Pediatrics: Newborn Care

Congratulations on your new baby! Just as we are certain you are a proud new parent, we are also certain that you will, on occasion, have questions about the health and growth of your child. Even the most experienced parent will notice the considerable variability in individual children and, at times, want some advice. This section of our web site is designed to provide new parents with information regarding the care of their healthy newborn. Hopefully this section of the booklet will help you with some routine questions. We would like to stress that you have fun with your new baby! We encourage frequent contact and handling; they are not as fragile as they may look. We are anxious to share with you in his progress.

Appearance

Parents are often concerned about an abnormal appearing shape to the newborn's head following birth. This "moulding" is normal as the baby's soft skull allows for the considerable forces exerted during delivery and is a protective mechanism. The head will gradually reshape to its normal configuration over a few days' time. Bruising, which sometimes accompanies a difficult delivery, will also fade in a few days. Often there is an area of swelling, or "caput" over the top of the head, which will also fade in a few days. Occasionally there can be bleeding under the tough membrane covering the skull bones, called a cephalohematoma, that feels like a tense "squishy" area, that may take up to a month to be resorbed.

Jaundice is a word describing a yellowish-orange tint to the skin that some babies experience in the first few days of life. The degree of jaundice is variable and is based on the level of bilirubin in the baby's blood, which is readily measured, if necessary. Bilirubin is a pigment which is the product of the breakdown of red blood cells. It is normally excreted by the liver. For the first few days after delivery the liver is not working up to full capacity and so the bilirubin may temporarily accumulate. Bilirubin usually reaches its maximum level on the 3rd day and then decreases to the normal adult level. Large excesses of this substance can be harmful to the baby, so if jaundice is detected, we may begin to monitor the bilirubin level (blood test). Most babies who develop jaundice resolve it on their own and need no treatment. But if the level should rise very high we may recommend therapy and we will discuss this with you.

Social Interaction

Newborns are completely dependent on their parents for food, warmth, love and security. Their abilities to experience these aspects of relationship are felt to be well developed, even at birth. Through all their senses they quickly become attached, or "bonded", to their parents -- especially their mother. They thrive on attention and there is no such thing as spoiling a young infant. They are also very tough little people and not only tolerate, but will appreciate close handling by mother and father. The hospital stay is a good time for you to get well acquainted with the new member of your family, without all the possible distractions of home. Take advantage of this time to get to know your new child.

Umbilical Cord

The umbilical cord, your baby's lifeline before delivery, is now only a remnant which has been clamped and cut shortly after birth. The "stump" that remains will dry to a leathery texture and fall off usually within 1-2 weeks. During this time you should promote its drying with alcohol cleaning with diaper changes, and avoid bathing this area or allowing wet diapers to overlap the cord. This will decrease the chance of infection and hurry the loss of the cord. Rarely, however, the area at the base of the umbilical cord may become infected. You should notify your doctor if you notice any pus or redness with hardening of the skin around the base. Also, after the cord falls off, if drainage of fluid persists beyond a week, you should call your doctor. There will sometimes be a small amount of bleeding for 4-5 days which then resolves. This is normal.

Some babies have a small "hernia" or intermittent extrusion of the umbilicus (belly button) with an increase in abdominal pressure. This is due to an enlarged opening in the wall of the abdomen where the umbilical cord blood vessels crossed through the wall. This hernia will be most noticeable when your child cries or strains to have a bowel movement. Almost all of these hernias resolve on their own during the first few years of life and require no medical treatment. They almost never cause any symptoms.

Circumcision

Circumcision is a controversial issue. One reason to circumcise a child is either a social (cultural) or religious custom, and this can be very important to the parent. There is some evidence that circumcised boys may have fewer urinary tract infections, and a lower risk of penile cancer as an adult, so there may be some medical benefit to the procedure.

There are some rare and usually minor risks to circumcision. Occasionally a bleeding tendency will become apparent after circumcision, and any time you surgically cut the skin there is a risk of infection. Many pediatricians now administer local anesthesia before the procedure is done.

The decision whether to circumcise a child should be made by the mother and father as soon as possible. Traditionally the procedure is done by the obstetrician, but your pediatrician is also trained and may perform the procedure. Care of the circumcision is really very simple and will be reviewed with you before you take the child home.

Care of the uncircumcised penis is also simple and consists of soap and water cleansing and frequent diaper changes to prevent rash. Do not forcibly try to retract the foreskin. The separation of the foreskin from the head of the penis will gradually happen, and usually is complete by about 5 years of age. Teach your son how to gently pull back the foreskin to cleanse the head of the penis and then always pull it back to its original position. Call your doctor if there are signs of infection (redness, swelling, pain, or pus), the foreskin cannot be pulled back over the head of the penis, or if it cannot be retracted by age 5.

Sleeping

Newborns sleep a majority of the time with, as usual, some variability between children. After a first few hours of wakefulness, following delivery, he may seem to sleep most of the time except during feedings while in the hospital. Since newborns feed mostly on demand, there is little you can do to adjust their schedule. Occasionally you can try (by rocking, walking, swinging) holding off the last evening feeding for an hour or so to try to "stretch" the amount of time before you are awakened for the morning feeding. Do not, however, expect the newborn to adjust right away to your household's schedule. He will, in time, conform. The majority of infants begin to sleep through the night by 4-6 months of age. Newborns seldom sleep longer than 4-5 hours at once during the night. We strongly recommend that your baby sleep on his back, but never on his tummy or side. The incidence of sudden infant death syndrome, or "SIDS" is shown to be related to sleeping on the baby's stomach and side. Also, sleeping with an adult and/or redundant soft bedding in the crib will increase the risk of SIDS.

Feeding

For a variety of reasons centered on nutritional superiority, defense against infection, and bonding between mother and infant, we encourage breast feeding as the best way to nourish your baby. However, excellent formulas have been developed which offer very similar nutrition on which infants will thrive. Also, the ability to emotionally bond with your infant is not as dependent on the physical act of breast feeding as much as the close contact during feeding regardless of the method you choose. The artificial formulas cannot, however, simulate the defense against infection afforded through breast milk.

Although we encourage nursing we recognize that many individual situations may interfere with the ability to breast feed. We will support and encourage the best nutrition for your baby as an individual.

Initially most newborns have little appetite. They were nourished very well prior to delivery and they take little volume in first 2-3 days of life even though their sucking reflex is generally strong. Babies are born with extra fluid in their bodies, which is lost in the first few days, and help them to tolerate smaller fluid intakes during that time. Babies normally lose up to 10% of their birth weight in the first week and will regain this weight by 14 days of age.

For breast fed infants, an initial offer of the breast in the delivery or recovery room may be very gratifying to both mother and child. After this, the baby will be fed on a semi-demand schedule, depending on how much "rooming in" you choose to do. The nurses in the nursery will bring him to you at least every 4 hours and he may stay for extended periods of time even if you do not wish 24 hour per day rooming.

We recommend starting out at 5-7 minutes on each breast and gradually working your way up (about 2 minutes per day) to about 10-15 minutes per feeding (90% of the available milk per breast is emptied within 5 minutes). Most infants demand feedings every 2-4 hours. Try to make the baby nurse every 2-3 hours during your waking hours to encourage longer periods of sleep at night.

Alternate which breast you begin nursing at each feeding, since the baby will suck most vigorously with the first breast offered and empty it most completely. It is important to nurse in a relaxed manner and try to devote most, if not all, of your attention toward the baby. There are many varied techniques to nursing and care of your breasts. Please ask for advice from your doctor or nurse, or ask for reading material. The hospital nurses are trained to help you get started breast feeding and can help you if challenges arise. Most hospitals also have lactation specialists to help you if there are any difficulties.

You may wash breasts with water alone and air dry. You can apply lanolin cream or a thin layer of A & D ointment after feedings to avoid nipple soreness. You do not need to wash your nipples prior to the next feeding.

Breast milk can be manually pumped and stored in the refrigerator for up to 48 hours for later use, or can be frozen for up to 30 days. If stored in a deep freeze it can be stored for up to 6 months. It should be stored frozen in sterile plastic containers or bags to better preserve more of its immune properties. Label and date each container. Don't refreeze unused portions of milk. Visit the CDC website for more information.

Inform us of any medications that the mother is taking since many can be transferred to the infant through breast milk. At one of the first checkups, we prescribe a multivitamin with iron drop for nursing infants. The mother should continue to take her prenatal vitamins as long as she is nursing.

Bottle fed babies also will feed mostly on a demand schedule and should be fed just as the nursed baby, in a relaxed atmosphere, held closely with much attention during feeding. Feeding is the most important activity of a newborn's day and the process should be very rewarding to both of you. We recommend a cow's milk prepared formula with supplemental iron such as Enfamil* Lipil* with Iron as the basic milk supply for the first year of life. (There may be circumstances when we may wish to switch formulas later on and those decisions and reasons will be discussed individually.)

We do not feel that a baby's formula need be "sterile", therefore there is no need to boil water or buy bottle sterilizers. We do encourage good hot water washing of bottles and utensils (either by hand or dishwasher).

An average size infant will likely need only about 12-15 oz. of formula per 24 hours initially. This will gradually increase as the infant grows, but should never exceed 32-36 oz. per 24 hours. When the infant needs more than that, at 4-6 months, additional foods will be recommended.

Burping your baby after feeding is a time-honored tradition which, to some degree, may help him relieve the air he swallows with the feeding. Some babies burp more than others and not all babies have to burp after every feeding. By the way, all babies pass gas. Most of what they pass is swallowed air, and is absolutely normal.

Spitting up is a fairly routine occurence with many babies and there is wide variability in the amount and severity. Many babies freely reflux the stomach contents back up the esophagus and into the mouth, causing the spit-up. This is not usually a problem unless the infant is irritable (presumably due to "heartburn") or not gaining weight well because he is losing so much of the milk. If this is a problem, talk to your doctor.

Don't feed the baby while he is lying flat. Don't allow the baby to fall asleep with the bottle. Never prop bottles on pillows, blankets, etc.

The bottom line with all methods of feeding infants is their growth, which reflects their nutritional status. Should any problem in growth progress be noted in the well baby check, a thorough review of feedings will be done to see if any deficiencies exist. Our goal is to help each individual baby attain the best possible growth and nutritional status.

Feeds

Infant formulas should be continued until 12 months of age, and after that time whole cow's milk should be used. At 2 years of age you may switch the child to 2% milk or other low fat milks. The vast majority of infants do not require the introduction of solids until 4-6 months of age. Prior to 4 months the introduction of solids may be more likely to induce food allergy, and they simply offer no advantage. Do not begin eggs until your doctor recommends, as they may be associated with allergic reactions if started too early. Other foods to avoid early are peanuts, seafood, citrus and honey.

Stools

All babies have variable stooling patterns and only generalities can be stated. In general, breast fed babies will have much looser stools than babies on prepared formulas, as well as more frequent stools (often with each feeding). On the other hand, some breast fed babies have only 1 stool per week, and are just fine. Stools can be yellow, green, or brown, they are all normal colors. Tarry black, white, or red stools are cause for alarm.

Diarrhea is defined by both the number and character of stool. One watery stool per day is not "diarrhea" per se. We would like to know if a newborn starts having multiple watery stools per day as they can lose water rapidly and become dehydrated.

Constipation is a very difficult term to define and is also based on number and consistency. In general, babies can go several days without a BM and be of no concern. If the time interval reaches near 6-7 days we would like to know, but this may be perfectly normal for him. Vary hard, pellet-like stools occasionally bother parents and are uncomfortable to the infant, but usually will resolve with only some increased liquid or water in the diet. Occasionally, it is helpful to give molasses, one tbsp. in 8 oz of formula. Do not give honey, as it may contain botulinum spores which could infect the infant. Please avoid any laxatives, enemas, or use of external stimulation in the anus in infants until you first discuss the stooling pattern with your doctor. Not only are some of these methods possibly harmful to the infant, but external manipulation of the infant's pattern may confuse the symptoms and delay proper treatment.

Diaper Rash

Diaper rash is very common in infants and may be due to a variety of causes. The best prevention of the usual irritant rash is frequent changing of diapers, avoidance of the use of plastic pants for extended periods, and allowing the baby's bottom to be "open to air" periodically. Over-the-counter ointments such as "A&D", "Desitin", "Dr. Smith's Ointment", or "Super Duper Diaper Doo", are soothing and protective for the baby's sensitive skin. Powder, if used, should not be applied with lotions (it forms a paste) and should be applied to the hands and then to the baby's bottom. Powder particles can be inhaled by the infant, so pouring should be done away from his face.

Rinsing dirty diapers (cloth) right away, using an extra rinse after washing, and use of mild soap to launder them will also help. There appears to be no major difference in incidence of diaper rash between cloth diapered and disposable diapered infants. Diarrhea is often a precipitation factor for diaper rash as the stool is often more acid and is therefore more irritating.

Some diaper rashes are caused by yeast infection, or Candida. Often these babies will also have a yeast infection in the mouth, called "thrush", which looks like white plaques on the tongue and inner cheeks that won't wipe off. The diaper area may look bright red and sore, worse in the creases and folds of skin, with scattered red bumps extending away from the red area. Lotrimin AF cream is available without prescription and is effective when applied 3-4 times per day for at least 7 days. If the rash is not clearing or the baby develops thrush, please call us during regular office hours.

Staph may also cause diaper rash and this usually appears as scattered red, sore bumps and pustules. This needs to be diagnosed and treated by your doctor, as an antibiotic is required to get rid of it. If neglected or left untreated, boils may develop from the more superficial bumps.

Bathing

Newborns are usually bathed most easily in or near a sink. There are inserts available specifically for this use. Until the umbilical cord has fallen off, in order to keep it dry, please sponge bathe the baby only using mild baby soap and avoiding the cord. Once the cord is off and healed, he may be immersed in shallow water after first testing the temperature and making sure it is safe. Always provide support to and never leave an infant alone in even the shallowest of water. Also never leave an infant alone in the bath with a young sibling.

For female infants, the genital area should be cleaned from front to back to avoid causing urinary problems. The whitish material in the area is normal and need not be removed.

Do not neglect shampoo, with scrubbing of the scalp to avoid buildup of "cradle cap". Always scrub from the front to the back of the scalp to avoid getting shampoo into the baby's eyes. Don't clean inside the ear canals with Q-tips since ear wax may be "packed" inside the ear canals. Teeth and gums can initially be cleaned with a washcloth. Tooth brushing can usually be done routinely at 12 months of age. Unless your doctor detects a dental problem, the first dental visit should be around 3 years of age.

Clothing

Babies, even newborns, basically can be dressed in similar layers in which you are comfortable. Much depends on season and house environment. They do not necessarily need to be bundled or always covered. If the house and nursery are warm, often only a T-shirt and diaper will do. Use your judgment and dress him according to the weather to which he is exposed. If his hands and feet are warm and his skin is nice and pink, then he is warm enough.

Shoes are not a necessary article of clothing for an infant. Modern orthopedic trends are to recommend a simple tennis shoe for the average child. High top shoes and leather shoes are a luxury, and are not necessary or particularly recommended as better for a child's feet.

Visiting

Although they are tough, we recommend that newborns not be exposed to large, enclosed crowds or to groups of children in order to reduce their risk of acquiring an infection. Visitors are fine, but again, use your best judgment if relatives or friends are ill. Babies are especially susceptible to illness for the first 6-8 weeks of life.

If the season is right we encourage fresh air for all infants, including newborns just home. There is no reason to avoid taking a baby outside if the weather is cooperative. Again, dress him as you would yourself, and avoid any prolonged exposure to temperature extremes. Brief exposure to even the coldest or warmest days is well tolerated (i.e., you can take your newborn out in the snow to the car to go visiting as long as he is properly dressed). Be careful if he is out in the sun at midday, babies sunburn very easily, even if they are only exposed to reflected light off a sidewalk.

Colic

Normal newborns cry about 2 hours a day. Crying increases until about 6-8 weeks of age, and may last a total of 3 hours per day.

Some infants in their first weeks or months go through a very fussy stage where nothing seems to relieve their crying and irritability. This "colic" has been blamed on many things, mostly gastrointestinal, but basically no one knows for sure why some babies do this. It can be very distressing to the family and there are no ready remedies. It is important to first distinguish colic from other causes of irritability in newborns; hunger, discomfort from dirty diapers, fever or illness. Ways of dealing with colic very from doctor to doctor and should your baby be "colicky" please discuss the situation with your physician.

Lacrimal Duct Stenosis

If your newborn has thick yellow or green drainage from one or both eyes that is continuous throughout the day, he/she may have a plugged tear duct. The white part of the eye remains white and the eyelids are not usually swollen. Please call during office hours and discuss it with the phone nurse.

The Sick Newborn

Newborn babies can have a variety of reasons for being ill and these illnesses can interfere with the usual initial interactions between parent and child. We will do our utmost to minimize the degree of separation of even the sickest newborn from his parents and will discuss each individual case with you and offer our reasons for whatever treatment might be necessary. Occasionally a very sick or very premature baby needs to be transferred to a neonatal intensive care unit for the best possible care. Should this situation arise we will make arrangements usually through Children's Mercy Hospital. Parents are allowed full access to their baby and encouraged to become involved in his care. We will be in frequent contact with doctors who may take over this type of treatment for a while and are available to help answer your questions at any time.

When to Call the Doctor

Newborns are all different and they change rapidly as they grow and develop. One of our reasons for seeing a baby frequently in his first 6 months is to pick up on subtle changes that may be occurring in his growth or physical exam. Many more acute situations may demand immediate attention. Some warning signs to notify your doctor about include:

• Fever over 38 Degrees C (100.4 Degrees F) rectally in a baby less than 2-3 months
• High fever over 40.0 Degrees C (104 Degrees F) rectally in any infant
• Forceful persistent vomiting, or persistent watery diarrhea
• Difficulty breathing, too rapid or deep, especially if it interferes with ability to nurse or take a bottle
• Extreme lethargy or irritability
• Convulsions, stiffening
• Possible head injury from a fall
• Lacerations (not abrasions)
• Refusal to eat for an extended period (greater than 2-3 feedings)
• Any accidental burns
• Any time you have an acute concern about your baby