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Traction alopecia is a form of hair loss that results from prolonged or repetitive tension on hair. Traction alopecia most commonly occurs along the frontal or temporal scalp, but can also occur in other sites of the scalp and in other hair-bearing areas (picture 1A-C).Having a high clinical suspici

ClosePelvic muscle exercisesPelvic muscle exercisesIdentify the correct muscles to contract. Women can do this by placing a finger in the vagin* and squeezing the muscles around their finger. Another way is for a woman to imagine that she is sitting on a marble. Imagine using the vagin*l muscles to gently lift the marble off the chair. The muscles of the buttocks, abdomen, and thighs should not be used. Second, hold the pelvic muscle contraction approximately 8 to 10 seconds, and then relax the muscles; adequate relaxation is as important as contraction. In the beginning, it may not be possible to hold the contraction for more than one second. Perform 8 to 12 contractions followed by relaxation three times. Try to do this every day, but no less than three or four times a week. The exercise regimen should be continued for at least 15 to 20 weeks. Over time, try to hold the contraction harder and for a longer time. These exercises need to be continued indefinitely to have a lasting effect, similar to other forms of exercise. In patients whose muscles are weak, the exercises should initially be done while lying down. As the muscles become stronger, the exercises may be done while sitting or standing. The muscles should be contracted during activities that can cause urine leakage, such as during physical exercise, lifting, coughing, or sneezing.Graphic 81507 Version 5.0

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon peripheral T cell lymphoma arising around textured-surface breast implants placed for either reconstructive or cosmetic indications. The association of breast implants with a cancer of the immune system has created un

Acne keloidalis nuchae (AKN) is a common, chronic disorder involving inflammation and scarring of the hair follicles, with the subsequent development of keloid-like papules and plaques and scarring alopecia (picture 1A-G). The characteristic site of involvement is the posterior scalp and neck. Infre

Hair and scalp dermoscopy, also known as trichoscopy, is a useful, noninvasive, adjunctive tool for the diagnosis of alopecia and other scalp and hair disorders. The utility of dermoscopy resides in improved visualization of abnormalities of follicular ostia, perifollicular skin, cutaneous blood ves

The "pelvic floor" refers to a group of muscles that support the organs in the pelvis. These organs include the bladder and rectum; in the female pelvis, they also include the uterus (figure 1).The pelvic floor muscles play an important role in bladder and bowel control. Like any muscles, they can b

Modern breast reconstruction began in 1964 with the introduction of the silicone breast implant. Since that time, implants have evolved, although the basic components have remained essentially unchanged. Implants themselves can be filled with either saline or silicone gel. Breast implants are used e

CloseExserohilum rostratumExserohilum rostratumThe genus is characterized by its conidia, which are ellipsoidal, distoseptate, and have a protruding and truncate hilum. Exserohilum spores have an inner cup-like structure, which is visible in the basal cell. Colonies are grey to blackish-brown, suede-like to floccose in texture, and have an olivaceous black reverse. Conidia are straight, curved or slightly bent, ellipsoidal to fusiform, and are formed apically through a pore (poroconidia) on a sympodially elongating geniculate conidiophore. Conidia have a strongly protruding, truncate hilum and the septum above the hilum is usually thickened and dark. The end cells are often paler than the other cells and the walls are often finely roughened. Conidial germination is bipolar.Reproduced from: United States Centers for Disease Control and Prevention. Multistate Meningitis Outbreak Investigation. Available at: https://www.cdc.gov/fungal/diseases/other/exserohilum-rostratum.html (Accessed on December 17, 2021).Graphic 86772 Version 8.0

Difficulty swallowing is a disturbing symptom that occurs in many patients with a serious life-limiting illness. In fact, swallowing disorders, distinct from diminished appetite, are part of the natural process at the end of life, irrespective of the etiology. Difficulty swallowing can impact the qu

CloseIncontinentia pigmentiIncontinentia pigmenti"Marble cake" hyperpigmentation in a female infant with incontinentia pigmenti.Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved.Graphic 63009 Version 6.0

CloseCommon poisoning syndromes (toxidromes)Common poisoning syndromes (toxidromes) Toxidrome Mental status Vital signs Skin Pupils Other manifestations Examples of causative agents Excitatory Sympathomimetic Hypervigilance Agitated delirium (can be violent) Hallucinations ParanoiaT: Increased HR: Increased RR: Increased BP: Increased Wet Dilated Seizures Widened pulse pressure Amphetamines Cocaine Cathinones Ephedrine Phenylpropanolamine Pseudoephedrine Anticholinergic Hypervigilance Agitated delirium (usually easily controlled) Hallucinations (picking at objects in air) Mumbling speech (described as "mouth full of marbles")T: Increased HR: Increased (but may be normal in early poisoning) RR: Increased BP: Increased or normal Dry and flushed Dilated Dry mucous membranes Decreased bowel sounds Urinary retention Choreoathetosis Seizures (rare) Diphenhydramine (and other antihistamines) Atropine and similar agents (hyoscyamine, dicyclomine, scopolamine, and naturally occurring belladonna alkaloids [eg, jimson weed]) Tricyclic antidepressants Cyclobenzaprine Orphenadrine Phenothiazines Hallucinogenic Hallucinations Perceptual distortions (typically visual) Depersonalization Synesthesia Agitation (can sometimes occur and without delirium)T: Increased or normal HR: Increased or normal RR: Increased or normal BP: Increased or normal Variable Dilated (usually) Nystagmus (phencyclidine, ketamine) Tachycardia, hypertension, agitated delirium (designer phenethylamines) Designer phenethylamines and tryptamines (eg, MDMA ["ecstasy"], MDEA) Ketamine and methoxetamine LSD and psilocybin Phencyclidine Mescaline Serotonin syndrome (serotonin toxicity) Agitated delirium Confusion Awake and unresponsiveT: Increased HR: Increased RR: Increased BP: Increased Wet, flushed, or normal Dilated Tremor, hyperreflexia, clonus (typically in lower extremities) Roving eye movements (ocular clonus) Diarrhea MAOIs Tricyclic antidepressants SSRIs and SNRIs Dextromethorphan Meperidine Refer to UpToDate content on combinations of agents that can cause serotonin syndrome Inhibitory Opioid Sedation ComaT: Decreased or normal HR: Decreased or normal RR: Decreased or apneic BP: Decreased or normal Variable Constricted (may be pinpoint) Noncardiogenic pulmonary edema Needle marks Can develop hypotension Opioids (eg, fentanyl and analogues, heroin, morphine, methadone, oxycodone, hydromorphone) Diphenoxylate Loperamide Sedative-hypnotic Sedation Confusion Stupor ComaT: Decreased or normal HR: Decreased or normal RR: Decreased, apneic, or normal BP: Decreased or normal Variable Variable Nystagmus Barbiturates can cause respiratory depression or apnea In most cases, isolated benzodiazepine ingestions do not cause respiratory depression Cyclical coma and myoclonic encephalopathy (carisoprodol, meprobamate, glutethimide) Benzodiazepines Barbiturates Ethanol and other alcohols Gabapentin and pregabalin Zolpidem Carisoprodol Glutethimide Meprobamate Cholinergic Sedation Confusion Stupor ComaT: Normal HR: Low (may be increased in early poisoning) RR: Decreased or increased BP: Decreased or normal Wet Constricted Seizures (typically occur early) Salivation Urinary and fecal incontinence Vomiting, diarrhea, abdominal cramps Bronchorrhea and bronchoconstriction Muscle fasciculations and paralysis Weakness Organophosphate and carbamate insecticides Nerve agents (eg, VX, tabun, sarin, soman, and Novichok) Nicotine Physostigmine Rivastigmine Bethanechol Pilocarpine UrecholineT: temperature; HR: heart rate; RR: respiratory rate; BP: blood pressure; MDMA: 3,4-methylenedioxymethamphetamine; MDEA: 3,4-methylenedioxy-N-ethylamphetamine; MAOIs: monoamine oxidase inhibitors; SSRIs: serotonin-specific reuptake inhibitors; SNRIs: serotonin-nonspecific reuptake inhibitors; VX: venomous agent X.Graphic 71268 Version 24.0

CloseBotryomycosis lesionBotryomycosis lesionLesion on the left knee.Reproduced with permission from: Magauran CE, Oethinger M, Armstrong WS. Photo Quiz: A marble under the skin. Clin Infect Dis 2008; 47:1579. Copyright ©2008 University of Chicago Press.Graphic 76152 Version 2.0

ClosePatient education: Pelvic muscle (Kegel) exercises (The Basics)Patient education: Pelvic muscle (Kegel) exercises (The Basics) Please read the Disclaimer at the end of this page.What are pelvic muscle exercises? — Pelvic muscle exercises are exercises that strengthen the muscles that support the organs in the pelvis. These organs include the bladder and rectum. In the female pelvis, they also include the uterus (figure 1). The pelvic muscles are also called the "pelvic floor."Pelvic muscle exercises are also known as "Kegel" exercises. They can help keep you from leaking urine, gas, or bowel movements, if leaks are a problem for you. They can also help with a condition called "pelvic organ prolapse." This is when the organs in the lower belly drop down and press against or bulge into the vagin*.How do I learn how to do pelvic muscle exercises? — If you want to try pelvic muscle exercises, start by talking to your doctor or nurse. They can talk to you about whether these exercises can help you. They can also teach you how to do them correctly.You will need to learn which muscles to tighten. It is sometimes hard to figure out the right muscles. Below are some ways you can practice: ●People with female or male anatomy – Squeeze the muscles you would use to avoid passing gas.●People with female anatomy – Put a finger inside your vagin* and squeeze the muscles around your finger. Or you can imagine that you are sitting on a marble and have to pick it up using your vagin*.●People with male anatomy – Squeeze the muscles that control the flow of urine. These exercises might help reduce urine leaks in people who have had surgery to treat prostate cancer or an enlarged prostate.No matter how you learn to do pelvic muscle exercises, it's important to know is that the muscles involved are not in your belly, thighs, or buttocks.After you learn which muscles to tighten, you can do the exercises in any position (standing, sitting, or lying down).Should I see a physical therapist? — Your doctor or nurse might suggest working with a physical therapist who has special training in pelvic floor issues. They can check your muscle strength and teach you specific exercises.How often should I do the exercises? — A common approach is to try to do a set of the exercises 3 times a day.For each set, do the following about 10 times:●Squeeze your pelvic muscles.●Hold the muscles tight for about 10 seconds. ●Relax the muscles completely.Keep up this routine for at least a few months. You will probably notice results, but it might take a few weeks to several months. How do pelvic muscle exercises help? — Pelvic muscle exercises can help:●Prevent urine leaks in people who have "stress incontinence" – This means they leak urine when they cough, laugh, sneeze, or strain.●Control sudden urges to urinate – These happen to people with "urinary urgency" or "urge incontinence."●Control the release of gas or bowel movements●Improve symptoms caused by pelvic organ prolapse – These can include pressure or bulging in the vagin*. If you have these symptoms, it's important to see your doctor or nurse to find out the cause.It might take a few months of doing the exercises regularly before you notice them working. If you have been doing pelvic muscle exercises for several months and they don't seem to be making a difference, tell your doctor or nurse. They might suggest seeing a physical therapist or trying other treatments for your condition.More on this topic Patient education: Urinary incontinence in females (The Basics) Patient education: Treatments for urgency incontinence in females (The Basics) Patient education: Surgery to treat stress urinary incontinence in females (The Basics) Patient education: Pelvic organ prolapse (The Basics) Patient education: Urinary incontinence treatments for women (Beyond the Basics) Patient education: Urinary incontinence in women (Beyond the Basics) Patient education: Pelvic floor muscle exercises (Beyond the Basics)This topic retrieved from UpToDate on: Jan 01, 2023.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 15929 Version 11.0

The goals of reconstructive surgery for the burn patient are first to restore function, then to restore aesthetic appearance. Nowhere else in the body is it more important to achieve good functional reconstruction matched with perfect cosmetic appearance than in the head and neck, and specifically t

Pseudofolliculitis barbae (pseudofolliculitis of the beard), often colloquially referred to as "razor bumps," "shave bumps," or "ingrown hairs," is a common cutaneous condition that develops as a result of the removal of facial hair. Pseudofolliculitis barbae most frequently occurs in association wi

CloseSample diet recommendations after Roux-en-Y gastric bypass and gastric sleeve proceduresSample diet recommendations after Roux-en-Y gastric bypass and gastric sleeve procedures Diet stage* Begin Fluids/food Guidelines Stage 1   Postoperative days 1 and 2Clear liquids: Non-carbonated; no calories No sugar; no caffeine Patients undergo a Gastrografin swallow test to rule out a leak on postoperative day 1 after Roux-en-Y gastric bypass. Sips of clear liquids may be started after the test. Stage 2   Postoperative day 3 (discharge diet)Clear liquids: Variety of no-sugar liquids or artificially sweetened liquids. Encourage patients to have salty fluids at home. Solid liquids: Sugar-free ice pops. Plus full liquids: Less than 25 grams sugar per serving; protein-rich liquids (limit 25 to 30 grams protein per serving of added powders). Patients should consume a minimum of 48 to 64 ounces of total fluids per day, 24 to 32 ounces or more ounces of clear liquids, plus 24 to 32 ounces of any combination of full liquids (meal replacement liquids):1% or skim milk, plain or mixed with:Whey or soy protein powder (limit 30 g protein per serving). Whey isolates if lactose intolerant. Lactaid milk or soy milk mixed with soy protein powder. Light yogurt, no fruit chunks; less than 20 grams of sugar per 8 ounces. Plain yogurt; Greek yogurt. Stage 3   Postoperative days 10 to 14*Increase clear liquids (total liquids 60 plus ounces per day) and replace full liquids with soft, moist, diced, ground, or pureed protein sources as tolerated. Soft solid foods including eggs; ground meats; poultry; soft, moist fish; added gravy; bouillon; light mayonnaise to moisten; cooked beans; hearty bean soups; cottage cheese; low-fat cheese; yogurt.Protein food choices are encouraged for 3 to 6 small meals per day; patients may only be able to tolerate a couple of tablespoons of food at each meal/snack. Protein should be moist and ground, pureed, or diced. Encourage patients not to drink with meals and to wait ∼30 minutes after each meal before resuming fluids. May continue to replace one meal or snack with a nutritional shake.   Patients continue to advance diet as tolerated; emphasis on slow, mindful eating; planning 5 to 6 small meals/snacks and adequate hydration Advance diet (amount and texture) as tolerated; patients should be incorporating well-cooked, soft vegetables and soft and/or peeled fruit. Include salads as tolerated. Adequate hydration is essential and a priority for all patients during the rapid weight loss phase.  Stage 3 lasts for months; every patient is different, and all patients should be encouraged to advance diet (texture and portions) at their own pace Frequent nutrition follow-up during this phase is imperative Continue to consume protein with some fruit or vegetable at each meal; some people tolerate salads one month postoperatively. AVOID rice, bread, and pasta until patient is comfortably consuming 60 grams protein per day and 3 to 5 servings of fruits/vegetables per day. Since grains are a rapid source of energy, they are not "essential" during the rapid weight loss phase, as caloric needs are met through utilizing body fat stores. The diet should provide all "essential" nutrients through food choices and supplementation. May switch to pill form of supplement. Stage 4   6 to 8 weeks after surgeryHealthy solid food diet, as hunger increases and more food is tolerated. Vitamin and mineral supplement daily.¶ Healthy, balanced diet consisting of adequate protein, fruits, vegetables, and whole grains. Calorie needs are determined based on height, weight, and age of the patient.RYGB: Roux-en-Y gastric bypass. * There is no standardization of diet stages; there is a wide variety of diet protocols varying from how long patients stay on each stage to what types of fluids/foods are recommended. Dietary advancement is based on nutritional needs and increasing tolerance for dietary texture, meaning that soft foods should be introduced successfully before any hard solids are allowed.¶ Nutritional laboratory tests should be drawn at 2, 6, and 12 months and yearly indefinitely and bone density tests at baseline and every 2 years.Table provided with permission: Sue Cummings, MS, RD, LDN; MGH Weight Center, Boston, MA.Graphic 62266 Version 5.0

CloseModifications in food texture and consistency for patients with swallowing disordersModifications in food texture and consistency for patients with swallowing disorders Texture/consistency Definition Example Indication Puree Blenderized food with added liquid to form smooth consistency; no chewing necessary Applesauce, yogurt, moist mashed potatoes, puddings Reduced tongue function for chewing, impaired pharyngeal contraction, esophageal stricture, reduced laryngeal closure Mechanically altered Ground, finely chopped, or minced foods that form a cohesive bolus with minimal chewing Orzo pasta, soft scrambled eggs, cottage cheese, ground meats Some limited chewing possible but protracted due to impaired tongue control Soft, moist Naturally soft foods requiring some chewing; food is easily cut into small pieces; serve with gravy to moisten Soft meats, canned fruits, baked fish; avoid raw vegetables, bread, and tough meats Reduced endurance for prolonged meal due to tongue weakness for chewing, reduced attention span Liquid Moderately thick (previously called nectar consistency) Similar in viscosity to gravy or honey; available in ready-to-serve packaging or use thickening agent Reduced oral or lingual control, premature spillage, delayed swallow initiation and airway closure Nectar consistency Similar in viscosity to thick tomato juice or nectar juice; flows more slowly than water Reduced bolus control, premature spillage, delayed swallow and airway closureAdapted by permission of Oxford University Press, USA. Dahlin CM, Cohen AK, Goldsmith T. Dysphagia, Xerostomia, and Hiccups. In: Oxford Textbook of Palliative Nursing, 3rd ed, Ferrell BR, Coyle N (Eds), Oxford University Press 2010. Copyright © 2010. www.oup.com.Graphic 95391 Version 3.0

ClosePatient education: Starting solid foods during infancy (Beyond the Basics)Patient education: Starting solid foods during infancy (Beyond the Basics)Authors:Teresa K Duryea, MDDavid M Fleischer, MD Section Editors:Kathleen J Motil, MD, PhDJan E Drutz, MD Deputy Editor:Mary M Torchia, MDLiterature review current through: Nov 2022. | This topic last updated: Mar 17, 2022.Please read the Disclaimer at the end of this page.SOLID FOODS OVERVIEW — The practice of introducing complementary foods (solid foods and liquids other than breast milk or infant formula) during the first year of life has varied over time and across cultures. The American Academy of Pediatrics and World Health Organization recommend that complementary foods be introduced around six months of age [1,2].This article will review when and how to start giving complementary foods, including which foods should be avoided. More detailed information about starting solids is available separately. (See"Introducing solid foods and vitamin and mineral supplementation during infancy".)Certain vitamins and minerals may be lacking in an infant's diet, especially in infants who were born prematurely. The importance of iron, fluoride, vitamin B12, and vitamin D will also be discussed here.WHEN SHOULD MY INFANT START SOLIDS?Developmental milestones — The best time to start solid foods depends not only on your child's age, but also on your child's ability to sit up, support their head, and meet other developmental milestones. These guidelines apply to all children, including those who have delays with gross motor skills. Your infant should be able to do the following:●Sit with support.●Have good head and neck control.●Push up with straight elbows from lying face down.●Show readiness for varied textures of supplemental foods by placing their hands or toys in their mouth.●Lean forward and open the mouth when interested in food, and lean back and turn away when uninterested in the food or not hungry.Additional skills are necessary before your infant should be allowed to progress to eating finger foods [3]:●By 8 to 10 months, infants begin to have the skills necessary to eat finger foods independently (can sit independently, grasp and release food, chew food [even without teeth], and swallow).●By 12 months, fine motor skills improve, allowing children to grasp pieces of food between two fingers.Why wait to start solids? — Introducing solid foods before age four to six months is not helpful and could be harmful. Reasons that expert groups recommend delaying the introduction of solid foods include the following:●Introducing solid foods before your infant is four to six months of age may interfere with their ability to take in an adequate number of calories or nutrients.●Young infants do not have the coordination and/or skills to safely swallow solid foods, which could lead to aspiration (inhaling food/liquid into the lungs).●Infants have a reflex (called the extrusion reflex) that causes them to raise the tongue and push against any object that is placed between their lips. This reflex usually disappears between four and five months of age. Trying to spoon-feed an infant who still has the extrusion reflex can be a frustrating and difficult experience for both of you.●By four months of age, most infants have doubled their birth weight. When your infant has doubled their birth weight and weighs at least 13 pounds (5.9 kg), you may need to begin supplementing their liquid diet with additional foods to support growth and satisfy hunger.●Withholding solid foods after your infant is six months of age may lead to decreased growth because children may not consume enough calories from breast milk or formula alone. In addition, delaying beyond six months may lead to resistance to trying solid foods. Withholding solid foods until after six months does not appear to prevent the development of allergies or eczema.SOLID FOOD PRECAUTIONSFoods to avoid — Certain foods should not be given to any child under 12 months, including liquid, whole cow's milk; hard, round foods that could cause choking (eg, nuts, grapes, raw carrots, or candies); and honey. Cow's milk is not recommended because it does not contain adequate iron; honey is not recommended due to the potential risk of exposure to a harmful bacteria toxin (botulism poisoning). (See"Botulism".)Food allergy concerns●Which infants are at higher risk for food allergy? – Although there is no international consensus of what defines an infant at high risk for food allergy, an allergy expert workgroup developed a gradient of risk assessment that includes five categories in order of increasing risk [4]:•Infants in the general population (lowest risk); some infants without identifiable risk factors develop food allergy, but the risk is low•Infants with a parent who has allergic disease•Infants with mild to moderate eczema•Infants with known food allergy•Infants with severe eczema (highest risk)The gradient risk assessment helps families to understand their infant's risk of developing food allergy compared with other infants. (See"Patient education: Eczema (atopic dermatitis) (Beyond the Basics)" and"Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)".)The recommendations for the timing of introducing highly allergenic foods are the same for infants at the highest risk as for infants in the general population because there is no evidence that pathophysiologic mechanisms of allergy sensitization differ among infants from one category to the next [4]. (See"Patient education: Eczema (atopic dermatitis) (Beyond the Basics)".)●When to introduce highly allergenic foods – For all infants, experts recommend that caregivers introduce traditional supplemental foods (eg, cereals; puréed fruits, vegetables, and meats) beginning between four and six months [1,2,4]. If your infant has no signs of allergy with the initial foods, additional foods can be introduced gradually, including the highly allergenic foods (eg, cow's milk, eggs, peanuts, tree nuts, soy, wheat, fish, and shellfish) [4]. Whole cow's milk should not be given to any child until after age 12 months, but yogurt and cheese can be given before 12 months. Whole nuts should not be given to infants because of the choking risk, but caregivers can spread a thin layer of nut butter on other foods, or purée nuts or nut butters with fruits or vegetables. (See 'Foods to avoid' above.)These recommendations are based on randomized trials that evaluated the specific timing of introducing highly allergenic foods and the risk of developing food allergies [4,5]. The studies did not find enough evidence to support waiting to introduce highly allergenic foods. In addition, the studies showed that early introduction of highly allergenic foods may actually decrease the risk of food allergy [6]. Although experts previously recommended that caregivers delay introducing highly allergenic foods to high-risk children for months or years after other foods, this practice is no longer recommended [7]. (See 'Types of supplemental foods' below and"Introducing highly allergenic foods to infants and children".)●How to introduce highly allergenic foods – The safest way to introduce highly allergenic foods has not been studied. It is possible for an allergic reaction to occur the first time a child eats a particular food. The most common symptoms of an allergic reaction seen in infants are hives and/or vomiting. We recommend giving highly allergenic foods to high-risk children in the following manner [4] (see"Introducing highly allergenic foods to infants and children"):•Your infant can be given an initial taste of one of these foods at home, rather than at day care or at a restaurant.•If there is no apparent reaction, the food can be introduced in gradually increasing amounts.•Consult your child's health care provider if your child has signs of an allergic reaction after eating a food or has moderate to severe eczema that is difficult to control. An allergy evaluation may be suggested in these cases. (See"Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)".)TYPES OF SUPPLEMENTAL FOODS — There is no one food that is recommended as a first food. Single-ingredient foods should be introduced first, one at a time, every few days, to determine if your child has an allergic reaction. As solid foods are introduced, infants should consume no more than 28 to 32 ounces of formula per day. Breastfed children can continue to nurse on demand.Cereal — Single-grain infant cereal is a good first supplemental food because it supplies additional calories and iron. Rice cereal is traditionally offered first because it is widely available and is least likely to cause an allergic reaction. Oat cereal is another good choice. However, wheat products (in cereal or other foods) may be offered by six months of age.Infant cereals can be prepared by adding breast milk, infant formula, or water. The consistency should initially be thin and may be made thicker over time. Cereal should be offered initially by spoon in small amounts (one teaspoon [5 mL]) at the end of breast- or bottle-feeding. Spoon-feeding helps to develop your infant's ability to coordinate mouth and swallowing movements as well as enhance future speech development. Gradually increase the amount of cereal to two tablespoons (30 mL) two to three times per day by 8 to 10 months of age and four times per day by 12 months of age [3].If your child refuses or appears uninterested in the cereal, try again the following day using a thinner mixture.Cereal should not be added to a bottle unless this is recommended by a health care provider as a treatment for gastroesophageal reflux (GER). Feeding cereal from a bottle can prevent your child from learning to eat with a spoon. Infants with GER should be given cereal from a spoon in addition to the cereal in a bottle. (See"Patient education: Acid reflux (gastroesophageal reflux) in infants (Beyond the Basics)".)Could cereal help my child sleep through the night? — Most caregivers are eager for their infant to sleep through the night. However, it is uncertain whether giving cereal to a child who is younger than four to six months old will help them to sleep better.Puréed foods — Single-ingredient puréed foods, including meats, vegetables, and fruits, should be introduced one at a time, every few days. If your child has no signs or symptoms of an allergic reaction, a second food may be added. Signs and symptoms of a food allergy include hives (skin welts) or other skin rash, facial swelling, vomiting, diarrhea, coughing, wheezing, difficulty breathing, weakness, or pale skin. Consult your child's health care provider if any of these problems occur. (See"Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)".)The goal is to expose your infant to new flavors and textures of food. The amount eaten is less important. The order in which foods are introduced (vegetable, fruit, or meat first) is probably less important than the texture and consistency of the food.By the time your infant is eight months of age, we suggest that they consume two to three tablespoons of fruits and vegetables twice per day [3]. ●First foods should be finely puréed, contain only one ingredient, and should not contain additives (salt, sugar). Vitamin C (also called ascorbic acid) is often added to commercially prepared infant foods.●Second foods are puréed or strained, often contain two or more ingredients (eg, fruit and grain, meat and vegetable), and should not contain additives (salt, sugar). Combination foods may be given after your child tolerates the individual components. Once thin purées are tolerated, thicker purées can be introduced.●Third foods are usually combinations of food types, some of which have texture to encourage chewing. Some are seasoned with spices, although foods should not contain added salt or sugar. Chunkier blends often contain puréed food with small pieces of pasta, vegetables, or meat.Safety issues with jarred baby food — Safety issues regarding jars of baby food include the following:●After opening a jar or container of baby food, store it in the refrigerator to avoid spoilage.●Jars of infant foods, once opened, should be discarded after two to three days according to most manufacturers.●Store-bought foods should be served from a bowl rather than out of the jar to avoid contaminating the unused portion. Food left in the bowl should be discarded.●Jarred foods may be served cold, room temperature, or warm.Preparing baby food at home — You may choose to make your own puréed baby food for a variety of reasons (eg, freshness, increased variety and texture, cost, avoidance of preservatives, etc). The United States Department of Agriculture provides guidelines for safe preparation of baby food at home.It is important to be careful when preparing certain foods at home. Home-prepared spinach, beets, green beans, squash, and carrots should not be given to infants younger than four months of age because they may contain enough of a chemical (nitrates) to cause a condition that reduces the amount of oxygen carried by the blood (methemoglobinemia) [8]. In addition, home-prepared foods should not be given as infant food if they contain large amounts of added salt and/or sugar [9].Finger foods — As your child gains the ability to feed themself, a greater variety of "adult" foods can be offered, including finely chopped, soft foods [3].Foods that are choking hazards are not recommended in children younger than four years. These foods include hot dogs, peanuts, tree nuts, grapes, raisins, raw carrots, popcorn, and round candies.Fruit juice — Fruit juice should be introduced when an infant is older than 12 months. Before age 12 months, fruit juice is usually not necessary or recommended [10].VITAMIN AND MINERAL SUPPLEMENTS — Some children require vitamin or mineral supplements.Iron — Iron deficiency is the most common nutrient deficiency in the United States. The amount of iron required depends upon your child's gestational age and birth weight.●Premature and very low birth weight infants are at risk for iron deficiency and should be given an iron supplement (in the form of multivitamin drops) beginning at one month of age and continuing until your child is at least 12 months of age.●Infants who are not premature who are given iron-fortified formula usually do not need any additional iron supplementation. Low-iron formulas are not recommended in any situation and are no longer available in the United States.After four to six months of age, a full-term breastfed infant may not get an adequate amount of iron from breast milk alone. At this time, some form of iron supplementation (eg, iron-fortified infant cereal) is recommended. An average of two servings (two ounces of dry cereal per serving) of iron-fortified cereal per day is sufficient to meet an infant's daily iron requirement. Additional iron can be given (in the form of multivitamin drops) if your infant cannot consume an adequate amount of iron-fortified cereal. (See"Patient education: Breastfeeding guide (Beyond the Basics)".)After solid foods have been introduced, at least one feeding per day should contain foods rich in vitamin C (eg, citrus fruits and juices, cantaloupe, strawberries, tomatoes, and dark green vegetables) to promote iron absorption from iron-rich foods (such as puréed meat) eaten during the same meal.Fluoride — Fluoride is a mineral that is often found in drinking water. Fluoride can reduce the risk that a young child will develop dental caries, also known as cavities [11]. However, not all drinking water contains an adequate amount of fluoride.A fluoride supplement is recommended for children between six months and three years if the fluoride level in the local water supply is low [11] or if your infant is drinking only breastmilk. To determine the level of fluoride content in your water supply, call the water department or bottler, or arrange to have well water tested.Vitamin B12 — The body requires a source of vitamin B12 to maintain blood cells; meat, eggs, and dairy products are the only food sources of vitamin B12. Low levels of vitamin B12 can lead to anemia, developmental delay, and other problems.A multivitamin supplement that includes B12 is recommended for breastfeeding infants of strict vegetarian (or vegan) mothers and for infants who are fed a vegetarian diet. Adequate B12 is available in most nonprescription infant vitamin drops and in certain brands of nutritional yeasts, most ready-to-eat cereals, many meat substitutes, and some milk alternatives. Fortified soy milk is a good source of B12 for children.Vitamin D — The body requires vitamin D to absorb calcium and phosphorus, which are essential minerals for the formation of bones. Inadequate levels of vitamin D in children can lead to a condition known as rickets, which causes bones to be fragile and to break easily. This is especially true in dark-skinned children.All infants, including those who breastfeed and/or bottle-feed, should be given a supplement containing 400 IU of vitamin D per day, starting within days of birth [12]. Vitamin D is included in most nonprescription infant vitamin drops. In some countries, it is possible to buy infant drops that contain only vitamin D. Once infants are drinking at least one liter of formula per day, the vitamin D drops are no longer necessary. Infant formulas have vitamin D added, and one liter of infant formula contains 400 IU (international units) of vitamin D.WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients and caregivers, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Weaning from breastfeeding (The Basics) Patient education: Starting solid foods with babies (The Basics) Patient education: Diet and health (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Food allergy symptoms and diagnosis (Beyond the Basics) Patient education: Eczema (atopic dermatitis) (Beyond the Basics) Patient education: Acid reflux (gastroesophageal reflux) in infants (Beyond the Basics) Patient education: Breastfeeding guide (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Dietary history and recommended dietary intake in children Poor weight gain in children younger than two years in resource-abundant countries: Etiology and evaluation Introducing formula to infants at risk for allergic disease Introducing solid foods and vitamin and mineral supplementation during infancy Poor weight gain in children younger than two years in resource-abundant countries: Management Poor weight gain in children older than two years in resource-abundant countries BotulismThe following organizations also provide reliable health information.●Medline Plus(www.nlm.nih.gov/medlineplus/infantandtoddlernutrition.html)●American Academy of Pediatrics(www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx)●Women, Infants, and Children Works Resource Center(https://wicworks.fns.usda.gov/resources/wic-learning-online-job-aids)●Food Allergy Research & Education(www.foodallergy.org)[1-3,5-13]World Health Organization: Complementary feeding. Available at: www.who.int/nutrition/topics/complementary_feeding/en/index.html (Accessed on April 28, 2010).Meek JY, Noble L, Section on  Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2022; 150.Texas Children's Hospital Pediatric Nutrition Reference Guide, 12th ed, Beaver B, Carvalho-Salemi J, Hastings E, et al (Eds), Texas Children's Hospital, Houston, TX 2019.Fleischer DM, Chan ES, Venter C, et al. A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition: Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology. J Allergy Clin Immunol Pract 2021; 9:22.Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015; 372:803.Greer FR, Sicherer SH, Burks AW, et al. The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods. Pediatrics 2019; 143.Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. J Allergy Clin Immunol 2010; 126:1105.Greer FR, Shannon M, American Academy of Pediatrics Committee on Nutrition, American Academy of Pediatrics Committee on Environmental Health. Infant methemoglobinemia: the role of dietary nitrate in food and water. Pediatrics 2005; 116:784.American Academy of Pediatrics Committee on Nutrition. Complementary feeding. In: Pediatric Nutrition, 8th ed, Kleinman RE, Greer FR (Eds), American Academy of Pediatrics, Itasca, IL 2019. p.163.Heyman MB, Abrams SA, SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION, COMMITTEE ON NUTRITION. Fruit Juice in Infants, Children, and Adolescents: Current Recommendations. Pediatrics 2017; 139.Clark MB, Slayton RL, Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics 2014; 134:626.Misra M, Pacaud D, Petryk A, et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics 2008; 122:398.Muraro A, Dreborg S, Halken S, et al. Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol 2004; 15:291.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 1185 Version 32.0References1 : World Health Organization: Complementary feeding. Available at: www.who.int/nutrition/topics/complementary_feeding/en/index.html (Accessed on April 28, 2010).2 : Policy Statement: Breastfeeding and the Use of Human Milk.3 : Policy Statement: Breastfeeding and the Use of Human Milk.4 : A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition: Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology.5 : Randomized trial of peanut consumption in infants at risk for peanut allergy.6 : The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods.7 : Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report.8 : Infant methemoglobinemia: the role of dietary nitrate in food and water.9 : Infant methemoglobinemia: the role of dietary nitrate in food and water.10 : Fruit Juice in Infants, Children, and Adolescents: Current Recommendations.11 : Fluoride use in caries prevention in the primary care setting.12 : Vitamin D deficiency in children and its management: review of current knowledge and recommendations.13 : Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations.

Complications following reconstructive or aesthetic breast surgery are important considerations for women pursuing these options. Reconstructive breast surgery following total mastectomy can be performed using implants as well as one's own tissues (autologous laps). Reconstruction following partial

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