. And, you know, I think particularly if you're introducing really early, those smooth foods are going to go over better.

As kids are a little bit older, they can tolerate more sort of fork mashed table foods once they start to really learn to chew and move things around in their mouth. Yeah, or even just like a dot of peanut butter on your finger.

Introducing Solids and Allergenic Foods 22:40

Yeah. They're also getting some of that with breastfeeding, right? So I feel like breast feeding babies get introduction from birth to all these proteins. It's tricky. For peanut, that wasn't enough to be preventative. So in the big study called the LEAP study that they did in Europe, what really made a difference was giving that protein straight to the baby, starting at four months. And the reason that study happened is because They noticed that kids of very similar genetic backgrounds that were living in Europe compared to those living Israel.

had very different rates of peanut allergy, and they figured out it was because these bomba were given so commonly as a first food in one country. And so they were sort of like we talked about before, like desensitizing to peanut early on. So that's how we learned about that. That was regardless of whether their mom was also breastfeeding and eating peanuts. Breastfeeding is definitely super important, but it doesn't quite have the preventative effect that we'd like to have, which is why this introduction recommendation came along.

That's really cool. And then some of the other, because I know, or last I knew, the only real big study was on peanuts in the early introduction. But do we just assume the sort of top eight allergens we want to introduce early, like milk, soy, wheat, eggs? Yeah. The data is a little bit more conflicted for other foods. That means that depending on the way it's studied, scientists have found some positive effects and some no harmful effects, but not good effects. And I think that has to do with a lot of things, but like which kids, it was introduced to and how it Was introduced so for my own kids I definitely as they were ready developmentally made sure that they got exposed to a wide range of foods and particularly allergens.

The key, particularly with peanut, which is the one we know the most about, is that once you do it, you want to keep doing it. So it's not like you give them peanut once at four months and pat yourself on the back that they didn't have an allergy, because in fact, it can take a couple exposures for that allergy to come along. And so once your doing, that you wanna do at least a few times a week and kind of keep it in the rotation. And then also keep an eye out for food allergies, like you said, where, you know, when they're very young, it's the blood in the stool.

But then once they start eating solids, that's more vomiting rash. Yeah, I'd say that when I think about a true allergy or an IgE-mediated allergy, the symptoms of those would be hives. So that's that rash with like those big welts all over the body and is usually very itchy. Vomiting can be a sign and certainly trouble breathing, wheezing or drooling. Those would all be reasons I wouldn't even call your doctor. I would call you emergency services number 911 here in the US if you saw things like that.

But the blood or mucus in the stool isn't necessarily a sign that your kid would have an allergy like that. And in fact, those kids may be the kids that are even more important to do some of this early introduction to other allergens like peanut and egg. Yeah. Then if they do have that allergic reaction, I always say wait until they're at least a year old and you've talked to your doctor before reintroducing that food. Yeah, and usually they'll do some blood and skin testing and that helps prognosticate that, helps us figure out who is safe or ready to think about reintroduction and under what circumstances is that someone who could introduce it at home or should be in a hospital or in an clinic office.

There are many offices in the US that are trying to get kids in, and many other countries around the world trying, to do some of those challenges early on, again to try to this ball rolling sooner, so to speak. Yeah. I feel like the two biggest times I saw constipation when I was working outpatient was when they first started solid foods because parents weren't necessarily giving water with it and kids were getting a little dehydrated because they're just eating all this extra food, but not drinking enough.

And then around a year of age when. They started giving them straight cows milk when, you know, Yeah. Often in like larger volumes than maybe they should have. Yeah, totally. And then the third time that's the most common after that is potty training.

Recognizing True Food Allergy Reactions 26:48

Um, and that has to do a lot with how kids are feeling in their own body and trying to hold onto the stool and maybe being a little afraid of the toilet. So yeah, those are definitely the three most times that we see parents worried or thinking that there might be constipation. Yeah. And when it comes up around potty training, I think that's often the hardest one to treat too, right? Because they get into that cycle of like, it hurts to poop because their poop was hard and so then they withhold more and then it's even bigger and more painful the next time.

Yeah, and when that happens, we think about a couple of things. We think backing off on any amount of pressure that we're applying to do this thing right now that is going to poop in the potty. Thinking about ways to make it fun and positive, and so sometimes like a basket of fun activities that they're only allowed to when they are sitting on the party. Rewarding just for sitting, so encouraging just sitting there, not necessarily producing anything. But then also with the help of your doctor, it's our job as the medical team and the parents to make sure that poop never is hard again so that we don't reinforce that idea that it might be painful.

And so we can do that with those pea foods that you talked about. Sometimes kids need medicine for that period of time also to help make that there's plenty of water in the stool and it is nice and soft. And tackling that early, like right when it shows up is really important because it's much easier to treat then than it is when they're five or six or seven and still having trouble with constipation or withholding. Yeah, definitely. And also the medicines that we do use for children are safe in children, right?

We usually use Miralax, which isn't habit-forming like the other Like adult laxatives are different. Right. Mirlax, which is also for adults, it's the same bottle, but it is a powder that is an osmotic agent, meaning that it just helps bring more water into the lumen, into where the stool is formed. And it actually, the medicine and the poop all come out together, so it doesn't get systemically absorbed. There have been big studies now to show that its safe for youth and kids. It's my favorite medicine when I have to turn to a medicine to use.

Potty Training Constipation and Safe Treatments 28:58

Mine too. I tell parents, it's kind of like those Orbeez gel beads, you know, that you put them in water and they puff up. It's like that on like a microscopic level. Yeah. So it just pulls water in and poofs up a bit. And they do have to drink lots of water to keep everything moving and to get it to work. One of the most common things that parents ask me is, How can I help improve my child's diet and particularly in those toddler years when kids are starting to exert their opinion about all sorts of things and so.

I think the most important advice I give people is to include your kids as early as you can in food and meal preparation in whatever way that works for your family. And I always think it's so interesting culturally. Some places we naturally include kids in the food prep when it is like cookies. And I always laugh about that because like they're going to like the cookies either way. You don't need to include them in that. And so like my kids have been involved in making the salad every night since they were 18 months.

They could, you know, stand safely next to the counter and they have their own little food cookie cutters and the cut out fun shapes of the vegetables and those all go into the. Salad and it's remarkable how interested they are in the Salads when they made it compared to when I made. It and particularly if they. Involved when they're most hungry so that time like post school or daycare when you know you're trying to get dinner ready and it feels a little crazy. It's when kids are most likely to steal a bite of that bell pepper and try it for the first time and maybe realize that they like it so.

That's one of the first things I talk to people about is engaging your kids very early in the food that you like as a family. And as much as that can be fresh fruits and vegetables, that could help head off that constipation from coming later and help keep their gut really healthy. Wow. Thank you, Dr. Martin. This has been fascinating talking to you. I love hearing about all the different stuff that you can help with in pediatric gastroenterology. And it really feels empowering for the parents listening to that.

There's so much that they can do at home before having to go to the doctors. So thank you so Any closing words? I don't think so. Thanks so much for having me.

Toddler Diet Tips and Closing Advice 31:08

And, you know, being a parent is really hard. Um, and I think I thought I understood that when I was a pediatrician before I wasn't mom. and then now that I'm a mom of two little ones, it hits a little different, right? And so, um, I. Listening to your gut is the right thing always. When you're worried about something, We gave you some tools here today to process that, but also it's never wrong to talk to your pediatrician and tell them what you're thinking about. And that's what we're here for.

That's our job, to help you decide when to be worried or not. Thanks for having me. Yeah, thank you. Thank you for tuning in. Make sure that you like and subscribe so that can be the first to know when new episodes come out. Also, you can check out the four first seasons of the Baby Manual podcast on your favorite podcasting platform. Or check my YouTube channel for lots of videos and shorts that will help you feel empowered as a new parent as I answer all of common questions that tend to come up in the couple of years of life.

Have a wonderful day.