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Pregnancy, babies & Pets

 

Are you concerned about having a baby around your pet?

pregnant woman cuddling a persian catFamilies all too often surrender their pets to pounds and refuges because they are pregnant, or have recently welcomed a new baby in their home. Fears that the family pet will jeopardize the safety of an unborn or newborn baby can add to the stress of expecting mothers and fathers and as a result, families often react drastically by giving up their pets. Animal Welfare League Qld is at the receiving end of these reactions. We see firsthand how heartbreaking it is for the families who give up their animals, not to mention how distressing it is for the dogs and cats that are given up.

Families can avoid taking such drastic measures with access to practical information about preparing their animals for the arrival of a baby and maintaining a safe and happy environment for ‘furry’ and ‘non‐furry’ family members alike.

This pregnancy, babies and pets guide will advise ‘expecting’ pet owners on how to make their home a safe and happy place for both their animals and their new babies; to encourage pet owners to take a ‘pregnant pause’ and think about the well being of their baby as well as their pets. We believe that educating families about safety with their children and pets will contribute to safer homes for growing children as well as happier homes for their companion animals.

 

Download a PDF version of the Pregnant Paws guide here


Companion animals in the home: Benefits for you and your baby

“The dog was created especially for children. He is the god of frolic.”
‐‐Henry Ward Beecher

Cats and dogs provide companionship, spontaneous, exuberant affection. In return, when we choose to take in an animal companion, we provide a caring a loving home for what should be the duration of its life. The emotional ‘contract’ you make with a companion animal is much the same as the one you make when choosing to bring a new baby into the world ‐ suddenly a life is in your hands, and the well being of this living creature depends on you.

Therefore, as a pet owner, you owe it to your animal to include, rather than exclude it in this wonderful new journey you are taking into parenthood. Initially it may seem daunting, taking care of a new baby as well as your household pet/s, but the benefits of keeping your pets in your (and your new baby’s) life, far outweigh the costs in time and effort.

During pregnancy, your companion cat/s and or dog/s can provide immense comfort, stress relief and can be a welcome diversion. Attuned to their human’s moods and feelings, some companion animals seem to sense their owner’s pregnancy even before they know themselves! Stroking your cat while it sleeps on your lap (or expanding belly) can lower the blood pressure and have a calming effect. Taking your dog for a gentle walk can be wonderful exercise, helping circulation and assisting with good positioning of the baby in the womb in preparation for birth.

Once baby is born and begins responding to the world around it, the benefits of including your pets in your and your baby’s life are clear. Babies seem to have an innate love of animals and are drawn to them with a natural, fond curiosity. Before they can even crawl, babies will reach out to touch and allow their gaze to follow the family pet around the room. As baby grows, so will its interest in the companion animals that share the house. If nurtured, your baby’s relationship with your pets can turn into a life‐long bond. Studies show that bonding between pet and child occurs in the first year of life and from this early interaction grows a strong and deepening attachment (Cusack, 1988).

There are even health benefits to keeping companion animals in the home for your baby. A Study published in 2002 in the Journal of the American Medical Association found that exposure to two or more dogs or cats in the first year of life may reduce the risk of allergic sensitivity to multiple allergens during childhood, including a reduced risk of asthma (August 28, 2002, vol. 288, No. 8). Studies have also shown a link between reduced risks of childhood obesity in families with a companion dog. These reasons alone should inspire any expectant parents to value the important role their companion animals could potentially play in their new baby’s life.

The bond between children and their companion animals can seem intensely deep, exclusive and even magical. To deny your new baby the opportunity to develop such a special connection in childhood with your companion animals because of unjustified fears that the animals may cause harm, would be an opportunity sorely missed. Taking a sensible and calm approach to preparing your home and your pets for the arrival of your new baby will mean allowing your baby the chance to know the joy that a companion animal can bring.

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Your dog and your baby

“Dogs are not our whole life, but they make our lives whole.”
‐‐Roger Caras

Pregnancy and Preparation

Your dog will most probably know you are pregnant before you do. He will certainly be able to sense your shift in mood and no doubt detect hormonal changes. Discovering you are pregnant should therefore be a joy that you share with your companion dog, especially because he was possibly the first to know! Use the months of your pregnancy to prepare your dog for the new arrival and include him in your happiness ‐ after all, your dog is a part of the family.

The key to creating this environment for your dog and therefore building a harmonious relationship between him, you and your new baby is PREPARATION.

International Dog Training experts Craig and Tracey Murray say that good preparation, starting as soon as you find out you are pregnant, is the key to success.

“The key is to create structure for your dog in a manner that he understands,” they say. “Set physical as well as behavioural boundaries and plan the behaviours you will expect from your dog once the baby arrives.”

A Word about Aggressive Dogs

People’s biggest fear is that their dog will become jealous of the new baby and bite or attack the newborn. The reality is that if your dog lives in a calm, structured environment, a new baby in the house will not significantly affect his world. He may be curious and interested, but it is unlikely that he would purposely harm your baby.

The type of dog that would attack a newborn baby, is going to be a dog with existing behavioural issues and is likely to show signs of aggression towards people and/or other dogs, long before there is a baby in the house. More often than not, these behavioural issues are either a result of the current or past owner’s handling of the animal, the dog’s history and/or a failure to socialize the dog appropriately.

If you recognize these types of behavioural issues in your dog, then you must take it seriously and seek professional help from an experienced dog behaviourist or trainer. The trick is to be honest with yourself and your dog. Some dog owners are lax when it comes to their dog’s behaviour and ignore serious problems without even realizing they are doing it. Dogs with serious aggression issues should be considered a risk and inappropriate companions for babies and young children.

Teaching Good Behaviour

“You must teach your dog before you can train your dog,” say Craig and Tracey. This should be your first step in preparing your dog for the new baby. Interactions with your dog should always be calm and positive. Dogs easily sense their owner’s moods and can especially pick up on anxiety and tension. Yelling at your dog, hitting him or punishing him when he does something you consider to be ‘bad’ will not teach him anything. It will only make him more nervous, unpredictable and more likely to engage in future misbehaviours. Rather, Reward your dog when he does behave appropriately or does something ‘good’. For example, when he is sitting calmly at your feet, spontaneously reward him with some encouraging words, pats and even a small food treat. Sitting at your feet (as opposed to on the couch) is something you will expect your dog to do whilst you are nursing your baby in the living area. Start enforcing this behaviour now.

All too often we ignore our dogs when they are behaving appropriately and only pay them attention when they do something wrong ‐ this tends to reinforce those behaviours that we don’t want! Rewarding good behaviour, as in the example above, is teaching your dog good behaviour.

Setting Boundaries

The second step in your preparations is to set the physical and behavioural boundaries that will be in place once the baby arrives.

For example, a physical boundary is a ‘dog‐free’ area of the house. This may be the area where your baby will sleep or play on the floor. To help your dog understand these boundaries, put up gates or playpens to keep the dog out. Practice spending time in these areas without your dog and reward your dog (with reinforcing speak, pats or food) when he waits outside these areas quietly and patiently. Ignore your dog if he behaves inappropriately (i.e. barking, scratching at the door, jumping) whilst you spend time in the ‘dog‐free’ areas.

An example of a behavioural boundary is not allowing your dog to sit in your lap or jump up on you. These are important behavioural boundaries because once your baby arrives, it will be spending much of its time in your arms, sleeping, nursing or being cradled. For the safety of your baby, your dog must get used to the fact that it can no longer invade your personal space. Train your dog not to sit on your lap by rewarding your dog when he is sitting near you, but not on you. If your dog has a habit of jumping up on you, start training him out of this behaviour by turning your back on him and removing all attention from him when he does start jumping up. Once he is calm and not jumping, reward him with pats and calm, positive praise.

Another example of a behavioural boundary is not allowing your dog to run beside you as you are walking up or down the stairs. This is a common behaviour for inside dogs and one that could pose a danger to someone carrying a baby up or down a flight of stairs, potentially getting under their feet and tripping them up. If your dog does exhibit this behaviour, or even has the potential to get under your feet whilst you are on the stairs, train it to wait at the top of the stairs until you have reached the bottom and vice‐versa when you are walking up the stairs. Again, do this by rewarding the behaviour that you do want, like praise if the dog waits and then climbs the stairs after you and removal of praise if he does not.

Bringing Baby Home

“The biggest mistake people make is trying to prepare their dog for the arrival of a new baby three days before it’s born ‐ it’s this lack of consideration for your dog that leads to problems” our dog training experts say. “If you have done the preparation in the months leading up, then by the time you are ready to bring your baby home there should no problems.”

Plan for a smooth meet‐and‐greet with your dog and baby by starting a couple of days before baby comes home.

Investigating new smells

Allow your dog the opportunity to investigate the new baby’s smell before its arrival. If you are to spend a couple of days in hospital, allow someone to bring home an item of clothing or a blanket that will have the baby’s smell on it. Let your dog sniff and investigate the blanket or clothes, whilst you reward him for being calm and gentle. Give your dog a food treat or lots of pats if he calmly investigates the blanket when you allow. If he jumps up or gets overexcited, wait until he is calm before you pay him attention. Do this with a different set of clothes or blanket from the hospital each day that baby and mum are away from home.

When you arrive home with your baby, you should greet your dog no differently than you would have without the baby. By now, if you have put in place the right preparations, your dog should not be jumping up on you and barking at you when you arrive home. Rather, your dog should have been taught that if he sits calmly, then he gets a warm greeting!

It is important to realize that if you greet your dog excitedly and loudly as you walk through the door when you arrive home, then your dog will respond in the same way. Greet him calmly and he will follow suit.

Introductions

Greet your dog calmly, go about your business, and reward him if he is doing the right thing, with calm positive talk as you do so. Do not make a big fuss, stress‐out or act nervous about introducing your dog to your baby ‐ your dog will sense this and it will make him nervous too!

Take a seat in the living room, where you would usually sit, and reward your dog once he is sitting calmly near you on the floor. Allow him then to sniff the little bundle in your arms and reward him (calm, positive praise is enough) if he stays calm. If he barks or tries to jump up into your lap or on the couch, stand up and remove your attention. Your dog will get the message soon enough!

Daily Routines and Quality Time

Many people fear that they will not have enough time for their companion dogs once the baby arrives. Whilst this is partly true ‐ you will not have as much time as you used to for anything ‐ there are many ways to include your companion dog in your daily routines. For example, as mother of a newborn (or father as the case may be) you will spend much time seated on the couch feeding your infant. This is an ideal opportunity to also spend time with your dog.

Allow your dog to lie at your feet and as long as he is behaving calmly, talk to him or even scratch his tummy with your foot as you feed your baby. Your dog will love this and most probably, so will your baby! Both of them will love hearing the sound of your voice and the reassurance that it provides.

Also, providing that you have spent time in your preparation period to teach your dog good behaviours whilst walking on a leash, you can include your dog in daily walks with your baby. Put baby in a baby sling or pouch and you will have both hands free to walk your dog and even throw the ball for him at the park. Both your dog and your baby will enjoy the fresh air and the exercise will be very beneficial to you and your dog.

If you are able to make the effort, do try to allocate at least a small amount of time in your day to have some ‘quality‐time’ with your dog. Even if it is only a few minutes during baby’s naptime, it will mean the world to your dog, who lives for the moment when you pay him attention ‐ just a small tummy rub or back scratch can go a long way in doggie currency!

Planning for Visitors

A new baby in the family means a sudden influx of visitors to the home. This is an important thing to consider, as a constant flow of visitors is something that will affect your dog. Unfortunately, not all your friends and family will understand the significance of the training and preparations you have been doing with your dog in the lead up to the baby’s arrival. Some of your visitors will not understand how to behave appropriately towards your dog and may unwittingly undo some of your teachings! For example, guests who greet your dog excitedly at the front door will encourage him to bark and make a fuss when people knock or enter, or guests who scold him when he does something inappropriate will undo the positive, reward‐based training you have been enforcing.

It is therefore worth considering your dog when you are planning for visitors. “If you know the interactions between your dog and the visitors won’t be calm then, for the benefit of you and your dog, move him to his rest area (see below) before the visitors arrive,” say our dog training experts Craig and Tracey Murray.

Dog Rest Area

Giving your dog its own rest‐area that is not a punishment area, but rather a place where he can relax and be calm away from visitors (and the baby) is essential. Be careful to always make his rest area a positive place to be and encourage him to go there, by giving him a bone to chew on or a treat ball to play with, at times when he is not being removed for a specific purpose. He will then relate his rest area to positive experiences and will be happy to go there at times when you need him to, such as before visitors arrive. Never use his rest area as a place to put him when he is being removed as punishment for doing something wrong.

 Building the Bond

It may seem to be an immense effort, nurturing your baby as well as your companion dog. But once you get over the hurdle of the first few months with your newborn and settle into your new role as a parent, your life will gradually become more balanced. You will start to see the benefits of including your dog in your new baby’s life, especially once baby begins to notice his furry companion!

There are ways that you can help to build a safe, positive relationship between your dog and your baby. Under supervision, your baby and your dog should be allowed to have frequent, gentle interactions.

First Impressions

Once your baby reaches around six‐months of age and is able to reach out and grab, your dog will be of great interest to her. As long as she is not yet crawling or upwardly mobile, you should be able to place her on the ground or in her bouncer and allow her to look at your dog whilst he sits calmly near her. Praise your dog when he is behaving calmly around your baby and use times such as this to pay some positive attention to him like giving him a tummy rub or pats.

Don’t panic if your dog gets close enough to have a sniff or even a lick of your baby’s head. This is your dog’s way of investigating this new creature in his life and scolding him for it will only confuse him. If you don’t want him to get too close, then calmly move away from your dog and praise him for keeping his distance from the baby.

On the Move

When your baby begins crawling and moving around, you will find yourself having to ‘baby‐proof’ your home to a whole new degree! This also means keeping a much closer eye on the interactions between your dog and baby. Your baby will desperately want to grab onto your dog and pull on and gum anything she can get her little hands on! It is best at this age to only allow your baby and dog to interact whilst baby is under your control. For example, sit baby on your knee and call your dog to come and sit near you. Guiding her hands, allow her to stroke your dog’s fur. Praise your dog if he remains calm during these kind of interactions.

When your baby is this age, it is best to keep her play area as a dog‐free zone so as to protect your dog from any unexpected grabbing and pulling by baby.

Keeping these early interactions between your baby and your dog positive will ensure that neither your baby nor your dog will have any reason to fear or have anxiety about each other. This in turn will create a safer environment for your baby and a happier and more relaxed one for you and your dog!

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Your cat and your baby

“I love cats because I enjoy my home; and little by little, they become its visible soul.” 
Jean Cocteau

Pregnancy and Preparation

Many expectant mothers reject their longtime companion cats once they discover they are pregnant, because of fears that cats carry disease that will transfer to the unborn baby. These fears are usually compounded by the poor advice often given to expectant mums by well‐meaning family, friends and even professionals, about the risks involved with keeping their companion cats. Peppered with unfounded claims and horror stories about ‘baby‐killing’ cats, this advice only serves to unnerve and needlessly stress the expecting mother. It is little wonder that the poor old family cat gets booted out and ends up at an animal shelter awaiting his fate! The truth is that with a little common sense, your companion cat poses very little risk to your unborn baby and poses very little risk to your baby once she is born.

The Truth about Toxoplasmosis

When people talk about the risk of cats spreading disease to unborn babies, the disease in question is called toxoplasmosis. Toxoplasmosis is a disease caused by a parasite that can potentially infect a cat that has eaten prey already harboring the parasite (i.e. birds, rats, mice). They can also contract the parasite from contaminated soil, as the toxoplasmosis parasite lives in the dirt. The risk is that a woman in her first or second trimester of pregnancy could contract toxoplasmosis, which could potentially cause birth defects in the baby.

There is however, little chance you will contract toxoplasmosis from your companion cat. In fact, “most toxoplasmosis infections are a result of eating or handling undercooked or raw meat,” says Head Veterinarian at the Animal Welfare League Qld, Dr John Gilmore.

“Nearly all other cases come from gardening or other unprotected contact with soil.” Considering this, if you are worried about contracting the parasite, it would be much more sensible to give up meat and gardening than it would be to give up your cat! Stopping short of this, there are some basic, common‐ sense heath procedures you can follow to protect yourself and your unborn baby from the toxoplasmosis parasite.

Using Commonsense

The best protection against toxoplasmosis is to first of all keep your cat safe and healthy. Keeping your cat indoors, particularly at night time, will not only keep your cat safe from outside dangers such as cars, dogs, feral cats, it will also prevent him from killing rodents or wildlife that may harbor the toxoplasmosis parasite. Cats catch the parasite from infected birds and rodents, so the less prey they kill, the less chance they have of contracting the disease in the first place!

Whether your cat is a rodent killer or not, it is a good idea to practice precautions when changing his litter tray. This is because the parasite that causes toxoplasmosis is passed in the cat’s poo through microscopic cysts. It takes between 24‐48 hours for the cysts to become infective, so scooping poos from the litter tray at least once daily will almost entirely eliminate risk of infection.

For extra safety, you can wear gloves whilst cleaning or scooping the litter tray or even ask another family member to do it for you if you like, however this isn’t essential. As long as you always wash your hands after contact with the litter tray (as you should always do regardless if you are pregnant or not), then you are on the safe side.

Remember that the hygiene practices described above should be used even more vigilantly when handling raw meat and gardening, as your risk of contracting toxoplasmosis from these activities is far greater than getting it from your cat.

It is useful to know, that a high proportion of people already have immunity to the parasite, having contracted it sometime during their lives without even knowing it. You can have your immunity to the parasite tested by the doctor if you are interested, but it is not essential.

Setting Boundaries

It is a good idea to set some physical as well as behavioural boundaries for your cat that you will expect him to follow once the baby arrives. Decide what these boundaries will be and begin getting your cat used to them AS SOON as you find out you are pregnant

A physical boundary is an area of the house that you will not want your cat to explore or a particular piece of furniture or space that you do not want your cat to sit in. For example, the baby’s crib; cribs and cots are very enticing to cats because they are snug, soft and warm (the perfect sleeping spot!). The best way to keep your cat from jumping in and settling down for a nap is to place a secure type of netting over the top (as in the picture, right). This type of netting can be purchased from online baby stores and specialty baby shops. Even a simple mosquito net over the crib will be enough to deter your cat from jumping in.

If you wish to keep your cat out of the entire room where your baby will sleep, then you will probably need to attach a fly‐screen door to the room, so you can keep your cat out, but still keep an eye on your sleeping baby. The sooner you set up your baby’s sleeping area and put in place these physical boundaries, the sooner your cat will get used to them.

Another reason why it is useful to set up your ‘baby areas’ sooner than later, is that it will allow your cat time to investigate the new objects in his space, so by the time the baby arrives, your cat will have lost all interest in them!

Behavioural boundaries are about setting expectations about how you want your cat to behave once the baby arrives. For example, if your cat is used to sitting on your lap whilst you are relaxing on the couch, you may want to start getting him used to sitting beside you instead. This is so when you are sitting and feeding or cradling your newborn, your cat does not try and crowd your space and get in your way. Encouraging him to sit beside you before the baby comes, will prepare him for the fact that your lap no longer exclusively belongs to him!

Bringing Baby Home

Sensationalised tales about cats suffocating babies in their cribs are popular, especially amongst fussing relatives who don’t have cats of their own! Cats in our society unfortunately bear unfair treatment and harsh opinions, with people claiming they are ‘evil’ and calculating animals that will cause harm to newborn babies if given the chance. The reality is that it’s near impossible to find one verified case of a companion cat directly killing an infant.

Introductions

A cat’s reaction to the arrival of a newborn baby in the home will likely be to initially run and hide! Cats typically are not fond of change and when there is a disturbance in their surroundings they can become stressed and nervous. It is for this reason that for the first few days, and possibly even weeks, after you bring your new baby home, your cat will probably stay out of the way.

Of course cats are very curious by nature, and eventually your cat will come out of hiding in order to investigate the new arrival. Once he does, allow him the opportunity to see and smell your baby, either whilst he is being cradled in your arms, as he lies in his bouncer or on a rug on the floor. Don’t panic if your cat gets close enough to sniff your baby’s head or sits near her. As long as they are both under your supervision, allowing your cat to spend time with your baby, and with you, is a positive thing!

Daily Routines and Quality Time

Once your cat has become used to the new presence in the house, he will expect things to get back to normal. Unfortunately for your cat, normal now means living with a noisy, high maintenance baby, and his time sitting and relaxing with you on the couch has been seriously compromised!

You may find that your cat will not want to spend as much time with you as he used to. This may be because you are now almost always occupied and certainly much busier than ever before. Cats enjoy calm, and as long as you are rushing around caring for a newborn, your cat will not want a bar of you!

There are however opportunities during your daily routine where you can include your cat in the care and nurturing of your baby. For example, as a new mother you will spend much of your time sitting and feeding your baby. This is a routine that you will carry out multiple times a day, and one that requires you to sit down and be calm. This is a perfect time to invite your cat to sit with you and enjoy your company.

As well as this, try to spend some quality, baby‐free time with your cat. In the evening after your baby has been settled into bed, or during baby’s nap time is a good chance to pay some love and attention to your cat. Your cat will be more willing to relax and sit with you if baby is out of the picture and he will be able to sense that you are more calm and relaxed too.

Building the Bond

As a companion animal owner, it is natural for you to want your baby to grow into a child that loves and respects animals. Keeping a companion animal in the home is a great way to teach your child the joy of animal companionship. There is much you can do in the first year of your baby’s life to build a safe, positive relationship between her and your cat. Of course, you should never leave your baby unsupervised at any time, with or without an animal in the house, but under supervision, your baby and your cat should be given the chance to build the foundations of a long‐lasting friendship.

First Impressions

Once your baby becomes aware of her surroundings, she will most certainly take an interest in your cat. You will then need to start teaching your baby how to interact gently with him. Your baby will want to pull on the cat’s tail and reach out and grab onto his soft, enticing fur. Some cats can be amazingly tolerant

of this type of treatment, before they will remove themselves from baby’s way; however it is still important to keep a close watch on your baby when she is at this ‘grabby’ age and in close proximity to your cat. Most cats will escape to a baby‐free zone rather than scratch or bite a baby, but there is a risk that your baby could actually hurt your cat and therefore cause him to become fearful of baby.

This is why it is important that you provide places for your cat to retreat when he has had enough, such as high shelves, cat trees or simply a room where your baby cannot go. It will allow your cat a place to get some ‘time‐ out’, which will become particularly important once baby becomes mobile!

On the Move

Once your baby begins to crawl and move around in the later stages of her first year, she will want to follow your cat wherever he goes! Your baby will also be able to get her little ‘paws’ onto a whole new range of household objects, including your cat’s food bowls and litter tray. Prepare an eating area for your cat that is totally out of your baby’s reach. It may come as a bit of an unexpected surprise to your cat that this little creature that was at first so passive, has now become such a force; it may take him a while to get used to your baby’s new enthusiasm. You need to provide an area where your cat can feel at ease enough to eat and go to the toilet without being accosted.

Place his food and water bowls on a high kitchen bench, table, shelf or in a room that he can access but your baby cannot. The same goes for his litter tray; make sure it is placed somewhere quiet so he can do his business in peace. Keep in mind that the litter tray area and the eating area should be two separate spaces, as cats tend not to like eating where they go to the toilet (and neither would we)!

Avoidance Tactics

Some cats will make the choice to avoid your baby altogether once he becomes mobile, and if this happens, this is just something you must accept. Not all cats can easily tolerate being hassled by small children and babies and who can blame them? If your cat does withdraw, be patient and never try to force your cat to interact with your baby ‐ this will likely lead to baby being scratched by a fed‐up puss! In time you may find that your cat will adjust to your baby’s new active lifestyle and take an interest once again. On the other hand, your cat may simply decide that it is all too much, and avoid baby altogether until she is old enough to know that pulling tails and tugging fur is not such fun for the cat attached!

Conclusion

The Animal Welfare League Qld is committed to securing a brighter future for companion animals in this country. Whilst the exact numbers of dogs and cats surrendered to refuges due to pregnancy or a new baby in the home are not known, it is anecdotally identified as a common reason for families to surrender their pets. Not only is the family companion animal at risk of being given up to a refuge, there is the potential for the animal in the family of a newborn to cause needless stress, through misbehaviour or demands for attention, and to have its exercise and enrichment needs neglected.

It is our sincere hope that this guide helps families to better prepare their companion animals for the arrival of their new baby and to more confidently manage them once the baby has arrived. Whether it be a dog, a cat or both that you are lucky enough to share your life with, it is important to remember that as it is with becoming a parent, when we take on a companion animal, the commitment to their well being should be for life.


References

Cusack, O. (1988). Pets and mental health. (1st ed. pp. 9, 91). USA: Routledge.

Cole Johnson, C., Ownby, D.R., Peterson, E.L. (2002). Exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age. Journal of American Medical Association, 288(8), 963‐971.