Infant Assessment and Development

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC CHAPTER NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 14 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Infant Assessment and Development

newborn’s abilities and behaviors are linked closely to Peristalsis Sudden infant death Abreastfeeding. Therefore, an understanding of newborn Placid baby syndrome (SIDS) re exes and characteristics is important when assessing Projectile vomiting Sudden unexplained infant breastfeeding. The lactation consultant can identify and help © Jones & Bartlett Learning, LLC © JonesProne & Bartlett Learning, LLCdeath (SUID) parents learn to watch and interpret their babies’ behaviors. In NOT FOR particular,SALE OR babies DISTRIBUTION signal to their mothers through hunger cues.NOT FORPyloric SALE stenosis OR DISTRIBUTIONSupine Patterns of behavior, growth, sleeping, crying, and digestion Rapid eye movement Swaddling vary from one baby to another. Certain infant conditions may (REM) rush require a change in your approach to assisting a mother. A Reexes Turgor complete medical history and assessment of the mother and Rooting Uvula infant will help you identify© Jones situations & that Bartlett may affect Learning, lactation. LLCSling © JonesVentral & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONSpitting up NOTVoiding FOR SALE OR DISTRIBUTION Sucking Yeast infection Key Terms

Acrocyanosis© Jones & Bartlett Learning,Fontanel LLC © Jones & Bartlett Learning, LLC AlveolarNOT ridge FOR SALE OR FoodDISTRIBUTION sensitivity NOT FOR SALE OR DISTRIBUTION Approach behaviors Frenulum Assessment of the Newborn Asymmetry Frenum A newborn’s rst assessment will be documented by Average baby Gastroesophageal reux means of an Apgar score, which ranges from 0 to 10 (see Avoidance behaviors (GER) Table 14-1). e Apgar score is performed at 1 minute © Jones &Bauer’s Bartlett response Learning, LLCGastroesophageal reux © Jonesof life & andBartlett again at Learning, 5 and 10 minutes. LLC e score rates ve NOT FOR BifurcatedSALE OR or bi dDISTRIBUTIONdisease (GERD) NOT FORcomponents: SALE heartOR DISTRIBUTIONrate, respiratory eort, muscle tone, Bovine IgG Grooming reex irritability, and color, each of which is given a score Buccal pads Hirschsprung’s disease of 0, 1, or 2. e score oers a quick status of the newborn Candidiasis Hunger cues and the response to resuscitation if needed (American Caput succedaneum Hydration Academy of Pediatrics [AAP], 2008). Scores are inu- Cephalhematoma © JonesHypertonic & Bartlett Learning, LLCenced by drugs, trauma, congenital© Jones anomalies, & Bartlett infections, Learning, LLC Clavicle NOT FORHypotonic SALE OR DISTRIBUTIONhypoxia, hypovolemia, andNOT prematurity. FOR SALEIf you work OR with DISTRIBUTION Cle lip Infant acne newborns in a hospital, Apgar scores are an intrinsic Cle palate Intravenous part of the baby’s information. If you work with the baby Colic Lactase aer hospital discharge, be aware that Apgar scores have Constipation Lactase de ciency (lactase less relevance. However, low 5-minute scores, with other Cosleeping© Jones & Bartlett Learning,non-persistence) LLC markers, ©may Jones identify & infantsBartlett at riskLearning, of developing LLC sei- Cow’sNOT milk FOR allergy SALE OR LactoseDISTRIBUTION overload zures. It alsoNOT gives FOR you SALEa snapshot OR of DISTRIBUTIONa baby who may have Dancer hand position Leukocytes had a challenging transition at birth with ensuing feeding Diaper rash Macular diculties. Diarrhea Molding Generally, your initial contact with a breastfeeding Down syndrome New Ballard Scale (NBS) mother would include an assessment of her baby. is © Jones &Erythema Bartlett toxicum Learning, LLCPalate © Jonesguideline & Bartlett applies Learning,especially when LLC there is concern about NOT FOR FlexionSALE OR DISTRIBUTIONPeriosteum NOT FORpoor weightSALE gain, OR foodDISTRIBUTION intolerance, irritability, lethargy,

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9781284078954_CH14_293_230.indd 293 18/06/15 6:35 pm 294 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORTABLE SALE 14-1 OR Apgar DISTRIBUTION Score NOTHypotonia FOR SALE OR DISTRIBUTION Five factors are used to evaluate the baby’s condition, and A hypotonic infant has very low body tone and tends to each factor is scored on a scale of 0 to 2, with 2 being the “droop” over the examiner’s hand. e extremities are best score. in extension, and there is minimal resistance to passive 1. Activity and muscle tone © Jones & Bartlett Learning, LLCmovement. e baby appears ©oppy, Jones sluggish, & Bartlett and accid Learning, LLC 2. Pulse (heart rate) (see Figure 14-1). A hypotonic baby may have diculty 3. Grimace response (medicallyNOT known FOR as SALE “re ex irritability”)OR DISTRIBUTIONstaying latched to the breast becauseNOT FORof a weak SALE suck. ORHe or DISTRIBUTION 4. Appearance (skin coloration) she may nd it dicult to maintain intraoral negative pres- 5. Respiration (breathing rate and effort) sure, even on the examiner’s nger. e infant frequently nurses with the shoulders elevated to just beneath the ears © Jones & Bartlett Learning, LLC in an eort ©to Jonessupport the& Bartlettneck and chin.Learning, In the ventral LLC position, the hypotonic baby lays over the examiner’s hand NOT FOR SALE OR DISTRIBUTION with the headNOT hanging FOR down, SALE unable OR to bringDISTRIBUTION it up. or sucking diculties. To perform the assessment, the Hypotonia is a marker for certain syndromes and neu- baby should be completely undressed and lying on a at rologic disorders. In fact, ineective sucking and hypo- rm surface. Evaluate the infant’s posture, skin, head, tonia are oen symptoms of an underlying problem, not oral structure, clavicle, re exes, color, elimination, and © Jones & Bartlett Learning, LLC © Jonesthe problem & Bartlett itself. ItLearning, may be associated LLC with prematu- hunger cues. Be alert for any areas on the baby’s body that rity, Down syndrome, autism spectrum disorder (ASD), NOT FORcause SALE pain orOR discomfort. DISTRIBUTION NOTPrader-Willi FOR SALE phenotype OR DISTRIBUTION of fragile X syndrome, or botu- If you are unfamiliar with assessing newborns, you will lism infection. nd the New Ballard Scale (NBS) helpful in assessing the normal newborn (see Table 14-2). is gestational assess- Hypertonia ment tool evaluates the tone of the infant’s total body, wrist, biceps muscle, knee© Jonesjoint, shoulder & Bartlett girdle, andLearning, pel- ALLC hypertonic infant has very rigid© Jones body tone. & With Bartlett hyperto Learning,- LLC vic girdle. “Girdle” refersNOT to the FOR bones SALE that encircleOR DISTRIBUTION the nia, the baby is oen in hyperextension,NOT FOR arching SALE away OR from DISTRIBUTION shoulder and pelvis. A detailed description and free online the breast and the mother (see Figure 14-2). e mother illustration of the scale are available at www.ballardscore. may report that her baby is dicult to comfort, pulls away com. Chapter 24 covers preterm infants, and Chapter 26 from contact, and does not snuggle into her chest or neck. discusses a variety of infant medical conditions. Instead, her baby leans back and away from her. © Jones & Bartlett Learning, LLC Many hypertonic© Jones babies & Bartlett cannot tolerate Learning, anyone LLC handling them and prefer to interact from a safe distance. PostureNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ey are oen very alert and squirmy, and they will hold Babies favor the fetal position, and healthy, full-term their heads erect from a prone (face-down) position or newborns generally hold their arms and legs in moderate on the shoulder. When held in the ventral position, a exion. eir sts are closed and usually held near their hypertonic baby will be virtually straight, liing both the © Jonesface. & Bartlett When awake, Learning, the infant LLC resists having the extremi- © Joneshead and & Bartlettbuttocks and Learning, maintaining LLC them on a horizontal NOT FORties SALE extended OR and DISTRIBUTION may cry at attempts to do so. As babies NOTplane. FOR Hypertonia SALE OR is associatedDISTRIBUTION with neurologic damage mature, they remain in the fetal position less oen and or disorders, respiratory syncytial virus (RSV) infec- will spend more time comfortably in semi-extension. tion, and prenatal drug exposure (including cocaine and Observing the baby’s body tone will give you clues about methamphetamine). potential problems. When held in the ventral (abdominal) position, normal ©infants Jones lie &on Bartlett their abdomen, Learning, SkinLLC © Jones & Bartlett Learning, LLC draped over the examiner’sNOT hand, FOR and SALE alternate OR between DISTRIBUTION NOT FOR SALE OR DISTRIBUTION trying to bring their head up and putting it down again. A healthy newborn’s skin is warm and dry, with a pink or At extreme positions, a baby’s body tone may be too loose ruddy appearance. e ruddiness is a result of increased (hypotonic) or too rigid (hypertonic). concentration of red blood cells in the blood vessels, Babies whose mothers have taken antidepressants in the coupled with minimal subcutaneous fat deposits. Small selective© Jonesserotonin & reuptake Bartlett inhibitor Learning, (SSRI) LLC class may moles and birthmarks© Jones are & notBartlett uncommon. Learning, Large congen- LLC exhibitNOT neonatal FOR behavioral SALE ORsyndrome. DISTRIBUTION is syndrome is ital moles, whileNOT rare, FOR are SALEmore likely OR to DISTRIBUTION develop into skin characterized as one or more of the following signs and cancer. symptoms: jitteriness, irritability, lethargy, hypotonia, Birthmarks may be simple, such as small red dots or hypertonia, hyperreexia, apnea, respiratory distress, “stork bites,” which usually fade away within a year or so. vomiting, poor feeding, or hypoglycemia (Kocherlakota, e baby may have pigmented birthmarks, a cluster of © Jones2014; & Bartlett Leibovitch Learning, et al., 2013). LLC Note that these babies can © Jonespigment & cells, Bartlett with colors Learning, ranging fromLLC tan to brown, gray NOT FORexhibit SALE either OR hypotonia DISTRIBUTION or hypertonia. NOTto FOR black, SALE and even OR blue. DISTRIBUTION Mongolian spots are large blue

9781284078954_CH14_293_230.indd 294 18/06/15 6:35 pm Assessment of the Newborn 295 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR TABLESALE 14-2 OR DISTRIBUTIONBallard Score Maturational AssessmentNOT of Gestational FOR SALE Age OR DISTRIBUTION MATURATIONAL ASSESSMENT OF GESTATIONAL AGE (New Ballard Score)

NAME ______DATE/TIME OF BIRTH ______SEX ______

HOSPITAL NO. ______DATE/TIME OF EXAM ______BIRTH WEIGHT ______

RACE ______© Jones &AGE Bartlett WHEN EXAMINED Learning, ______LLC LENGTH ©______Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION APGAR SCORE: 1 MINUTE______5 MINUTES______10 MINUTES______HEAD CIRC. ______

EXAMINER ______

NEUROMUSCULAR MATURITY –1 0 1 2 3 4 5 RECORD © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,SCORE LLC Posture NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTIONHERE Square window (wrist) > 90o 90o 60o 45o 30o 0o

Arm © Jones & recoilBartlett Learning, LLC © Jones & Bartlett Learning, LLC 180o 140o–180o 110o–140o 90o–110o < 90o NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Popliteal angle 180o 160o 140o 120o 100o 90o < 90o

Scarf sign

Heel to © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ear NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

PHYSICAL MATURITY Sticky, Gelatinous, Smooth, Superficial Cracking, Parchment, Leathery, MATURITY RATING RECORD Skin friable, red, pink, peeling pale areas, deep cracking, cracked, SCORE transparent translucent visible and/or rash, rare veins no vessels wrinkled Score Weeks © Jones & Bartlett Learning,veins few LLC veins © Jones & Bartlett Learning,HERE LLC –10 20 LanugoNOTNone FOR SALESparse OR AbundantDISTRIBUTIONThinning Bald areas Mostly baldNOT FOR SALE OR DISTRIBUTION –5 22

Plantar Heel-toe > 50 mm, Faint Anterior Creases Creases 0 24 surface 40–50 mm: –1 no crease red marks tranverse anterior over < 40 mm: –2 crease only two-thirds entire sole 5 26

© Jones & BreastBartlettImperceptible Learning,Barely LLCFlat areola, Stippled Raised© JonesFull areola,& Bartlett Learning,10 LLC28 NOT FOR SALE OR DISTRIBUTIONperceptible no bud areola, areola,NOT FOR5–10 mm SALE bud OR DISTRIBUTION 1–2 mm bud 3–4 mm bud 15 30

Lids fused Lids open; Slightly Well-curved Pinna formed Thick 20 32 Eye/Ear loosely: –1 pinna flat, curved pinna, pinna, and firm, cartilage, tightly: –2 stays folded soft, slow soft but instant recoil ear stiff 25 34 recoil ready recoil © Jones & Bartlett Learning, LLC ©30 Jones36 & Bartlett Learning, LLC Genitals Scrotum Scrotum Testes in Testes Testes down, Testes (male) flat, smooth empty,NOT FORupper SALEcanal, descending, OR DISTRIBUTIONgood rugae pendulous, NOT35 FOR38 SALE OR DISTRIBUTION faint rugae rare rugae few rugae deep rugae 40 40 Genitals Clitoris Clitoris Clitoris Labia majora Labia majora Labia majora (female) prominent, prominent, prominent, and minora large, labia cover clitoris 45 42 labia flat labia minora labia minora equally minora small and labia 50 44 © Jones & Bartlettsmall Learning,enlarged prominent LLC minora © Jones & Bartlett Learning, LLC GESTATIONAL AGE NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION(weeks)

By dates______By ultrasound______By exam______Ballard JL, Khoury JC, Ellers-Walsman BL, & Lipp R. New Ballard score, expanded to include extremely premature infants. Journal of Pediatrics. © Jones &1991:119(3):7. Bartlett Learning,Reprinted with permission LLC from Elsevier. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 295 18/06/15 6:35 pm 296 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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to gray pigmented birthmarks usually found on the lower Lanugo back and buttocks of newborns. ey occur most oen in © Jones & Bartlett Learning, LanugoLLC is the Latin word for© “down,” Jones meaning & Bartlett the ne Learning, LLC dark-skinned infants and usually fade away within a few NOT FOR SALE OR DISTRIBUTIONsmall hairs found on some plants.NOT InFOR newborns, SALE lanugo OR DISTRIBUTION years. describes the ne, downy hair covering the body. It usu- Vascular birthmarks, which are due to abnormal blood ally appears in utero at about 5 months’ gestation and is vessel development, include port wine stains and heman- shed at 7 to 8 months’ gestation. Lanugo is most abundant giomas and may be associated with syndromes and glau- on preterm babies who are born at 5 to 6 months’ gesta- coma (Kanada et al., 2012). Dis guring or debilitating © Jones & Bartlett Learning, LLC tion (Blackburn,© Jones 2013). & Bartlett Learning, LLC conditionsNOT may FOR be treatedSALE with OR laser DISTRIBUTION or steroid therapies NOT FOR SALE OR DISTRIBUTION (Tollefson & Frieden, 2012). A hemangioma near or on Hydration the infant’s lips or nose may aect breastfeeding (see Color Plate 14). e mother may need help with alterna- Hydration can be assessed by evaluating the turgor (resil- tive feeding arrangements until treatment is obtained. iency) of the baby’s skin. Turgor is the normal strength and tension of the skin, caused by outward pressure of the cells © Jones & Bartlett Learning, LLC © Jonesand the & uid Bartlett that surrounds Learning, them. LLCe baby’s chest, abdo- NOT FOR SALE OR DISTRIBUTION NOTmen, FOR or thighSALE is aOR good DISTRIBUTION area on which to test skin turgor. When gently grasped between your nger and thumb, the skin should spring back to its original shape when the tissue is released. It should not leave an indentation, fold, or wrinkled appearance. Loose skin that slowly returns to a posi- © Jones & Bartlett Learning, tionLLC level with the tissue next ©to itJones is a sign & of Bartlett dehydration Learning, LLC NOT FOR SALE OR DISTRIBUTION(Moses, 2013). e baby’s skin NOTmay be FOR dry, aky, SALE or peeling, OR DISTRIBUTION especially by the end of the rst or second week aer birth. is appearance is normal and not a sign of dehydration. Color © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Skin color will vary depending on the baby’s ethnic ori- NOT FOR SALE OR DISTRIBUTION gin. A signi cantNOT increase FOR SALE in the newborn’s OR DISTRIBUTION bilirubin level creates a yellowing in the skin color from jaundice, also called hyperbilirubinemia (see Color Plate 15). You can FIGURE 14-2 Hypertonic baby who arches away from the mother. assess for jaundice in natural light by pressing the baby’s © Jones & Bartlett Learning, LLC © Jonesskin with & yourBartlett index Learning, nger and noting LLC the color when you Printed with permission of Linda Kutner. li your nger. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 296 18/06/15 6:35 pm Assessment of the Newborn 297 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEFor a quick OR DISTRIBUTIONestimation, some caregivers use a methodNOT FORMottling SALE OR DISTRIBUTION referred to as the “rule of ves” to estimate bilirubin Mottling (cutis marmorata) is a white and reddish color- levels in the infant. Jaundice becomes visible in the ation of the skin on the baby’s trunk and extremities (see sclera (white portion of the eye) when the bilirubin Color Plate 19). is condition is a vascular response to level reaches approximately 5 mg/dL. Continuing down cold and usually clears when the skin is warmed. Some the body, the level increases© Jones progressively & Bartlett from Learning, the face LLC © Jones & Bartlett Learning, LLC babies’ skin may mottle easily for several weeks, months, to the feet by approximately 5 mg/100 mL. Jaundice to NOT FOR SALE OR DISTRIBUTIONor even into early childhood.NOT No FOR treatment SALE is OR needed DISTRIBUTION the level of the shoulders correlates to a bilirubin level (Lewis, 2014b). of 5 to 7 mg/dL. Between the shoulders and umbilicus, levels will range from 7 to 10 mg/dL. Between the Milia umbilicus and knees, levels are in the range of 10 to 12 mg/dL.© Jones Bilirubin & Bartlett levels areLearning, greater than LLC 15 mg/dL Milia are ©very Jones small &“whiteheads” Bartlett Learning,that are actually LLC ker- belowNOT the FORknees. SALE OR DISTRIBUTION atin depositsNOT within FOR the SALE dermis OR (see DISTRIBUTION Color Plate 20). As Progression of color occurs only when the bilirubin level many as half of all newborns exhibit milia. ey usually is rising. When it begins to fall, the skin color fades grad- occur on the forehead, cheeks, nose, and chin but may ually in all aected areas at the same time (AAP, 2004). also occur on the trunk and in the diaper area (Zuniga If you observe jaundice in an infant, refer the parents to & Nguyen, 2013). Milia usually resolve by the end of the © Jones &the Bartlett baby’s primary Learning, healthcare LLC provider immediately so© Jones rst &month. Bartlett Learning, LLC that levels can be measured precisely with a blood test. NOT FOR SALE OR DISTRIBUTION NOT FORDiaper SALE Rash OR DISTRIBUTION Chapter 23 provides an in-depth discussion of jaundice and its implications. Diaper rash appears as a small, reddened, pimple-like Acrocyanosis Acrocyanosis describes a bluish tinge to rash. Frequent diaper changes, careful washing, air dry- ing (even leaving the diaper o a while), and over-the- the newborn’s hands ©and Jones feet (see & Color Bartlett Plate 16).Learning, It may LLC © Jones & Bartlett Learning, LLC be present aer birth because of poor peripheral circula- counter ointments or creams aid in healing. A diaper rash tion, especially if theNOT child FORexperiences SALE exposure OR DISTRIBUTION to cold that does not clear up withNOT appropriate FOR treatmentSALE OR may DISTRIBUTION be (Stanford School of Medicine, 2014). e bluish color a yeast infection. Yeast infection diaper rashes tend to be should disappear aer a few days. Parents oen need reas- raised, larger red patches and look more like welts than surance that this condition is normal and not a sign that small red dots. Any diaper rash that does not clear quickly their baby is cold. should be checked by a healthcare provider to rule out a © Jones & Bartlett Learning, LLC bacterial ©or yeastJones infection & Bartlett (Shin, 2014). Learning, LLC ErythemaNOT FOR Toxicum SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Cradle Cap Erythema toxicum is a pink to red macular area with Cradle cap (seborrheic dermatitis) is a thick, scaly dan- a yellow or white center (see Color Plate 17). It is the dru mostly found on the scalp (see Color Plate 21) and most common skin eruption in newborns, occurring sometimes on the face, ears, neck, and even in the dia- © Jones &in Bartlett as many asLearning, 70 percent LLCof infants. Erythema toxicum© Jones & Bartlett Learning, LLC per area. It usually occurs within the rst 6 weeks of life. has no apparent significance and requires no treatment NOT FOR SALE OR DISTRIBUTION NOT FORCradle SALE cap looks OR unattractive DISTRIBUTION and can be distressing to (Tarang & Anupam, 2011). It is common on the new- parents. It may be caused by overactive sebaceous glands, born’s trunk or limbs and is temporary. It may be pres- although a yeast infection should also be ruled out (Das ent at birth but usually appears during the second or & Das, 2014). Cradle cap is self-limiting and goes away as third days after birth and then disappears within about the baby gets older. e physician may prescribe an anti- 1 week. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC fungal shampoo if regular cleansing does not help. e NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Infant Acne baby should be evaluated for immunode ciency in the event of unresolved scaling accompanied by diarrhea and Infant acne resembles adolescent acne. It appears on the low weight gain or failure to thrive. face, primarily on the nose, forehead, and cheeks (see Color© JonesPlate 18). & e Bartlett appearance Learning, changes LLCdepending on Head © Jones & Bartlett Learning, LLC whether the baby is hot, cool, crying, or quiet. In most cases,NOT infant FOR acne SALE starts at OR about DISTRIBUTION 2 weeks of age and disap- e newborn’sNOT FORhead SALEis large, ORaccounting DISTRIBUTION for approxi- pears at 8 to 10 weeks. It is believed to be the result of seba- mately one-fourth of total body size. e skull bones are ceous gland stimulation by maternal or infant hormones so and pliable. ey remain unfused at birth to accom- (Lewis, 2014b). If a baby’s newborn acne does resolve on modate the infant’s descent through the birth canal dur- © Jones &its Bartlett own, the Learning,baby’s healthcare LLC provider can rule out any© Jonesing second-stage& Bartlett labor.Learning, Aer birth, LLC the head may appear underlying adrenal or endocrine factors. asymmetric because of the overlap of skull bones, referred NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 297 18/06/15 6:35 pm 298 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORto asSALE molding OR. Severe DISTRIBUTION molding may cause temporary di- NOTFontanel FOR SALE OR DISTRIBUTION culty with latch. You can help the mother position her baby e fontanel is a space between the bones of an infant’s so that no pressure is put on the baby’s head. Laid-back skull that is covered by tough membranes. e posterior (reclined) or side-lying positions may be most comfortable. fontanel closes at about 2 months. e anterior fontanel Caput Succedaneum © Jones & Bartlett Learning, LLCremains so until the baby ©reaches Jones about & Bartlett 18 months. Learning, LLC Increased brain pressure may cause a fontanel to become Caput succedaneum is NOTa collection FOR ofSALE uid betweenOR DISTRIBUTION the tense or to bulge. e fontanelNOT of a dehydrated FOR SALE infant OR may DISTRIBUTION newborn’s skin and cranial bone (see Figure 14-3). It usu- be so and sunken, especially when in the supine position. ally forms during labor on the presenting area of the head in the cervical opening. e longer the head is engaged during Facial Asymmetry labor, the greater the swelling can be. is condition occurs in 20 to© 40Jones percent & of Bartlett vacuum extractionsLearning, (Volpe, LLC 2008). Facial asymmetry© Jones may &result Bartlett from injury Learning, to the nervesLLC ere mayNOT be FOR red or SALE bruised OR discoloration, DISTRIBUTION and the baby from birth trauma.NOT FORIf the baby’sSALE tongue OR DISTRIBUTIONis not centered in may be sensitive to pressure on the aected area. Swelling the mouth as a result, the mother can position her nipple begins to subside soon aer birth. Vacuum extraction and over the center of the baby’s tongue rather than the center the resulting caput have been associated with bald spots of the mouth. Some mothers nd that these babies respond (alopecia) in a few cases (Lykoudis et al., 2007). Severe well to feeding in the clutch or football hold position. © Jonescaputs & Bartlett and cephalhematomas Learning, LLC(discussed below) are associ- © JonesFacial & asymmetry Bartlett mayLearning, also occur LLC in utero during devel- NOT FORated SALE with feeding OR DISTRIBUTIONdiculties (Genna, 2008). NOTopment FOR whenSALE the OR infant’s DISTRIBUTION face is wedged against his or her own body or the uterus. e asymmetry usually resolves Cephalhematoma over several days following birth, depending on the severity. Many parents nd that babies with facial asymmetry A cephalhematoma is a pool of blood between the bones of respond well to chiropractic care (International Chi- the head and the periosteum, the covering of the bone (see © Jones & Bartlett Learning, ropracticLLC Pediatric Association,© Jones 2014) or & to Bartlett physical Learning,or LLC Color Plate 22). e resultant swelling may begin to form occupational therapy. during labor and slowly NOTbecome FOR larger SALE in the rst OR few DISTRIBUTION days NOT FOR SALE OR DISTRIBUTION aer birth. It may take up to 6 weeks to resolve completely. Eyes Cephalhematoma is usually a result of trauma, oen from an extended second stage of labor, forceps, or vacuum extrac- Most babies’ eyes are grayish blue at birth, with the nal tion (Doumouchtsis© Jones & &Bartlett Arulkumaran, Learning, 2008; Goetzinger LLC & eye color developing© Jones at 6& to Bartlett 12 months Learning, of age. Sometimes LLC Macones, 2008). Because the area may be sensitive to touch, babies will have broken capillaries in the sclera resulting the motherNOT will FOR want SALE to nurse OR in a positionDISTRIBUTION that avoids con- from the birth;NOT these FOR usually SALE resolve OR within DISTRIBUTION the rst 10 days tact with her baby’s head. Be aware that bruising increases postpartum. In addition, some infants may demonstrate the risk for feeding diculties and for jaundice as the blood swelling of the eyelids, which typically recedes by a few is reabsorbed into the child’s blood vessels. days aer birth. Jaundice can cause a yellow staining in © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

A. B.

Caput succedaneum Cephalhematoma Skin © Jones & Bartlett Learning, LLC Skin © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Periosteum Periosteum Brain Brain Skull Skull Dura Dura

Periosteum Periosteum Brain Brain © Jones & BartlettSkull Learning, LLC © Jones &Skull Bartlett Learning, LLC Dura Dura NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 14-3 Common hematomas of the newborn scalp.

9781284078954_CH14_293_230.indd 298 18/06/15 6:35 pm Assessment of the Newborn 299 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR theSALE sclera OR (the DISTRIBUTIONwhite portion) of the eye that appears whenNOT FOR SALE OR DISTRIBUTION the baby’s bilirubin level exceeds 5 mg/dL. Neck e neck surrounds the infant’s esophagus and trachea. e epiglottis is the ©cartilage Jones that & overhangsBartlett theLearning, trachea LLC © Jones & Bartlett Learning, LLC and closes during swallowingNOT FOR to prevent SALE food OR from DISTRIBUTION enter- NOT FOR SALE OR DISTRIBUTION ing the trachea (see Figure 14-4). An infant’s neck is very short. Because it is too weak to provide head support, the newborn’s head needs to be supported at all times. Sup- porting the baby’s neck and shoulders at feedings will keep© the Jones mother & from Bartlett pushing Learning, on the child’s LLC head, which © Jones & Bartlett Learning, LLC can NOTbe counterproductive. FOR SALE OR It may DISTRIBUTION help to describe to the NOT FOR SALE OR DISTRIBUTION mother that her hand is like the baby’s “second neck.” She can support the neck and shoulders and gently scoop the baby toward her with the palm of her hand. is avoids pressure on the head while still supporting the head’s © Jones &weight Bartlett (La Leche Learning, League International,LLC 2013). © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Torticollis A baby whose head is continually turned to the side, usually to the right, may have torticollis—literally, “twisted neck” (see Figure 14-5). Torticollis in infants is caused by a shortening of the muscle that extends from the FIGURE 14-5 Baby with torticollis. base of the ear down ©to Jonesthe clavicle. & Bartlette cause mayLearning, be the LLC © Jones & Bartlett Learning, LLC Printed with permission of Catherine Watson Genna, BS, IBCLC. baby’s position or lackNOT of space FOR in the SALE womb, OR birth DISTRIBUTION trauma, NOT FOR SALE OR DISTRIBUTION or low amniotic uid. Rarely, torticollis can be a marker for serious problems, so the baby needs to be seen by the clutch hold) for feedings can provide better control over primary care practitioner for assessment. Congenital torti- the infant’s neck position. Some children with torticollis collis has been found to be a signi cant risk factor for later may feed well in the cradle hold for one side and not the neurodevelopmental© Jones & Bartlett conditions Learning, (Schertz et LLCal., 2013). other. In ©such Jones a case, &the Bartlett mother can Learning, scoot the child LLC over ANOT baby withFOR torticollis SALE mayOR only DISTRIBUTION be comfortable breast- to the otherNOT breast FOR without SALE changing OR DISTRIBUTIONthe angle of the neck. feeding with his or her head turned to the side. Placing She can also try nursing lying down, with the bed provid- the baby in the side-sitting position (also called football or ing postural support. e mother can try other nursing positions as her baby’s range of motion improves through physical therapy or chiropractic care. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORJaw SALE OR DISTRIBUTION e baby’s jaw (mandible) is the part of the head that moves for feeding. All babies are born with degrees of receding jaws. Achieving a deep latch can be challenging when a baby’s jaw is severely recessed or very small © Jones & Bartlett Learning, LLC(micrognathia). A severely© recedingJones &or Bartlettsmall jaw Learning,is a LLC NOT FOR SALE OR DISTRIBUTIONmarker for a variety of geneticNOT conditions, FOR SALE including OR Pierre DISTRIBUTION Robin sequence (Vipulananthan et al., 2014). As the baby grows, the jaw comes forward. See Chapter 26 for more discussion of infant conditions. Bottle feeding interferes negatively with oral facial development (Carrascoza et al., © Jones & Bartlett Learning, LLC 2006) and© later Jones dental & development Bartlett Learning, (Moimaz et al.,LLC 2014). NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Oral Structure Visual inspection of the mouth is an important element of an infant assessment. Look for gum lines that are smooth and a © Jones & Bartlett Learning, LLC © Jonespalate & thatBartlett is intact Learning, and gently arched. LLC e tongue should be NOT FOR SALE OR DISTRIBUTION NOT FORable to SALE extend overOR theDISTRIBUTION lower alveolar ridge (gum line) and FIGURE 14-4 Swallowing anatomy. up to the middle of the baby’s mouth when it is open wide.

9781284078954_CH14_293_230.indd 299 18/06/15 6:35 pm 300 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORLips SALE OR DISTRIBUTION NOT2014a). FOR Rarely,SALE a OR baby DISTRIBUTION will be born with a baby tooth already erupted (natal tooth) or with a tumor on the gum A baby’s lips close around the breast and form a seal to cre- pad (Eghbalian & Monsef, 2009). ate negative pressure. When assessing a baby’s lips, look for friction blisters, which are typically seen on the midline of Lingual Frenulum the top lip. Known as “sucking© Jones blisters,” & Bartlett they can beLearning, signs LLC © Jones & Bartlett Learning, LLC that the baby is not generating enough negative pressure e lingual frenulum is the skin under the tongue. It teth- to maintain latch. e babyNOT compensates FOR SALE by using OR DISTRIBUTIONthe lip ers the tongue to the oor of NOTthe mouth FOR and SALE controls OR the DISTRIBUTION muscles (orbicularis oris) to compress the breast. If you tongue’s motion. Frenula can vary in position, thickness, observe sucking blisters in a newborn, ask the mother if and length. A tongue that cannot extend over the alveolar the baby was born with the blister or whether it developed ridge may be due to ankyloglossia—a tight frenulum, also referred to as tongue-tie (see Color Plate 23). Ankyloglos- aer birth.© Jones Babies can& Bartlett be born with Learning, lip blisters LLCfrom suck- © Jones & Bartlett Learning, LLC ing on their hands in the womb. If it occurred aer birth, sia, a midline defect, may restrict movement of the tongue check theNOT baby’s FOR latch SALE to determine OR DISTRIBUTION if assistance is needed. in several ways.NOT Anterior FOR SALErestriction OR (tethering DISTRIBUTION to the tip e most noticeable defect involving the lips is a c l e of the tongue) may cause the classic heart-shaped appear- lip. A baby may have a cle lip combined with a cle in ance when crying. Mid-tongue and posterior restriction the hard or so palate, or a cle lip with normal palatal may be more subtle. It is also possible to have a sublingual tongue-tie, referred to as “hidden.” © Jonesdevelopment. & Bartlett A Learning, baby may also LLC have a cle palate with no © Jones & Bartlett Learning, LLC lip defect. Chapter 26 discusses cles in more depth. Ankyloglossia is estimated to occur in 2.8 to 10.7 per- NOT FORLip SALE tone isOR an importantDISTRIBUTION consideration in breastfeeding. NOTcent FOR of infantsSALE (Edmunds OR DISTRIBUTION et al., 2011) and seems to be Tight, pursed lips are a marker for impaired intraoral pres- more common in males (Hong et al., 2010; Ricke, 2005). sure in the baby—a frequent occurance in preterm infants. ere may also be a familial link (Han et al., 2012). Breast- So, accid lips with a poor seal and little resistance can feeding diculties are common in conjunction with this condition. A tight frenulum can make it dicult for the be a sign of low muscle tone.© Jones is type & ofBartlett deviation Learning, occurs LLC © Jones & Bartlett Learning, LLC in babies with neurologic issues, such as Down syndrome, baby to stay attached to the breast during feeding and may and in babies who haveNOT been aectedFOR SALE by maternal OR DISTRIBUTIONdrugs result in poor milk transfer andNOT low FOR weight SALE gain (Garbin OR DISTRIBUTION and medications or birth trauma such as facial nerve et al., 2013). Be alert to the possibility of a tight frenu- injury (Werner et al., 2011). Be aware that the philtrum— lum as the cause of chronic nipple soreness, cracked and the midline space between the upper lip and the nose—has bleeding nipples with “positional stripe” bruising or scab- bing, slow weight gain, long feedings, low milk produc- a slight© dip. Jones A at philtrum& Bartlett can be Learning, a marker for LLC neurologic © Jones & Bartlett Learning, LLC issues, especially fetal alcohol syndrome. tion, mastitis, or plugged ducts. NOT FOR SALE OR DISTRIBUTION Clipping NOTthe frenulum FOR SALE (frenotomy OR DISTRIBUTIONor frenulotomy) Tongue releases the lingual frenulum and usually improves tongue movement. Clipping is an in-oce procedure in which In breastfeeding, the baby’s tongue draws the breast into the a small cut is made at the anterior portion of the frenu- mouth and forms a groove or trough. Suckling draws a bolus lum (see Figure 14-6). is enables the baby’s tongue to of milk through the trough toward the back of the mouth © Jones & Bartlett Learning, LLC © Jonesextend &adequately Bartlett to Learning,produce a good LLC latch and milk trans- where it is swallowed. Observe the size and shape of the fer (Buryk et al., 2011). NOT FORbaby’s SALE tongue OR for DISTRIBUTIONany anomalies that could aect troughing NOT FOR SALE OR DISTRIBUTION Breastfeeding-supportive providers have observed the or movement, especially if the mother complains of pain negative eects of ankyloglossia on breastfeeding for with breastfeeding. Assess whether the tongue is short or many years. Since the publication of the seminal study on humped, unusually thick or thin, or long or abnormally this condition (Ballard et al., 2002), the volume of medi- large. Macroglossia (large tongue) is a marker for genetic © Jones & Bartlett Learning, calLLC research literature has exploded© Jones on the & topic.Bartlett Infants Learning, LLC disorders, including Down syndrome and Beckwith-Wie- with a tight frenulum are signi cantly more likely to be demann syndrome. It is alsoNOT associated FOR SALEwith the ORlow muscleDISTRIBUTION NOT FOR SALE OR DISTRIBUTION exclusively bottle fed by 1 week of age (Ricke et al., 2005). tone found in children with neurologic damage. Breastfeeding improves dramatically in most infants who Alveolar Ridge (Gum Line) have frenotomies, with parental satisfaction high and few complications reported (Edmunds et al., 2011, 2012; e baby’s© Jones alveolar & ridge Bartlett should Learning, be smooth and LLC uniform. Geddes et al.,© 2008;Jones Kumar & Bartlett & Kalke, 2012;Learning, Steehler LLC et al., Occasionally,NOT FOR a baby SALE will be bornOR DISTRIBUTIONwith a very bumpy gum 2012). ImprovementsNOT FOR are SALE more signi cantOR DISTRIBUTION (86 percent) line, from which it appears teeth are about to erupt. ese when the procedure is performed within the rst week of bumps may be white or yellowish gingival cysts (“Epstein life compared with 74 percent aer the rst week (Steehler pearls”), a benign condition. Epstein pearls may also et al., 2012). occur on the palate. ese cysts resolve a few weeks or Ankyloglossia can be detected prenatally through ultra- © Jonesmonths & Bartlett aer birth, Learning, and no treatment LLC is required (Lewis, © Jonessound &imaging Bartlett as early Learning, as 22 weeks’ LLC gestation (Allen & NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 300 18/06/15 6:35 pm Assessment of the Newborn 301 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORFrenum SALE OR DISTRIBUTION e labial frenum is the fold of skin that anchors the upper lip to the top gum (see Color Plate 24). A large frenum results in a gap between the two top front teeth, although it does © Jones & Bartlett Learning, LLCnot usually interfere with ©the Jones infant’s latch.& Bartlett Some babies’ Learning, LLC frena are so prominent that it is dicult for them to ange NOT FOR SALE OR DISTRIBUTIONthe upper lip; in such cases, NOTtheir mothers FOR SALEmay report OR nipple DISTRIBUTION compression and discomfort while breastfeeding. Clipping and treatment are usually done for aesthetic reasons. Clini- cians report good results in having labial frena clipped when © Jones & Bartlett Learning, LLC their constriction© Jones interferes & Bartlett with latch Learning, (Kotlow, 2010, LLC 2011). Laser treatment is increasingly the method of choice for NOT FOR SALE OR DISTRIBUTION both labialNOT (maxillary) FOR frenum SALE and OR lingual DISTRIBUTION frenulum release because it prevents bleeding and oers faster healing (De Santis et al., 2013; Junqueira et al., 2014; Reddy et al., 2014). Buccal Pads © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORBuccal SALE pads insideOR DISTRIBUTION the cheeks (also called fat pads or FIGURE 14-6 Frenotomy procedure. sucking pads) add to the thickness of the cheek wall (see Figure 14-7). ey help decrease the space within the Printed with permission of Catherine Watson Genna, BS, IBCLC. infant’s mouth, thereby increasing negative pressure and facilitating milk transfer. Buccal pads may not be present © Jones & Bartlett Learning, LLCin an infant who is malnourished© Jones or born & Bartlett preterm. When Learning, LLC Spadola, 2013). UltrasoundNOT FOR provides SALE visual OR understand DISTRIBUTION- working with a thin or pretermNOT baby FOR with SALE feeding OR dicul DISTRIBUTION- ing of an infant’s compensation when the ability to main- ties, you can place your gloved nger inside the mouth and tain a latch and suck is compromised. Milk intake, milk your thumb on the outside of the cheek to feel the thick- transfer, LATCH scores, and mothers’ pain scores improve ness of the fat pads (Wilson-Clay & Hoover, 2013). When signi cantly aer the babies’ frenula are clipped. Prior to the pads are very thin, your ngers will almost touch. the ©procedure, Jones babies& Bartlett either compress Learning, the tip LLC of the nipple To facilitate© Jones breastfeeding & Bartlett in such Learning, cases, it may beLLC neces- or compressNOT FOR the baseSALE of the OR nipple DISTRIBUTION with the tongue; these sary to positionNOT FORthe infant SALE at the OR breast DISTRIBUTION in such a way that issues are resolved or lessened aer frenotomy (Geddes et the mother can use her nger against the baby’s cheeks al., 2008). to compensate for the lack of fat pads, using the Dancer Ankyloglossia occurs in stages and varies in terms of hand position (see Figure 15-6 in Chapter 15). As the its severity, including its eects on both form and func- baby grows, the size of the fat pads diminishes as the cheek © Jones &tion Bartlett of the child’s Learning, mouth. TypesLLC 1 and 2 can be resolved by© Jonesmuscles & Bartlett become stronger Learning, and provide LLC more stability. NOT FOR clippingSALE OR(frenotomy DISTRIBUTION or frenulotomy). More severe casesNOT FOR SALE OR DISTRIBUTION (types 3 and 4) may require frenuloplasty, a more invasive procedure that involves a V-shaped cut and stitches. Infant latch has been shown to improve signi cantly aer treatment for posterior ankyloglossia, with positive breastfeeding outcomes© Jones(O’Callahan & Bartlett et al., 2013). Learning, LLC © Jones & Bartlett Learning, LLC When you work withNOT families FOR whose SALE babies OR have DISTRIBUTION tight NOT FOR SALE OR DISTRIBUTION frenula, educating the parents empowers them to seek the appropriate help. A list of healthcare providers in your community who are knowledgeable about evaluating and treating tongue-ties is a useful resource. Encourage the family© Jones to share &the Bartlett results of Learning, their child’s evaluationLLC and © Jones & Bartlett Learning, LLC treatmentNOT FORwith their SALE primary OR careDISTRIBUTION provider. Such sharing NOT FOR SALE OR DISTRIBUTION helps raise awareness and support in the medical community for treating ankyloglossia and other oral anomalies. Resources for healthcare providers include a protocol FIGURE 14-7 Buccal pads. on neonatal ankyloglossia developed by the Academy of © Jones &Breastfeeding Bartlett Learning, Medicine (ABM, LLC 2009). © JonesPrinted & withBartlett permission Learning, of Catherine Watson LLC Genna, BS, IBCLC. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 301 18/06/15 6:35 pm 302 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORPalates SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION e roof of the mouth contains a hard palate and so palate. e hard palate is located in the front of the mouth; the so palate lies behind it, in line with the end of the upper alveolar ridge. e© condition Jones and& Bartlett shape of the Learning, palate LLC © Jones & Bartlett Learning, LLC can become a factor in establishing breastfeeding. When observing the palate, noteNOT whether FOR it SALEhas a smooth OR DISTRIBUTION slope NOT FOR SALE OR DISTRIBUTION or is highly vaulted, grooved, or bubble shaped. If the palate is high, explore under the tongue for a tight frenulum. Some high palates may be caused by the baby’s tongue being unable© Jones to reach & Bartlett the roof of Learning, the mouth to LLC spread the © Jones & Bartlett Learning, LLC palate during uterine development. Sometimes a palate is grooved,NOT high, FOR or SALEchanneled OR because DISTRIBUTION of extended intu- NOT FOR SALE OR DISTRIBUTION bation with preterm or ill babies. Usually, however, high palates occur naturally. A high, arched, or bubble palate can sometimes cause © Jonesthe & mother’sBartlett nipple Learning, to “catch” LLC in the groove and therefore © Jones & Bartlett Learning, LLC not elongate for breastfeeding. is type of palate makes NOT FORit more SALE dicult OR forDISTRIBUTION the tongue to compress the breast tis- NOT FOR SALE OR DISTRIBUTION sue adequately in order to feed eectively. Mothers whose infants have such palates oen complain of nipple soreness, long feedings, and an unsatis ed infant who needs to nurse frequently. Small© Jones protein- lled & Bartlett cysts (EpsteinLearning, LLC © Jones & Bartlett Learning, LLC pearls), like those sometimes found on the gum lines, may also occur on the palate.NOT ey areFOR not SALEa cause forOR concern DISTRIBUTION NOT FOR SALE OR DISTRIBUTION because they typically resolve spontaneously aer birth. FIGURE 14-8 Bifurcated uvula. When an infant has a cle lip, the condition is imme- Printed with permission of Dr. Isidre Vilacosta. diately obvious to everyone. Frequently, infants with cle lips also© Joneshave cle & Bartlettpalates. Occasionally, Learning, however, LLC an © Jones & Bartlett Learning, LLC infant may have a cle of the so palate that escapes ini- between the baby’s gums and lips, on the inside of the tial diagnosis.NOT FOR Infants SALE with aOR cle DISTRIBUTION of the so palate may cheeks, and NOTon the FORtongue. SALE It is thick OR and DISTRIBUTION patchy, not the choke and gag while nursing. Milk can escape from the thin, uniform white coating usually found on an infant’s baby’s nose when letdown occurs and stridor or wheezing tongue. rush, which is most frequently caused by the may be heard. Changing positioning at the breast is oen organism Candida albicans, is also known as candidiasis. helpful to assess this kind of cle palate. e infection may appear on the mother’s nipples as well as © Jones &Some Bartlett infants Learning, may have submucosal LLC cles, in which skin © Jonesin the baby’s & Bartlett mouth, makingLearning, it imperative LLC that both mother NOT FORcovers SALE a cle OR of theDISTRIBUTION hard or so palate. In this condition, NOTand FOR baby SALE receive ORtreatment DISTRIBUTION at the same time. See the dis- a notched “V” shape may be observed on the hard pal- cussion in Chapter 17 on yeast as a cause of nipple pain. ate. ese babies oen have a bifurcated (bid, or split in two parts) uvula (see Figure 14-8). Submucosal cles and Clavicle bi d uvulas are markers© for Jones a variety & of Bartlett genetic disorders, Learning, eLLC clavicle (collarbone) can be© aJones source of & discomfort Bartlett forLearning, LLC with diering rates of severity (Shprintzen, 2008). Babies NOT FOR SALE OR DISTRIBUTIONa newborn. An injured clavicleNOT is a common FOR SALE birth trauma, OR DISTRIBUTION with submucosal cles may not feed eectively, result- usually identi ed during the baby’s initial examination. In ing in low weight gain. Submucosal cles are frequently some cases, however, it may escape detection until later. In not diagnosed until speech impediments are seen. Other response to the damage, the baby may restrict the use of the markers are Eustachian tube dysfunction, hearing loss, injured arm and resist breastfeeding in a position that places and swallowing© Jones diculties & Bartlett (Oji etLearning, al., 2013; ten LLC Dam et al., pressure on ©the Jones fractured & area. Bartlett For example, Learning, a baby LLCwith a 2013). See Chapter 26 for more information on breast- NOT FOR SALE OR DISTRIBUTION fractured leNOT clavicle FOR may SALEbe uncomfortable OR DISTRIBUTION feeding at the feeding an infant who has a cle of the lip, palate, or both. right breast in the cradle hold. An x-ray will con rm the Thrush fracture. Treatment typically consists of immobilizing the arm by pinning it in a shirt or blanket. A fractured clavicle rush is a yeast infection oen characterized by white heals quickly, usually within 2 months, and without special © Jonespatches & Bartlett that cannot Learning, be removed LLC without causing bleed- © Jonescare (Wall & Bartlett et al., 2014). Learning, Aer healing, LLC there may be a callus NOT FORing SALE (see Color OR Plate DISTRIBUTION 25). is kind of infection may occur NOTon FOR the clavicle, SALE which OR willDISTRIBUTION disappear as the baby grows.

9781284078954_CH14_293_230.indd 302 18/06/15 6:35 pm Assessment of the Newborn 303 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR ChestSALE OR DISTRIBUTION NOT FORTABLE SALE 14-3 ORGestational DISTRIBUTION Development of Newborn Reflexes To assess the chest, observe it while the infant is breath- Nutritive Sucking ing. Labored breathing—evidenced by marked retractions or observable indentations in the chest—may be a symp- 9 weeks Move mouth and lower face 12 weeks Swallow tom of respiratory or© cardiac Jones problems. & Bartlett If you Learning,work with LLC © Jones & Bartlett Learning, LLC a baby who exhibits this type of breathing, the baby needs 18–24 weeks Nonnutritive suck NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to be assessed by a physician right away. 32–34 weeks Nutritive suck and swallow Nipple appearance on the baby’s chest is a sign of mat- Associated Re exes and Responses uration. e more preterm the baby is, the atter the nipple bud will be. Supernumary nipples may be present 26–27 weeks Gag re ex with: tongue protrusion, head either bilaterally or unilaterally and may be mistaken for and jaw extension, contraction of the © Jones & Bartlett Learning, LLC © Jonespharynx & Bartlett Learning, LLC moles. As discussed in Chapter 7, the infant breast may be swollenNOT FOR and even SALE leak “witch’sOR DISTRIBUTION milk,” a uid caused by 28 weeksNOT FOR Phasic SALEbite—rhythmic OR DISTRIBUTION opening and closing transplacental transfer of maternal hormones (Jain et al., of the jaw in response to gum stimulation 2013). is uid disappears within the rst 3 weeks aer 28 weeks Transverse tongue response—movement of birth. the tongue toward the side of stimulation when its lateral surface is touched © Jones & Bartlett Learning, LLC © Jones32 weeks & Bartlett Rooting Learning, re ex—searching LLC response (pro- NOT FOR Re exesSALE OR DISTRIBUTION NOT FOR SALE OR gressivelyDISTRIBUTION toward the side of facial Reexes in the newborn are present until the central ner- stimulation) vous system has matured. ey serve as a form of com- 40 weeks Tongue protrusion response—protrusion munication that tells us much about what the baby needs. when anterior tongue is touched (inhibited as infant grows) Some reexes are protective,© Jones such & as Bartlett blinking orLearning, gagging. LLC © Jones & Bartlett Learning, LLC Other reexes indicate a need for more or dierent inter- Printed with permission of the International Lactation Consultant action (Lewis, 2014b).NOT e MoroFOR (or SALE startle) OR reex DISTRIBUTION results Association. NOT FOR SALE OR DISTRIBUTION when the infant is exposed to a loud noise, causing the midline spacing between the nose and mouth) to encour- infant’s legs to draw up and arms to ing out. e grasp age a deeper, asymmetrical latch with the baby’s head tilting reex is initiated by touching the palm of the baby’s hand. back slightly. If le© unassistedJones & aer Bartlett birth, Learning,the grasp reex LLC would help © Jones & Bartlett Learning, LLC the baby move to the breast. Sucking ArchingNOT FORindicates SALE a need OR for DISTRIBUTION dierent positioning or NOT FOR SALE OR DISTRIBUTION An object placed far enough back into the baby’s mouth a pause from activity. It resembles the positioning of a near the juncture between the hard and so palate will elicit hypertonic infant (Figure 14-2). If pressure exerted on the back of the head pushes the baby’s face into a surface, as against the breast during a feeding, the baby may arch © Jones &backward. Bartlett Pressure Learning, on the LLC soles of the baby’s feet will elicit© Jones & Bartlett Learning, LLC NOT FOR spontaneousSALE OR crawlingDISTRIBUTION eorts and extension of the baby’sNOT FOR SALE OR DISTRIBUTION head, referred to as Bauer’s response. When positioning for a feeding, be careful not to press the baby’s feet against the back or side of the couch or chair, pressure that could cause the baby to arch© away Jones from & the Bartlett breast. Learning, LLC © Jones & Bartlett Learning, LLC Rooting NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A full-term healthy newborn has many reexes that aid breastfeeding (see Table 14-3). Rooting is at the forefront of these reexes (Widstrom et al., 2011). Lightly stroking the ©baby’s Jones cheek & will Bartlett cause the Learning, baby’s head LLCto turn in the © Jones & Bartlett Learning, LLC directionNOT ofFOR the stimulus.SALE OR e DISTRIBUTIONmouth will open and the NOT FOR SALE OR DISTRIBUTION tongue will come forward, as illustrated in Figure 14-9. Gently touching the baby’s upper lip causes the mouth to open. e mother can initiate the rooting reex by brush- ing her nipple against her baby’s cheek, stimulating the FIGURE 14-9 Rooting for the nipple is a feeding readiness signal from the baby. © Jones &baby Bartlett to turn Learning, toward her breast LLC and search for the nipple.© Jones & Bartlett Learning, LLC NOT FOR SheSALE can alsoOR gently DISTRIBUTION brush the baby’s nose or philtrum (theNOT FORPrinted SALE with permission OR DISTRIBUTIONof Debbie Shinskie.

9781284078954_CH14_293_230.indd 303 18/06/15 6:35 pm 304 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORsucking. SALE Babies OR demonstrate DISTRIBUTION two types of sucking. A high- NOTburp FOR the SALE baby before OR puttingDISTRIBUTION him or her to the breast. A ow nutritive suck, characterized by a long, deep suck– vigorous feeder will need to nurse before becoming upset swallow–breathe pattern, elicits about one suck per second. so as to cut down on the amount of air intake. A low-ow nonnutritive suck elicits about two sucks per second. It is characterized by a light suck, almost a utter, Spitting Up with short jaw excursions© and Jones little or& no Bartlett audible swallowLearning,- LLC © Jones & Bartlett Learning, LLC ing. Chapter 16 providesNOT a detailed FOR discussion SALE ofOR sucking. DISTRIBUTIONe passage between the baby’sNOT stomach FOR SALEand mouth OR isDISTRIBUTION very short. e muscle valve at the upper end of the stomach (the cardiac sphincter, or lower esophageal sphincter) is not as ecient as it will be later in life. As a result, babies Digestion spit up quite oen during the early months. Some infants Babies ©exhibit Jones their & own Bartlett unique Learning,growth and activityLLC pat- spit up more© than Jones others & do.Bartlett Frequent Learning, spitting up LLCcould terns. PatternsNOT FOR of digesting SALE foodOR andDISTRIBUTION expelling waste are be a sign of overfeedingNOT FOR or SALE overactive OR milk DISTRIBUTION production. If equally individualized. Encourage parents to learn these the mother waits too long between feedings, the baby may characteristics to become familiar with their baby’s diges- be upset and gulp air with the milk. Mucus in the baby’s tive patterns and particular needs. Patterns of digestion stomach can also cause spitting up, especially directly need to take into account the baby’s disposition, eating aer birth and when the baby has an upper respiratory © Jonesand & Bartlettsleeping patterns, Learning, and body LLC temperature. A change in © Jonesinfection. & Bartlett Learning, LLC NOT FORpattern SALE can ORalert DISTRIBUTION parents to a problem or illness before it NOT FORAlthough SALE spitting OR up DISTRIBUTION is messy and inconvenient, it is not becomes serious. If the parents notice a change, encour- usually a reason for concern. Because cow’s milk protein age them to consider the baby’s overall pattern before intolerance and nicotine can cause spitting up, however, contacting the caregiver. is will help them determine the mother may want to consider adjustments in her life- whether the current issue represents one small change in style and diet. Her baby will bene t if she quits smoking their baby’s habits or a more© Jones signi cant & Bartlett change. eLearning, par- orLLC at least reduces the number© ofJones cigarettes & Bartlettsmoked. She Learning, LLC ents also should observeNOT skin color,FOR changes SALE in OR breathing, DISTRIBUTION can burp her baby more oenNOT both FOR before SALE and during OR aDISTRIBUTION or other signs of illness such as glassy eyes or abdominal feeding. More frequent feeding may also help to reduce cramping. Four functions that occur during digestion— spitting up. Occasionally, if the mother experiences an burping, spitting or vomiting, voiding, and stooling—are overproduction of milk, limiting the baby to one breast discussed in the following sections. per feeding may help. Make this recommendation only © Jones & Bartlett Learning, LLC aer a complete© Jones feeding & assessment Bartlett toLearning, ascertain that LLC the mother has overproduction. BurpingNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Projectile Vomiting Breastfed babies may need to be burped even though they usually do not take in as much air as bottle-fed babies. Spitting up diers from vomiting in terms of the force Babies who suck vigorously may gulp air when they nurse. with which the baby expels milk. e baby may dribble © JonesIf & the Bartlett mother watches Learning, for hunger LLC cues and begins a feed- © Jonesmilk out & withBartlett every Learning,burp or may LLCregurgitate with some NOT FORing SALE before herOR baby DISTRIBUTION becomes ravenous, her baby will cry NOTforce. FOR A violentSALE expulsion OR DISTRIBUTION of milk is considered projectile less, resulting in less air in the stomach. Burping increases vomiting and requires a physician’s attention. Even comfort by decreasing gas pains and reducing spitting up. breastfed babies can experience gastroenteritis or stom- Gentle patting or rubbing helps air bubbles coalesce and ach u. Babies become dehydrated much faster than older rise to the top of the baby’s stomach to be expelled. If a children or adults. us, if a baby vomits more than twice baby consistently spits up© aerJones nursing, & Bartlett the mother Learning, may inLLC a 4-hour period, the parents© need Jones to contact & Bartlett their med Learning,- LLC not be taking enough timeNOT for burping.FOR SALE OR DISTRIBUTIONical provider immediately. NOT FOR SALE OR DISTRIBUTION ere are several ways to help the baby release swal- If a baby several weeks old suddenly begins vomiting or lowed air. e mother can rock her baby in her lap and if vomiting becomes progressively worse with a decreas- gently rub her baby’s back. Another method is to hold the ing number of wet diapers, the baby may have pyloric baby against her shoulder and massage or pat in the mid- stenosis. With pyloric stenosis, the outow valve of the dle of ©the Jones back with & aBartlett rm pressure Learning, from the LLCbottom up. baby’s stomach© Jones does not & open Bartlett satisfactorily Learning, to permit LLC the She canNOT also layFOR her babySALE on hisOR or DISTRIBUTION her stomach across her contents of NOTthe stomach FOR toSALE pass. eOR condition DISTRIBUTION seems to lap, turn her baby’s head to one side so that the nose is be most common in rstborn white male infants. free, and gently rub the back from the bottom up. Infant exposure to macrolides (a class of antibiotics that Holding babies at a 45-degree angle aer feedings will includes erythromycin, azithromycin, clarithromycin, help bring up air before being laid down for sleep. A baby and roxithromycin) prenatally and postnatally through © Jonessling & Bartlett, infant seat, Learning, or swing can LLC accomplish this position- © Jonesbreastmilk & Bartlett is associated Learning, with pyloric LLC stenosis (Honein & NOT FORing. SALE If the babyOR DISTRIBUTIONhas been crying, the mother can try to NOTCragan, FOR SALE2014; Lund OR etDISTRIBUTION al., 2014). Projectile vomiting is

9781284078954_CH14_293_230.indd 304 18/06/15 6:35 pm Digestion 305 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR alsoSALE associated OR DISTRIBUTION with the use of the steroid prostaglandinNOT FORallergy SALE could beOR a factor. DISTRIBUTION e oending protein may come for cyanotic congenital heart disease (Perme et al., 2013). either from the mother’s diet or from supplemental for- ese side eects of other medications demonstrate the mula. e use of antireux medications is now associated importance of taking complete histories on both the with the development of food allergies, leading research- mother and the baby. ers to urge caution in prescribing these medications for A sudden onset ©of Jonesvomiting & canBartlett also indicate Learning, an LLCinfants (DeMuth et al., 2013;© TrikhaJones et &al., Bartlett 2013). Learning, LLC obstruction of the intestines or a strangulated hernia. NOT FOR SALE OR DISTRIBUTIONEffects on the Infant NOT FOR SALE OR DISTRIBUTION Both of these conditions require immediate medical eval- e constant regurgitation of milk uation and may result in surgery. Your role in supporting into the esophagus can cause severe irritation or pain for the family at that point changes to helping the mother pro- the infant. Some infants with GER learn to limit their intake tect her milk production until the baby is able to directly aer associating a full stomach with the pain that accom- breastfeed© Jones again. & SeeBartlett Chapter Learning, 25 for more LLC information panies reux.© Jones Frequent & spittingBartlett up andLearning, limited intake LLC can on theNOT lactation FOR consultant’s SALE OR role DISTRIBUTION with a baby who is ill or lead to poorNOT weight FOR gain. SALE If an infant OR DISTRIBUTION with reux has been hospitalized. self-limiting intake because of discomfort, the mother’s milk production may be low because the baby removes Gastroesophageal Re ux only small amounts of milk at each feeding. erefore, the infant with no or slow weight gain whose mother has lim- © Jones &Some Bartlett infants Learning, spit up only LLCoccasionally, while others seem© Jonesited &milk Bartlett production Learning, may experience LLC an exacerbation of NOT FOR toSALE spit up OR all the DISTRIBUTION time. Spitting up multiple times in one dayNOT FORsymptoms SALE when OR the DISTRIBUTION mother attempts to increase her milk can be a sign of gastroesophageal re ux (GER). GER is production. Other infants with reux may display signs of a backow of the contents of the stomach into the esoph- discomfort that look like hunger signs and so may actually agus. It oen occurs when the lower esophageal sphinc- be overfed, with excessive weight gain of 2 or more ounces ter fails to close or is so so that it does not stay securely per day. Because of this possibility, it is important to look closed. e acidic gastric© Jones juices & may Bartlett produce Learning, burning LLCfor signs of reux in any infant© Jones whose &weight Bartlett gain is Learning, out- LLC pain in the esophagus.NOT Reux FOR is aSALE common OR physiologic DISTRIBUTION side the normal range in eitherNOT direction. FOR SALE OR DISTRIBUTION occurrence in infancy. It is age related, with reduced fre- Regurgitating human milk is not as irritating as regur- quency as the baby grows. GER resolves in most infants by gitating formula. Because infants digest human milk more the time they start walking (Smith et al., 2013). quickly than infant formulas, they absorb more milk in Note that GER is distinct from gastroesophageal re ux the same amount of time. For these reasons, and because disease© Jones (GERD) &, whichBartlett is a medicalLearning, diagnosis. LLC GERD is of the many© Jones health &risks Bartlett of arti cial Learning, feeding, LLCit is not de nedNOT as FORGER thatSALE is associated OR DISTRIBUTION with persistent symp- appropriateNOT to switchFOR aSALE breastfed OR infant DISTRIBUTION to formula as a toms or complications, including esophagitis, low weight treatment for GER. gain, failure to thrive, and respiratory disorders (Vanden- Coping Strategies Infants who experience GER need plas, 2014; Vandenplas et al., 2012). Always be diligent to to be fed in an upright position so that gravity can help the refer parents to their baby’s healthcare provider imme- milk stay down. Holding the baby upright aer a feeding diately if a baby’s symptoms do not improve with coping © Jones & Bartlett Learning, LLC © Joneswill &also Bartlett help keep Learning, the milk down. LLC In addition, these babies strategies. NOT FOR SALE OR DISTRIBUTION NOT FORbene t SALE from smaller,OR DISTRIBUTION more frequent feedings. Another Identifying Gastroesophageal Re ux Infants with reux strategy is to nurse from only one breast at a feeding, pro- may spit up several times aer a feeding. Some may spit up vided the mother has adequate milk production. All these even during a feeding. Silent reux may also occur, a condi- actions will help limit the amount of milk the infant takes tion in which the stomach contents fail to come all the way in at a feeding, yet ensure that the child gets the fatty hind- back up. In such a case,© theJones infant &does Bartlett not spit upLearning, but may LLCmilk and is able to digest and© Jonesretain more & Bartlettcalories. Learning, LLC experience burning andNOT discomfort. FOR SALE Infants whoOR are DISTRIBUTION breast- As another measure to counteractNOT FOR GER, SALE parents OR might DISTRIBUTION fed experience a more rapid resolution of GER compared try putting the infant to sleep on an incline and using a with arti cially fed infants (Campanozzi et al., 2009). paci er aer feedings. Like many interventions, these Food allergy can contribute to GERD, colic, or measures have mixed results (Jung et al., 2012; Neu et al., constipation in infancy. Infants with these conditions 2012). However, they are worth a try, especially in view oen© respondJones to& aBartlett maternal Learning,dairy elimination LLC diet or a of the increased© Jones eort & Bartlettto avoid medications.Learning, LLCCarriers, non-bovine-basedNOT FOR SALE formula OR if supplementedDISTRIBUTION (Paddack et seats, andNOT positions FOR that SALE avoid ORpressure DISTRIBUTION on the abdomen al., 2012). Weaning to one of these formulas, as is oen but keep the trunk supported and extended are preferred suggested by care providers, is not appropriate. GER is when the child has GER. is may mean limiting the use associated with, and sometimes induced by, cow’s milk of car seats to car riding only. Burping positions can be allergy (Borrelli et al., 2012; Semeniuk et al., 2012; limited to ones that avoid pressure on the baby’s stomach. © Jones & Vandenplas Bartlett etLearning, al., 2012). If LLC a mother tells you her baby has© JonesSome & parentsBartlett nd Learning, relief from infantLLC massage and chiro- NOT FOR reuxSALE or ORif you DISTRIBUTION see signs consistent with GER, cow’s milkNOT FORpractic SALE care. OR DISTRIBUTION

9781284078954_CH14_293_230.indd 305 18/06/15 6:35 pm 306 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORMothers SALE mayOR be DISTRIBUTION told they can mix their milk with cereal NOTbuilds FOR parents’ SALE con denceOR DISTRIBUTION that exclusive breastfeeding or a commercial thickener (such as Simply ick) to see if provides sucient nourishment for their baby. If concerns the thicker uid will stay down better. It is almost impos- arise about intake, the diary provides a helpful record for sible to thicken a mother’s milk with rice cereal because medical care providers. ere is wide variability in stool- the enzymes in human milk begin digesting starches ing and voiding among infants in the early days aer almost immediately. When© Jones milk is thickened,& Bartlett some Learning, fami- LLCbirth, especially when there are© dierencesJones & inBartlett breastfeed Learning,- LLC lies have compensated forNOT the slowness FOR SALE of feeding OR by DISTRIBUTION using ing routine. NOT FOR SALE OR DISTRIBUTION bottle nipples with larger holes, which defeats the purpose of thickening. Furthermore, the fact that the milk is not Voiding spit up does not mean that the reux and pain have been Color of a healthy newborn’s urine ranges from pale treated eectively. Many women will abandon breastfeed- yellow to clear. Newborns have small, frequent voids, ing if they© Jones are told & they Bartlett must express Learning, their milk LLC and feed with most voids© Jones in full-term & Bartlett babies Learning, occurring LLCwhen it by bottleNOT to FOR provide SALE thickening. OR DISTRIBUTION e use of thickeners they are awake.NOT In FORthe rst SALE week ofOR life, DISTRIBUTION the baby should was associated with necrotizing enterocolitis in over 22 have an increasing number of voids daily. Many hos- infants (Beal et al., 2012; Woods et al., 2012). Whether it pitals correlate the number of voids and stools to the is manufacturing contamination or the xanthan gum itself number of days old the baby is, up to day 4 or 5. By 4 is still being researched. or 5 days of age, the baby should be voiding at least 6 © Jones &Having Bartlett an infant Learning, with reux LLC can be very stressful for © Jonestimes in& 24Bartlett hours. Learning, LLC NOT FORparents. SALE ey OR sometimes DISTRIBUTION feel that their baby is colicky all NOT FOR SALE OR DISTRIBUTION day long. In some cases, the baby may be upset only at Urate Crystals Pink (copper or “brick dust”) stains that feeding time, which can feel like personal rejection to the appear with urination are urate crystals, whose presence mother. From a counseling standpoint, parents need vali- indicates excess uric acid (see Color Plate 26). Urate crys- dation that reux is stressful and that caring for their child tals generally are not signi cant in the rst 1 to 3 days of is draining. Acknowledge© the Jones parents’ & grief Bartlett that their Learning, baby life.LLC Assessment of the baby’s hydration© Jones status & Bartlett is necessary Learning, LLC is not the pleasant, cooing,NOT cuddly FOR baby SALE they OR had DISTRIBUTION envi- if the stains appear aer this time,NOT however. FOR SALE OR DISTRIBUTION sioned. Reassuring them that they are not bad parents can Stooling help them move forward and enjoy the moments when their baby is content. Support from other parents, friends, A breastfed baby’s stools dier greatly from those of a and relatives helps alleviate the sense of isolation parents formula-fed baby. e newborn’s rst stools are a black, may feel.© JonesColic symptoms & Bartlett usually Learning, decrease in LLCthe second tarry meconium,© Jones usually & Bartlettpassed within Learning, the rst LLC24 to half ofNOT the rst FOR year SALEof life and OR subside DISTRIBUTION by the child’s rst 36 hours (seeNOT Color FOR Plate SALE 27). TransitionalOR DISTRIBUTION stools are birthday. greenish black to greenish brown as the meconium gives way to brown and then to a golden or mustard yellow Medications In the case of severe reux, the physi- color when the baby is approximately 48 to 72 hours old cian will need to be more involved in the child’s care. (see Color Plate 28). e texture may range from watery © JonesFor & someBartlett infants, Learning, reux can LLCbe severe enough to require © Jonesto seedy & yellowBartlett to a Learning,toothpaste consistency. LLC ere is no NOT FORmedication. SALE OR Some DISTRIBUTION medications used for reux decrease NOTstrong FOR odor SALE to the OR stools DISTRIBUTION of a breastfed infant. the acid level in the infant’s stomach. Others encour- Infants in the rst month of life should have a minimum age the infant’s stomach to pass the milk more quickly of three or more so, yellow, runny stools each day. An into the intestines. Overprescribing of antireux medi- infant who has fewer than three stools in a 24-hour period cations is a concern and many babies prescribed these may not be getting enough to eat and will need to be drugs do not meet the© diagnosticJones & criteria Bartlett for Learning,GERD weighed,LLC examined, and monitored© Jones for adequate& Bartlett intake. Learning, LLC (Quitadamo et al., 2014;NOT Vandenplas, FOR SALE 2014). ORMost DISTRIBUTION phy- Encourage parents to becomeNOT familiar FOR with SALE their baby’sOR DISTRIBUTION sicians will usually try medications before resorting to a stooling patterns. Every baby’s digestive system, and thus more invasive test such as a barium swallow, endoscopy, the pattern for expelling waste, is individual to that par- pH probe, or x-ray exam. ese tests are indicated when ticular baby. One study found that the median number of the baby has poor weight gain or does not respond to stools per day is 6 in the rst month of life and that stool- medications.© Jones & Bartlett Learning, LLC ing frequency© isJones higher in& breastfedBartlett infants Learning, (Tunc, 2008). LLC NOT FOR SALE OR DISTRIBUTION Babies’ bowelNOT habits FOR change SALE with OR age. DISTRIBUTION A mother may Elimination nd that at around 4 to 6 weeks of age, her baby will begin going for longer periods between bowel movements. Fre- Elimination patterns are signi cant indicators of a baby’s quency of elimination in older breastfed infants can range intake. Keeping a diary of feedings, voids, and stools for from a baby having several stools every day to stooling © Jonesthe & rstBartlett week orLearning, two postpartum LLC helps parents identify © Jonesonly once & Bartlett every 3 days.Learning, Both patterns LLC are acceptable. NOT FORand SALE assess patternsOR DISTRIBUTION in their new baby’s behavior. It also NOTStooling FOR SALEmay decrease OR DISTRIBUTION to once a day in the second month

9781284078954_CH14_293_230.indd 306 18/06/15 6:35 pm Digestion 307 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR TABLESALE 14-4 OR DISTRIBUTIONStool Patterns of a Breastfed Baby NOT FOR SALE OR DISTRIBUTION Characteristics Normal Stool Variations Possible Causes Color A newborn’s stool is black, brown, Unexplained color changes. Black, Mother’s or baby’s diet. or green in the rst 3 days. This brown, or red spots. Mother’s cracked nipples (possible is meconium. Later, color ranges bleeding—there is no harm to the from© Jones brown or & green Bartlett to mustard Learning, LLC baby).© Jones & Bartlett Learning, LLC yellow.NOT FOR SALE OR DISTRIBUTION BleedingNOT fromFOR baby’s SALE rectum. OR If noDISTRIBUTION known cause, the mother should consult the physician. Consistency Ranges from a toothpaste-like Very watery. Foods in diet other than mother’s texture to a liquid with curds. milk, antibiotics, or illness. © Jones & Bartlett Learning, LLC Hard pellets. © Jones & FoodsBartlett in diet Learning, other than mother’s LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALEmilk, insufcientOR DISTRIBUTION uids, or baby tense or ill. Mucous. Newborn mucus, cold, congestion, or allergy to mother’s or baby’s diet. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Fibrous. Bananas and cereal present in the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTIONbaby’s diet. Odor Very little, not unpleasant. Unpleasant. New foods in addition to mother’s milk, antibiotics, or illness. Frequency Ranges from 1 with every feed to Sudden change in frequency. Foods, maturity, or illness. 4© a Jonesday under & 1 Bartlettmonth of age. Learning, Watch LLC carefully and look for © Jones & Bartlett Learning, LLC Decrease in frequency after the other symptoms. rstNOT month FOR of life. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Volume Varies with frequency. More fre- Any sudden change. Watch Foods, maturity, or illness. quent stools means less volume carefully and be alert to other per diaper. symptoms. Ease© of Jones expulsion & Bartlett Easy and semicontrolled Learning, with LLC Flows out continually.© Jones & BartlettFoods other Learning, than mother’s LLCmilk, NOT FOR SALEsome OR straining DISTRIBUTION by the baby. NOT FOR SALEillness, OR or antibiotics. DISTRIBUTION Very difcult with extreme straining. Foods other than mother’s milk or insufcient uids.

© Jones &of Bartlett life, a pattern Learning, that could LLC continue until supplemental© JonesInfrequent & Bartlett stooling Learning, could be causedLLC by Hirschsprung’s NOT FOR foodsSALE are OR started. DISTRIBUTION e characteristics of healthy breastfedNOT FORdisease SALE, a condition OR DISTRIBUTION in which a part of the infant’s intes- stools are described in Table 14-4, along with variations tines lacks proper innervation and the stool cannot pass and their possible causes. easily beyond that point. Symptoms in infants include difcult bowel movements, poor feeding, poor weight gain, Infrequent Stooling When an infant is not stooling and a large, bloated abdomen from the impacted stool and appropriately in the rst© Jones month of & life, Bartlett the clinician Learning, needs LLCgas. Early diagnosis is important© Jones to prevent & Bartlett serious comLearning,- LLC to do a complete feedingNOT assessment. FOR SALE Infrequent OR DISTRIBUTION stooling plications, including enterocolitisNOT FOR and SALEcolonic ORrupture DISTRIBUTION in the rst month may be due to insucient milk intake. (Mabula et al., 2014). Breastfed infants with this condition A baby who is voiding but not stooling or gaining weight may escape detection until the parents add solid foods to may not be feeding frequently enough or may be feeding their diet and their stools become more bulky and solid. ineectively. Such a child may not be receiving enough Although this is a rare condition, any exclusively breastfed high-fat© Jones hindmilk, & Bartlett especially Learning, if the mother LLC is limiting infant who© isJones gaining & adequate Bartlett amounts Learning, of weight LLC but not the NOTfrequency FOR or SALE duration OR of feedings.DISTRIBUTION Infrequent stool- stooling NOTfrequently FOR needs SALE careful OR evaluation DISTRIBUTION and moni- ing sometimes is the parents’ rst indication of low milk toring. Cow’s milk allergy has been shown to both mimic production. Stooling frequency usually corrects itself with and inuence Hirschsprung’s disease (Ikeda et al., 2011; additional feeding or longer feedings to ensure that the Umeda et al., 2013). infant receives more hindmilk. is intervention works © Jones &when Bartlett the mother Learning, has adequate LLC milk production and the© JonesConstipation & Bartlett Constipation Learning, is LLC rare in breastfed infants. NOT FOR babySALE is able OR to DISTRIBUTION transfer milk well. NOT FORLack ofSALE a daily OR bowel DISTRIBUTION movement and straining at stool-

9781284078954_CH14_293_230.indd 307 18/06/15 6:35 pm 308 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORing SALEare normal OR aspects DISTRIBUTION of toileting and not signs of con- NOTLactation FOR SALE consultants OR DISTRIBUTION can help mothers understand, stipation. In infants, constipation is diagnosed by stool interpret, and respect their babies’ communication so consistency and not by frequency. A so stool indicates they respond accordingly. Attachment is important for that the infant is not constipated. Constipated stools are developing maternal feelings. Women with anxiety or molded and rm to the touch like pellets or marbles. In fear of attachment have higher rates of depression than young infants, nursing more© Jones frequently & Bartlett will resolve Learning, most LLCthose with feelings of security© and Jones attachment & Bartlett (Monk Learning,et LLC infrequent stooling. MaternalNOT FOR iron SALEsupplements OR DISTRIBUTION have al., 2008; Ponizovsky & Drannikov,NOT FOR 2013). SALE ere isOR also DISTRIBUTION been reported anecdotally to contribute to an infant’s a correlation between maternal depression and early constipation. If this is the case, discontinuing these sup- breastfeeding cessation (Dias & Figueiredo et al., 2014; plements for a few days may return the child’s digestive Lindau et al., 2014). system to normal. Smiling is an important development in babies that Constipation© Jones sometimes & Bartlett occurs Learning, when solid LLC foods are appears to be© dependentJones & onBartlett interaction. Learning, Social smiling LLC added NOTto the FOR baby’s SALE diet. If ORthe DISTRIBUTIONbaby is receiving large emerges outNOT of attentive FOR engagementSALE OR with DISTRIBUTION an interactive amounts of cereal, it can be stopped or decreased for sev- caregiver (Parlade et al., 2009). e concept of mutually eral days until normal stooling is reestablished and then responsive orientation, in which parental responsive- reintroduced in smaller amounts less frequently. Add- ness elicits responses from infants, is associated with the ing more fruits and vegetables and, when the baby is old development of self-regulation and self-representation © Jonesenough, & Bartlett yogurt, Learning, oatmeal, or pruneLLC juice may help. Parents © Jones(Kochanska & Bartlett et al., 2008). Learning, Lactation LLC consultants can teach NOT FORshould SALE not ORtreat DISTRIBUTIONtheir infant with suppositories without NOTparents FOR toSALE recognize OR infant DISTRIBUTION signals and give positive feed- consulting the baby’s healthcare provider. back when they respond appropriately to their babies’ cues. Smiling and other developmental milestones are Diarrhea It is important to recognize the dierence addressed in Chapter 18. between diarrhea and the typically loose stool of a breastfed baby. A mother© Jones who has & beenBartlett supplement Learning,- LLC © Jones & Bartlett Learning, LLC ing with formula and thenNOT returns FOR toSALE exclusive OR breastDISTRIBUTION- Approach and Avoidance BehaviorsNOT FOR SALE OR DISTRIBUTION feeding may mistakenly believe her baby has diarrhea. Infants exhibit speci c behavior that indicates a willing- A mother whose previous children were not breastfed ness to be approached. is so-called approach behavior might also need to recognize the dierence. Likewise, is integrated, stable, balanced, exploratory, and self-reg- grandmothers or other caregivers who are unfamiliar ulated. e signals illustrated in Figure 14-10 are char- with breastfeeding© Jones & may Bartlett worry thatLearning, a normal LLCbreastmilk acteristic of© a Jonesmore mature & Bartlett infant. Learning,Conversely, infants LLC stool isNOT diarrhea. FOR SALE OR DISTRIBUTION display avoidanceNOT FORbehavior SALE that OR indicates DISTRIBUTION a desire to With diarrhea, the stool is much looser than nor- withdraw, as shown in Figure 14-11. Recognizing these mal, is very watery, and may be greenish and very foul behaviors will help parents know how to respond to their smelling. It may indicate the beginning of an illness baby. Tables 14-5 and 14-6 describe infant approach and or a reaction to antibiotics taken by either the mother avoidance behaviors. © Jonesor & the Bartlett baby. If Learning, diarrhea is suspected,LLC urge the mother © Jones & Bartlett Learning, LLC NOT FORto SALEcontinue OR breastfeeding. DISTRIBUTION Diarrhea removes valuable NOT FOR SALE OR DISTRIBUTION intestinal bacteria that aid in the digestion of food. Such bacterial colonization can be restored with human milk feedings. When a baby exhibits diarrhea, the mother should contact the baby’s caregiver© immediately Jones & becauseBartlett babies Learning, can LLC © Jones & Bartlett Learning, LLC become dehydrated veryNOT quickly. FOR Human SALE milk OR is DISTRIBUTIONnot a NOT FOR SALE OR DISTRIBUTION dairy product; it is a clear uid that provides all the elec- trolytes a baby needs. Mothers should therefore continue breastfeeding and avoid supplementing with any electro- lyte solution. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Infant Communication A full-term, nonmedicated human baby is exquisitely wired and very competent to breastfeed. Respect- FIGURE 14-10 An infant exhibiting approach behavior. © Jonesing & theBartlett baby’s Learning,innate ability LLC to nurse capitalizes on the © Jones & Bartlett Learning, LLC NOT FORchild’s SALE neurobehaviors OR DISTRIBUTION and is empowering to mothers. NOTPrinted FOR with SALE permission OR of KoriDISTRIBUTION Martin.

9781284078954_CH14_293_230.indd 308 18/06/15 6:35 pm Infant Communication 309 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORHunger SALE Cues OR and DISTRIBUTION Stages of Alertness Many infant approach behaviors signal an interest to breastfeed. For example, hunger cues may indicate hunger, thirst, or a need to be comforted at the breast. e infant © Jones & Bartlett Learning, LLCwill give cues the same way,© regardlessJones & of Bartlett the reason. Learning, An LLC interest in feeding depends on the baby’s level of alert- NOT FOR SALE OR DISTRIBUTIONness, as described in TableNOT 14-7 FOR. Teaching SALE hunger OR cuesDISTRIBUTION to parents will help them know when their baby is ready to nurse. If parents wait until their baby cries to initiate feeding, the baby will already be exhibiting the nal sign © Jones & Bartlett Learning, LLC of hunger.© Pointing Jones out & hunger Bartlett cues Learning,during a breastfeeding LLC assessment will help the mother recognize what to look for. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Knowing When to Initiate a Feeding

FIGURE 14-11 An infant exhibiting avoidance behavior. Hunger cues may be evident when the baby is in a light sleep, drowsy, and quietly alert. e baby will begin to © Jones &Printed Bartlett with permission Learning, of Kori Martin.LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TABLE 14-5 Infant Approach Behaviors Behavior Description Tongue extension The infant’s tongue either is extended toward a stimulus or it repeatedly extends and relaxes. Hand on face ©The Jones infant’s hand & Bartlett or hands are Learning, placed onto LLChis face or over his ears and are maintained© Jones there & Bartlett for a brief period. Learning, LLC Sounds NOTThe infant FOR emits SALE undifferentiated OR DISTRIBUTION sounds. At times, it may sound like a whimper.NOT FOR SALE OR DISTRIBUTION Hand clasp The infant grasps his own hands or clutches his hands to his own body. His hands each may be closed and touch each other. Foot clasp The infant positions his feet against each other, foot sole to foot sole. Or he folds his legs in a crossed posi- © Jones & Bartletttion with Learning, his feet grasping LLC his legs or resting on them.© Jones & Bartlett Learning, LLC FingerNOT fold FOR SALEThe infantOR DISTRIBUTIONinterweaves one or more ngers of each hand.NOT FOR SALE OR DISTRIBUTION Tuck The infant curls or turns his trunk or shoulders, pulls up his legs, and tucks his arms. He uses the examiner’s hands or body to attain tuck exion. Body movement The infant adjusts his body, his extremities, or his head into a more exed position. He may turn to the side or attempt to attain a tonic neck response. © Jones &Hand Bartlett to mouth Learning, The infantLLC attempts to bring his hand© or Jonesngers to &his Bartlett mouth. He Learning,does not have LLCto be successful. NOT FOR GraspingSALE OR DISTRIBUTIONThe infant makes grasping movementsNOT with FORhis hands. SALE He may OR grasp DISTRIBUTION either toward his own face or body, in midair, toward the examiner’s hands or body, or toward the side of the bassinet. Leg and foot brace The infant extends his legs and/or feet toward an object in order to stabilize himself. He may push against the examiner’s body or hands, the surface he is on, or the sides of the bassinet. Once touching, he may ex his legs or he may restart the bracing. Mouthing ©The Jones infant makes & Bartlett mouthing Learning,movements with LLC his lips or jaws. © Jones & Bartlett Learning, LLC Suck searchNOT The infant FOR extends SALE his lips OR forward DISTRIBUTION or opens his mouth in a searching fashion,NOT usually FOR moving SALE his head OR at DISTRIBUTION the same time. Sucking The infant sucks on his own hands or ngers, clothing, the examiner’s ngers, a pacier, or other object that he has either obtained himself or that the examiner has inserted into his mouth. Hand© holdingJones & Bartlett The infant Learning, holds onto the LLC examiner’s hand or nger with© his Jones own hands. & Bartlett He may have Learning, placed them LLC there NOT FOR SALEhimself, OR DISTRIBUTIONor the examiner may have positioned them there.NOT The FOR infant SALE then actively OR holdsDISTRIBUTION on. “Ooh” face The infant rounds his mouth and purses his lips or extends them in an “ooh” conguration. This may be with his eyes open or closed. Locking visually The infant locks onto the examiner’s face or an object or sight in the environment. He may lock on and/or auditorily above or to the side of the examiner’s face and maintain his gaze in one direction for observable © Jones & Bartlett Learning,periods. LLC The sound component of ©an Jonesenvironmental & Bartlett stimulus may Learning, contribute toLLC his locking. NOT FOR AdaptedSALE and OR printed DISTRIBUTION with permission of Sarah Coulter Danner. NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 309 18/06/15 6:35 pm 310 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORTABLE SALE 14-6 OR Infant DISTRIBUTION Avoidance Behaviors NOT FOR SALE OR DISTRIBUTION Behavior Description Spit up The infant spits up, with more than a passive drool. However, the amount of vomit may be quite minimal. Gag The infant appears to choke momentarily or to gulp or gag. Swallowing and respiration © Jones & Bartlettpatterns Learning,are not synchronized. LLC This is often accompanied© byJones at least & mild Bartlett mouth Learning, LLC NOT FOR SALEopening. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Hiccough The infant hiccoughs. Bowel movement grunting or straining The infant’s face and body display the straining often associated with bowel movements. He emits the grunting sounds often associated with bowel movements. Grimace,© lipJones retraction & Bartlett Learning,The infant’s LLC lips retract noticeably. His face© Jones is distorted & inBartlett a retracting Learning, direction. LLC Trunkal NOTarching FOR SALE OR DISTRIBUTIONThe infant arches his trunk away from theNOT bed FORor the mother’sSALE body.OR DISTRIBUTION Finger splay The infant’s hands open strongly, and the ngers are extended and separated from each other. Airplane The infant’s arms either are fully extended out to the side at approximately shoulder level or the upper and lower arm are at an angle to each other and are extended out © Jones & Bartlett Learning, LLC at the shoulder. © Jones & Bartlett Learning, LLC NOT FORSalute SALE OR DISTRIBUTION The infant’s arms areNOT fully extended FOR SALE into midair, OR either DISTRIBUTION singly or simultaneously. Sitting on air The infant’s legs are extended into midair, either singly or simultaneously. This may occur when the infant is lying at on his back or upright. Sneezing, yawning, sighing, or coughing The infant sneezes, yawns, sighs, or coughs. Averting © Jones & BartlettThe infant activelyLearning, averts hisLLC eyes. He may momentarily close© Jones them. & Bartlett Learning, LLC Frowning NOT FOR SALEThe infant OR knits DISTRIBUTION his brows or darkens his eyes by contractingNOT his muscles.FOR SALE OR DISTRIBUTION Startle The infant’s limbs jerk once, occasionally followed brie y by a slight amount of jitteriness and possibly crying. Adapted and printed with permission of Sarah Coulter Danner. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC wriggle,NOT and FORtightly SALE closed OReyes DISTRIBUTIONmay exhibit rapid eye or mouth isNOT touched FOR at this SALE stage, OR the babyDISTRIBUTION will begin to movement (REM). Cues progress to passing one or root. Soon, more vigorous sucking begins. e baby then both hands over the head, bringing a hand to the mouth will settle back into a less active state. (Figure 14-12), and making sucking motions. If the cheek

© JonesTABLE & Bartlett 14-7 TheLearning, Six Infant LLC States © Jones & Bartlett Learning, LLC NOT FORInfant SALE State OR DISTRIBUTIONDescription NOT FOR SALE OR DISTRIBUTION Deep sleep Characterized by limp extremities, a placid face, quiet breathing, no body movement, and no rapid eye movement (REM). The baby lies very still, with an occasional twitch or sucking movement. He cannot easily be aroused. Light or active sleep © JonesResistance & Bartlett in the extremities Learning, when moved, LLC mouthing or sucking motions,© Jones body movement, & Bartlett and Learning, LLC facial grimaces. The baby is awakened more easily and is likely to remain awake if disturbed. NOT FORMost ofSALE the baby’s OR sleep DISTRIBUTION is spent in this state, with less regular breathingNOT andFOR rapid SALE eye move- OR DISTRIBUTION ment (his eyes utter beneath the eyelids). Although he may stir and move about, he can return to sleep if left undisturbed. Drowsy The baby is aroused easily and may drift back to sleep. His eyes may open and close intermit- tently, and he may murmur, whisper, yawn, and stretch. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Quiet alert The baby looks around and interacts with others. This is an excellent time to breastfeed. The baby NOT FOR SALE ORis DISTRIBUTIONextremely responsive. His body is still and watchful,NOT hisFOR eyes SALE are bright, OR and DISTRIBUTION his breathing is even and regular. Active alert The baby moves his extremities and plays. He is even more attentive, being wide-eyed, with rapid and irregular breathing. He may become fussy and is more sensitive to the discomfort of a wet © Jones & Bartlett Learning, LLCdiaper or excessive stimulation.© Jones & Bartlett Learning, LLC NOT FORCrying SALE OR DISTRIBUTIONThe baby is agitated and needsNOT comforting. FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 310 18/06/15 6:35 pm Infant Behavior Patterns 311 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORvarious SALE behavior OR patterns, DISTRIBUTION dispositions, and sleeping and eating patterns will help you oer appropriate sugges- tions. It may take some time for parents to discover all the variations and subtle nuances. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Average Baby NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Exclusively breastfed newborns typically nurse between 8 and 12 times in 24 hours. Nursing more frequently is very normal because intake is small (Bergman, 2013). Babies sometimes cluster their feedings so that they blend into one © Jones & Bartlett Learning, LLC another, with© Jones few distinctions & Bartlett between Learning, starting and LLC stop- NOT FOR SALE OR DISTRIBUTION ping. NewbornsNOT FORusually SALE sleep from OR 12 DISTRIBUTION to 20 hours per day, possibly with one or two longer periods of sleep balanced FIGURE 14-12 An infant exhibiting hunger cues. by one or two fussy periods. Fussy periods typically occur in the early evening. Usually responsive when handled, the Printed with permission of Kori Martin. average baby is generally quiet, alert, and listening while © Jones & Bartlett Learning, LLC © Jonesawake. & BartlettSome babies Learning, learn self-soothing LLC by sucking on a st NOT FOR SALEe baby OR may DISTRIBUTION exhibit hunger cues several times in theNOT FORor displaying SALE some OR otherDISTRIBUTION type of comfort measure. span of 20 to 30 minutes. If these signals remain unheeded, the baby could become frustrated and cry. Conversely, the Easy Baby baby might become exhausted and fall back asleep without having received any nourishment. A missed feeding Some babies have a breastfeeding pattern typical of an opportunity can have© consequences Jones & Bartlettfor the next Learning, feed. is LLCaverage baby, consisting of© approximatelyJones & Bartlett 8 to 12 Learning,feed- LLC pattern is common inNOT infants FOR who SALE are born OR prematurely, DISTRIBUTION ings in 24 hours. However,NOT they FORhave longer SALE sleep OR peri DISTRIBUTION- health compromised, or fed by the clock or ignored. ods and are less demanding, with relatively little or no Crying can cause a newborn’s motor functions to fussiness. Mothers oen refer to these babies as being “so appear disorganized. It may take several minutes for the easy.” is mother may need to make a conscious eort to infant to settle enough to breastfeed. Some infants may be give her baby the tactile stimulation and attention needed unable© Jones to breastfeed & Bartlett at all until Learning, they have sleptLLC again for for emotional© Jones growth & and Bartlett physical Learning, development. LLC Having a while.NOT In FOR either SALE case, the OR mother DISTRIBUTION has missed a feeding an undemandingNOT FOR baby SALEmay allow OR her DISTRIBUTION more free time, and opportunity. If she needs to wake her baby for a feeding, she will want to take care not to overexert herself physi- she should do so when the baby is drowsy or in a light cally as a result. She can be encouraged to devote time to sleep. Most babies move from deep sleep to light sleep in her baby even in the absence of many bids for attention. approximately 20- to 30-minute cycles. © Jones & Bartlett Learning, LLC © JonesPlacid & Bartlett Baby Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Infant Behavior Patterns Some babies demonstrate placid behavior and request as few as 4 to 6 feedings in 24 hours. e mother will need e rst few weeks of a baby’s life are a series of adjustments to be alert for possible undernourishment. A placid baby for everyone. For parents, it is a period when love, patience, sleeps as much as 18 to 20 hours per day and is usually and understanding for© Jonestheir infant & Bartlettare most Learning,important. LLCquietly alert and tranquil ©when Jones awake. & DespiteBartlett making Learning, LLC Because newborns totallyNOT rely FOR on SALEtheir mothers OR DISTRIBUTION to meet few demands for attention,NOT the infrequent FOR SALE feedings OR do DISTRIBUTIONnot their needs, a mother may spend nearly all of her time and indicate a lack of hunger. e infant may wake, feel hun- energies during the rst month caring for her baby. She gry and need to nurse, yet not cry or demonstrate speci c may feel physically drained and emotionally frustrated by hunger cues. Rather, the infant soon falls back asleep and the infant’s helplessness. At the same time, she may enjoy later wakes again and repeats the same pattern. e result the ©closeness Jones and & warmthBartlett of theirLearning, growing relationship.LLC can be an© undernourished Jones & Bartlett baby. Learning, LLC Infants’NOT dispositionsFOR SALE and OR patterns DISTRIBUTION of sleeping and eating Lack ofNOT attention FOR and SALE stimuli forOR a placid DISTRIBUTION baby can lead to can aect the nourishment they receive. First-time moth- poor emotional nourishment. e mother may not meet the ers sometimes become concerned about their babies’ dis- infant’s needs for nourishment because the baby does not positions. It helps them to know that babies experience know how to give the necessary cues. With such vital phys- a variety of behavior patterns, ranging from easygoing ical and emotional needs going unful lled, the baby may © Jones &and Bartlett undemanding Learning, to active LLC and fussy. Studies show that© Jonesbecome & Bartlett withdrawn Learning, and lethargic. LLC Mothers oen describe NOT FOR anSALE infant’s OR temperament DISTRIBUTION is inborn. Understanding theNOT FORa placid SALE baby asOR being DISTRIBUTION “such a good baby” who does not

9781284078954_CH14_293_230.indd 311 18/06/15 6:35 pm 312 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORcry SALEand sleeps OR through DISTRIBUTION the night. You can discreetly ask the NOT FOR SALE OR DISTRIBUTION mother of a “good” baby about breastfeeding and elimination patterns. ese babies may be slow weight gainers. e mother of a placid baby must take care to meet her baby’s needs without receiving the necessary cues. She can use a monitor or place a© noise Jones device & inBartlett the crib, Learning,such as LLC © Jones & Bartlett Learning, LLC a safe rattle, bell, or squeakyNOT toy, FOR to alert SALE her to OR movement DISTRIBUTION NOT FOR SALE OR DISTRIBUTION in the crib. A placid baby will bene t from being carried in a sling or baby carrier and being kept close to the mother and other family members, even without bids for attention. e mother can take advantage of natural waking by ©picking Jones up &her Bartlett baby to nurse. Learning, Parents LLCof a placid © Jones & Bartlett Learning, LLC baby shouldNOT avoidFOR pacifying SALE ORtechniques DISTRIBUTION such as paci ers, NOT FOR SALE OR DISTRIBUTION cradles, or swings. Babies who pacify themselves through thumb sucking can be encouraged to satisfy their sucking needs at the breast instead. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Active and Fussy Baby NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Active, fussy babies may nurse more frequently than the average baby, perhaps because of a greater need for comforting. Such a baby may seem insatiable at the breast and impatient for the milk to let down. The baby will sleep fewer hours than© Jones average. & When Bartlett awake, Learning, he or LLC © Jones & Bartlett Learning, LLC she will be active and frequentlyNOT FOR unable SALE to self-calm. OR DISTRIBUTION In FIGURE 14-13 Parents can wearNOT their FOR baby SALE in a sling OR for DISTRIBUTION addition, there may be several periods of inconsolable comforting. crying during the day. The baby may overreact to free- dom and stimulation and will need gentle, slow, and soothing movements from caregivers as a calming measure. The© Jones mother & can Bartlett keep her Learning, fussy baby LLCwarm and intake in relation© Jones to weight & Bartlett gain, including Learning, alertness, LLC skin use swaddlingNOT FOR to avoid SALE startling. OR DISTRIBUTION She and other family turgor, moistNOT mucous FOR membranes, SALE OR and adequateDISTRIBUTION output. members can hold the baby often, close to their bodies. An active, fussy baby may respond well to nursing, doz- Caloric Intake ing, and playing at the breast for generous periods. e greater need to be comforted at the breast, combined with e calorie content of human milk depends on its fat con- © Jonesincreased & Bartlett milk Learning,intake, may resultLLC in frequent spitting up © Jonestent, given & Bartlett that half ofLearning, the energy LLCcontent of milk comes NOT FORfrom SALE being ORoverly DISTRIBUTION full. Nursing on only one breast at a NOTfrom FOR the SALE fat. Fat contentOR DISTRIBUTION varies between women, the time feeding would allow leisurely sucking on a drained breast of day, the fullness of the breast, and between breasts. to reduce the amount of milk to a level the baby can han- Most women report one breast makes more milk than the dle. Air swallowed because of over-eagerness at feedings other. See Chapter 9 for the discussion on normal milk may require that the baby be burped oen. Some of these production and infant intake ranges. babies do well when carried© Jones in a sling & Bartlett and held Learning,upright LLCHealthy, full-term infants self-regulate© Jones their & Bartlett food intake, Learning, LLC aer nursing (see FigureNOT 14-13 ).FOR When SALE using a OR baby DISTRIBUTION sling, provided no arbitrary schedulingNOT or time FOR limits SALE are imposed OR DISTRIBUTION parents are cautioned to make sure the baby’s face is visi- on feeding. Giving babies water can aect their caloric ble and is not pressed tightly against the wearer. intake because the volume makes them feel full. Sterile

water has no calories, and sugar (dextrose) water (D5W) has only a limited amount of energy—6 kcal/29.57 mL Infant© Growth Jones & Bartlett Learning, LLC (1 oz). Over© the Jones course &of Bartlettthe day, the Learning, baby takes LLCin the NOT FOR SALE OR DISTRIBUTION amount of milkNOT needed FOR for SALE growth. OR Calorie DISTRIBUTION content of the Lactation consultants regularly assess several factors in milk is an issue only when caring for preterm babies or infant growth as part of their routine duties. Note the babies with illness, low weight gain, failure to thrive, or infant’s weight gain since the last weight check. Also look disorders. See Chapter 24 for a discussion of these babies. at the rate of weight gain since the baby’s lowest weight Babies utilize breastmilk very eciently, and breastfed © Jones(rather & Bartlett than birth Learning, weight). RecordLLC the baby’s growth in © Jonesinfants &have Bartlett a leaner bodyLearning, mass than LLC arti cially fed infants. NOT FORlength SALE and headOR circumference.DISTRIBUTION Monitor signs of adequate NOTe FOR lower SALE caloric OR (energy) DISTRIBUTION intakes by breastfed infants

9781284078954_CH14_293_230.indd 312 18/06/15 6:35 pm Infant Growth 313 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR explainSALE theirOR lowerDISTRIBUTION percentage of body fat beginning NOTat FORcan cause SALE a uid OR shi DISTRIBUTION to the infant that arti cially increases 5 months (Dewey, 2007). Compared with formula-fed initial birth weight (Mulder et al., 2010). Infants who experi- infants, breastfed infants’ energy intake is lower through- ence uid shis typically void large amounts of urine in the out their rst year (Hester et al., 2012). Energy needs per rst 24 hours of life and can lose more weight than a baby day decrease as the baby gets older. Arti cially fed infants born without intravenous interventions. Exposure to med- have higher sleeping© metabolic Jones rates,& Bartlett higher rectalLearning, tem- LLCications during labor can depress© Jones the baby’s & Bartlett central nervous Learning, LLC peratures, and higherNOT heart FOR rates thanSALE breastfed OR DISTRIBUTION infants. system and lead to fewer feedingsNOT FORin the rstSALE days OR of life— DISTRIBUTION is may account for the dierences in energy intake and another factor that will aect weight gain in the early days. expenditure rates. e link between formula feeding and A weight loss of more than 7 percent of birth weight obesity is explored in Chapters 9 and 10. indicates a need for evaluation and possible assistance with breastfeeding. By day 3, a full-term infant usually © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Weight Gain does not continue to lose weight. e baby’s weight should NOT FOR SALE OR DISTRIBUTION stabilize byNOT the FORend of SALE the rst OR week, DISTRIBUTION and birth weight Newborns initially may lose as much as 7 percent of birth should be regained by 10 to 14 days aer birth. Infants weight because of a loss of uids and the passage of meco- who are not back to birth weight by this time require eval- nium. Excessive intravenous uids received during labor uation. Table 14-8 presents monthly weight ranges and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR TABLESALE 14-8OR DISTRIBUTIONTypical Infant Weight Gain NOT FOR SALE OR DISTRIBUTION Range of Weekly Infant Weight Gain Girls Grams Boys Grams Month Girls Ounces Boys Ounces 175–325 225–350 1 6.2–11.5 7.9–12.3 200–300 © Jones &225–350 Bartlett Learning,2 LLC 7.1–10.6 © Jones & 7.9–12.3Bartlett Learning, LLC 150–225 NOT FOR175–225 SALE OR DISTRIBUTION3 5.3–6.2 NOT FOR SALE6.2–7.9 OR DISTRIBUTION 100–200 150–200 4 3.5–7.1 5.3–7.1 100–150 100–150 5 3.5–5.3 3.5–5.3 75–125 75–125 6 2.6–4.4 2.6–4.4 75–125© Jones & Bartlett Learning,75–125 LLC 7 © Jones2.6–4.4 & Bartlett Learning,2.6–4.4 LLC 50–100NOT FOR SALE OR DISTRIBUTION75–100 8 NOT1.8–3.5 FOR SALE OR DISTRIBUTION2.6–3.5 50–100 50–75 9 1.8–3.5 1.8–2.6 50–75 50–100 10 1.8–2.6 1.8–3.5 50–100 50–75 11 1.8–3.5 1.8–2.6 © Jones &50–75 Bartlett Learning, LLC 50–75 © 12Jones & Bartlett1.8–2.6 Learning, LLC 1.8–2.6 NOT FOR InfantSALE Weight OR DISTRIBUTIONRange NOT FOR SALE OR DISTRIBUTION Girls Kilograms Boys Kilograms Month Girls Pounds/Ounces Boys Pounds/Ounces 2.3–4.4 2.3–4.6 Birth 5.1–9.11 5.1–10.1 3.0–5.7 3.2–6.0 1 6.9–12.9 7.1–13.3 3.8–6.9 © Jones &4.1–7.4 Bartlett Learning,2 LLC 8.6–15.3 © Jones & 9.0–16.4Bartlett Learning, LLC 4.4–7.8 NOT FOR4.8–8.3 SALE OR DISTRIBUTION3 9.11–17.3 NOT FOR 10.9–18.4SALE OR DISTRIBUTION 4.8–8.6 5.4–9.1 4 10.9–19 11.14–20.1 5.2–9.2 5.8–9.7 5 11.8–20.4 12.12–21.6 5.5–9.7 6.1–10.2 6 12.1–21.6 13.8–22.8 5.8–10.2© Jones & Bartlett Learning,6.4–10.7 LLC 7 © Jones12.12–22.8 & Bartlett Learning,14.1–23.9 LLC 6.0–10.6NOT FOR SALE OR DISTRIBUTION6.7–11.1 8 NOT13.3–23.6 FOR SALE OR DISTRIBUTION14.12–24.8 6.2–11.0 6.9–11.4 9 13.11–24.4 15.3–25.1 6.4–11.3 7.1–11.8 10 14.1–24.14 15.11- 26.0 6.6–11.7 7.3–12.1 11 14.9–25.12 16.1–26.11 © Jones &6.8–12.0 Bartlett Learning, LLC 7.5–12.4 © 12Jones & Bartlett15.0–26.8 Learning, LLC 16.5–27.3 NOT FOR ReproducedSALE OR from DISTRIBUTION 2006 World Health Organization Growth Charts. NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 313 18/06/15 6:35 pm 314 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORweekly SALE weight OR gain DISTRIBUTION ranges for infants through the rst NOTas FOR 20 hours SALE per day. OR Understanding DISTRIBUTION her baby’s typical sleep year based on the World Health Organization (WHO) patterns will help a mother adapt to her child’s unique growth charts. It is important to recognize that growth needs. e factors that cause variations among babies’ patterns vary from one baby to the next. sleep patterns may be developmental, environmental, or Arti cially fed infants exhibit higher weight for age nutritional in nature. For example, overtiredness or over- than breastfed infants, who© Jones follow the & WHOBartlett standard Learning, for LLCstimulation can cause fretfulness© Jones before and & Bartlettduring sleep. Learning, LLC growth (Van Dijk & Innis,NOT 2009). FOR Arti cially SALE OR fed DISTRIBUTIONbabies Sounds, lights, the temperatureNOT of the FOR room SALE and bedding, OR DISTRIBUTION weigh an average of 600–650 grams more than breastfed and low humidity (which causes diculty in breathing) babies. From 6 to 12 months, formula-fed infants tend to can all aect (and sometimes interfere with) sleep. Further- weigh more than breastfed infants. ey consume a higher more, nucleotides in human milk exhibit signi cant circa- volume and more energy-dense milk in early life, leading dian rhythms that could explain the “hypnotic” response to faster© growthJones and & programmingBartlett Learning, a greater risk LLC of long- in the infant ©nursing Jones at night & Bartlett (Sánchez Learning, et al., 2009). LLC term obesityNOT (HesterFOR SALE et al., 2012).ere OR DISTRIBUTION do not appear to Babies whoNOT sleep FOR separated SALE from OR their DISTRIBUTION mothers may be signi cant height dierences between adults who were wake at night to seek nourishment and physical contact. breastfed or arti cially fed. e absence of the mother’s body warmth and skin contact can make it more dicult for the baby to fall asleep and Obesity sleep undisturbed. A baby may also have trouble sleep- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Assessing infant growth is of key interest in view of the ing if the mother consumes too much caeine because NOT FORobesity SALE epidemic OR DISTRIBUTION among youth, as discussed in Chap- NOTthis FOR substance SALE passes OR DISTRIBUTIONthrough her milk. Developmental ter 10. Arti cial feeding is a predictor of obesity in both factors that aect sleep are discussed in Chapter 18. infancy and adulthood. e role of nutrition early in life is increasingly recognized as contributing to growth and Encouraging the Baby to Sleep metabolic changes in later© Joneslife. See Chapters& Bartlett 9 and Learning, 10 for LLC © Jones & Bartlett Learning, LLC discussion on arti cial feeding, the gut microbiome, and Many parents voice concerns about their babies’ sleep hab- the role of metabolic programmingNOT FOR for SALE lifelong OR health. DISTRIBUTIONits. You can help a mother determineNOT whetherFOR SALE she has realisOR -DISTRIBUTION tic expectations for her baby. Perhaps she can keep a written Growth Charts record for several days of her baby’s sleep patterns over a 24-hour period, including even 5-minute naps. Gaining a Infant growth charts are frequently printed by formula better understanding of her baby’s behavior can help her companies© Jones with their & logosBartlett and given Learning, to healthcare LLC provid- relax and not© allow Jones sleep & to Bartlett be such an Learning, important goal. LLC If ers. eseNOT documents FOR SALE are based OR principally DISTRIBUTION on 1977 growth the mother feelsNOT she FOR is not SALE getting OR enough DISTRIBUTION sleep, you can charts from the U.S. National Center for Health Statistics encourage her to sleep when her baby does, especially in the (NCHS). e original charts were based on one ethnic and early postpartum period. If she returns to work or school, demographic group of primarily formula-fed infants. As a the mother can retire early in the evening and take her baby consequence, they are not reliable for charting growth in to bed with her. Or, during the night, her partner can bring © Jonesbreastfed & Bartlett babies. Learning, Charts released LLC by the Centers for Dis- © Jonesthe baby & to Bartlett bed for nursing, Learning, allowing LLC her to stay in bed. NOT FORease SALE Control OR and DISTRIBUTION Prevention (CDC) in 2000 also exhibited NOT FOREstablishing SALE a bedtimeOR DISTRIBUTION ritual can be enjoyable for both notable dierences between the typical growth pattern of parents and baby. A routine helps the baby associate the rit- breastfed infants and the expected growth curve. ual with going to sleep at an established time every night. e CDC now recommends the use of the WHO Quiet, soothing activities directly before bedtime—such as growth charts for all infants until the age of 2 years. e a bath, story, rocking, and nursing—prepare the baby for 2006 WHO growth charts© areJones the best & indicatorBartlett of Learning, growth sleep.LLC Parents can warm the baby’s© Jones sleeping &area Bartlett with a heat Learning,- LLC for breastfed infants. eNOT growth FOR charts, SALE which ORare printed DISTRIBUTION ing pad or hot water bottle andNOT remove FOR it right SALE before layingOR DISTRIBUTION in Appendix B, are based on the growth of exclusively or the baby down. Flannel sheets can help keep the infant from predominantly breastfed children (WHO, 2006). Data was waking because of the initial coolness of cotton sheets. compiled at seven international study centers to develop If a baby sleeps for longer periods during the day than at these international growth charts for infants and children night, parents can try waking the baby more frequently dur- through© 5Jones years of &age. Bartlett Learning, LLC ing the day to© discourage Jones & longer Bartlett sleep periods. Learning, is practice LLC NOT FOR SALE OR DISTRIBUTION enables the motherNOT FORto nurse SALE more oen OR andDISTRIBUTION helps the baby’s rhythm come into harmony with the rest of the family. Sleeping Patterns Breastfeeding Issues with Sleep All babies require a great amount of sleep and the speci c © Jonesamount & Bartlett of sleep Learning, each baby needs LLC varies. Some babies sleep © JonesAn older & Bartlettbaby who Learning, is well nourished LLC is usually able NOT FORas fewSALE as 8 hours OR DISTRIBUTIONin a 24-hour period; others sleep as many NOTto FOR sleep SALEfor long OR periods DISTRIBUTION at night. Nursing frequently

9781284078954_CH14_293_230.indd 314 18/06/15 6:35 pm Sleeping Patterns 315 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR duringSALE theOR dayDISTRIBUTION will accomplish this goal. NursingNOT FORCosleeping SALE infantsOR DISTRIBUTION become aroused more oen and in directly before bedtime ensures a full stomach and helps greater synchrony with their mothers than do separate soothe the baby. If the mother nurses while lying in the sleepers. is relationship suggests that cosleeping may middle of the bed, she can then move her baby to the reduce the risk of sudden infant death syndrome (SIDS). crib when he or she is in a deeper sleep. Some mothers More frequent arousals also promote nighttime breast- keep the baby in their© Jonesbed until & morning Bartlett or Learning,until aer LLCfeeding. Mothers who cosleep© Jones with &their Bartlett babies nurseLearning, LLC the next feeding. SeeNOT the discussion FOR SALE of cosleeping OR DISTRIBUTION in the them 3 times more frequentlyNOT thanFOR do SALE mothers OR whose DISTRIBUTION next section. babies sleep in a separate room (Gettler & McKenna, When the baby wakes in the middle of the night to 2011). Bed sharing was associated with a longer duration nurse, avoiding stimulation will facilitate a return to sleep. of breastfeeding in another study (Huang et al., 2013). Placement of a nightlight near the baby’s bed eliminates e AAP (2012) recognizes the need for closeness to the ©need Jones to turn & on Bartlett a bright light.Learning, A soiled LLCdiaper can be facilitate ©breastfeeding Jones & Bartlettand recommends Learning, that LLCmothers changedNOT before FOR nursing SALE on OR the DISTRIBUTIONsecond breast so the baby and babiesNOT sleep FOR in proximity SALE to OR each DISTRIBUTION other. At the same can nurse back to sleep undisturbed. Keeping the baby time, an expanded statement released by the AAP Task and mother warm will help both of them return to sleep Force on SIDS advises against parent–infant bed sharing more easily. For some babies, nighttime feedings account and supports the generic use of paci ers (AAP, 2011). e for as much as 20 percent of their total 24-hour intake ABM (2008) issued revised guidelines for safe cosleeping © Jones &(Kent Bartlett et al., Learning,2006). Babies LLC who do not wake to nurse ©at Jonesin response & Bartlett to the Learning, AAP’s statements LLC (see Figure 14-15). NOT FOR nightSALE typically OR DISTRIBUTION feed more in the morning. NOT FORContrary SALE to OR popular DISTRIBUTION thinking, exclusively breastfeeding mothers were found to get more nighttime sleep than Cosleeping mothers feeding formula during the rst month aer birth. e breastfeeding mothers averaged 30 minutes e cultural expectation in many industrialized coun- more sleep, and measures of sleep fragmentation did tries is that babies should© Jones sleep & through Bartlett the Learning,night and LLCnot dier between the two© groupsJones (Doan & Bartlett et al., 2014). Learning, LLC that independence (separation)NOT FOR is SALEdesirable. OR is DISTRIBUTION notion Mothers who routinely sleepNOT with FOR their SALE infants OR receive DISTRIBUTION is at odds with human babies’ biological need to be close more total hours of sleep than do those who routinely to their parents for safety and development (Gettler & sleep separately, just not in one block of time (Mosko et McKenna, 2011; McKenna et al., 2007). Human babies al., 1997). Moreover, routine bed sharing mothers eval- have an intense biological need to be close to their moth- uate their sleep more positively than do solitary sleeping ers,© including Jones at & night. Bartlett Many Learning,parents opt for LLC a family bed mothers. ©As Jones an alternative & Bartlett to sharing Learning, their bed with LLC their sharedNOT by FORmother, SALE father, OR and DISTRIBUTION baby to meet this need. child, someNOT parents FOR use SALE a crib, orOR cosleeper, DISTRIBUTION that attaches Cosleeping helps babies fall asleep more easily, and to their bed. e AAP does not recommend for or against babies wake easily when moved (Figure 14-14). Cos- bedside sleepers. For more information on this topic, see leeping is also helpful with a baby who wakes frequently the discussion of responsive parenting in Chapter 20. during the night. © Jones & Bartlett Learning, LLC © JonesPrevalence & Bartlett of Cosleeping Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORCosleeping SALE was OR the DISTRIBUTION cultural norm until the 20th century. Sweeping cultural changes in the United States brought mechanistic, scienti c, and behavioristic models of child development that de ned “normal” behavior based on © Jones & Bartlett Learning, LLCbottle-feeding babies. Cosleeping© Jones is more& Bartlett common Learning, in LLC Western culture today, mirroring most non-Western cul- NOT FOR SALE OR DISTRIBUTIONtures where an infant and motherNOT FORremain SALE together OR contin DISTRIBUTION- ually, both day and night. e warmth and familiar smell of the mother comforts the infant when sleeping in the parents’ bed (referred to as cosleeping). e infant can © Jones & Bartlett Learning, LLC nuzzle at© the Jones breast and& Bartlett nurse ad Learning,lib, and the mother LLC is not required to leave her bed to nurse her hungry infant. NOT FOR SALE OR DISTRIBUTION us, theNOT mother FOR is able SALE both ORto get DISTRIBUTION the sleep she needs and to meet her infant’s needs.

Concerns About Cosleeping © Jones & Bartlett Learning, LLC © JonesSome & parentsBartlett worry Learning, that it is LLC emotionally unhealthy NOT FOR FIGURESALE OR14-14 DISTRIBUTION Mother cosleeping with baby. NOT FORfor an SALE infant ORto share DISTRIBUTION a bed with the parents or that

9781284078954_CH14_293_230.indd 315 18/06/15 6:35 pm 316 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORParents SALE who cosleepOR DISTRIBUTION with their infant can evaluate Precautions for cribs and adult beds: their sleep environment and make it as safe as possible • Use a rm mattress to avoid suffocation. • Have no gaps between the mattress and the frame. for their baby. Both parents should feel comfortable with • Keep bedding tight around the mattress. the decision to cosleep with their baby and be commit- • Avoid strings or ties on baby’s and parents’ nightclothes. ted to following appropriate safety precautions. While no • Avoid soft items such© as Jones comforters, & pillows,Bartlett featherbeds, Learning, LLCone sleep environment is guaranteed© Jones to be & risk Bartlett free, there Learning, LLC stuffed animals, lambNOT skins, andFOR bean SALE bags. OR DISTRIBUTIONare ways of reducing risks inNOT both cribsFOR and SALE adult ORbeds. DISTRIBUTION • Keep the baby’s face uncovered to allow ventilation. Rigidly admonishing parents who cosleep fails to respect • Put the baby on his or her back to sleep. their responsiveness to their babies. A more reasonable • Do not overheat the room or overdress baby. approach is to recognize the need to increase infant sleep • Do not place a crib near window cords or sashes. safety while protecting breastfeeding. Additional© Jones precautions & Bartlettfor cribs: Learning, LLC © Jones & Bartlett Learning, LLC • When baby learns to sit, lower the mattress level to avoid fallingNOT or FOR climbing SALE out. OR DISTRIBUTION Sudden UnexplainedNOT FOR Infant SALE Death OR DISTRIBUTION • When baby learns to stand, set the mattress level at its lowest point and remove crib bumpers. e title of sudden infant death syndrome (SIDS) has • When baby reaches a height of 35 inches or the side rail been expanded in recent years to sudden unexplained is less than three-quarters of his or her height, move the infant death (SUID). It describes deaths in infants less © Jones & Bartlettbaby to another Learning, bed. LLC © Jonesthan 1 &year Bartlett of age that Learning, occur suddenly LLC and unexpectedly, NOT FOR SALE• Crib bumpers, OR DISTRIBUTION if used, should have at least six ties, no NOTand FOR the causeSALE of deathOR DISTRIBUTIONis not immediately obvious prior to longer than six inches. investigation (Shapiro-Mendoza, et al., 2014). About half • Hang crib mobiles well out of reach and remove when baby can sit or reach. of these SUIDs are attributed to SIDS, the leading cause of • Remove crib gyms when baby can get up on all fours. SUID. e three most frequently reported causes of death Additional precautions for cosleeping: in infants 0 to 12 months are SIDS, unknown cause, and • Parents pull back and© fasten Jones long hair.& Bartlett Learning, accidentalLLC suocation/strangulation© Jones in bed. & BartlettFor example, Learning, LLC • Do not use alcohol orNOT other drugs,FOR including SALE over-the- OR DISTRIBUTIONin the United States in 2011, 1910NOT deaths FOR were SALE reported OR as DISTRIBUTION counter or prescription medications. SIDS, 869 as cause unknown, and 624 as accidental suo- • Have no head/foot board railings with spaces wider than cation and strangulation in bed (CDC, 2014). allowed in safety-approved cribs. SIDS describes the sudden death of an infant younger • Use no bed rails with infants less than 1 year. than 1 year of age that remains unexplained aer an • ©Do Jonesnot allow siblings& Bartlett or pets in Learning, bed with a baby LLC less than autopsy, examination© Jones of &the Bartlett death scene, Learning, and review LLCof the 1 year old. • NOTDo not cosleepFOR inSALE a waterbed. OR DISTRIBUTION clinical history.NOT SIDS FOR occurs SALE in all OR socioeconomic, DISTRIBUTION racial, • Avoid placing bed directly alongside furniture or a wall. and ethnic groups. African American and Native Ameri- Additional precautions regarding infant sleep: can babies are 2 to 3 times more likely to die of SIDS than • Do not sleep with baby on sofas or overstuffed chairs. Caucasian babies. Most SIDS deaths occur when a baby is • Do not put baby to sleep alone in an adult bed. between 2 and 4 months of age, with 90 percent of all SIDS © Jones & Bartlett• Do not place Learning, baby to sleep LLC in car or infant seats. © Jonesdeaths &occurring Bartlett before Learning, the child reaches LLC 6 months of age. NOT FOR SALE• Obese OR mothers DISTRIBUTION who are not breastfeeding avoid cosleeping. NOTMost FOR babies SALE who ORdie of DISTRIBUTION SIDS appear to be healthy prior to • Refrain from cosleeping if mother smoked during her death. Sixty percent of SIDS victims are male and 40 per- pregnancy or if mother or partner currently smoke. cent are female (CDC, 2014). Research suggests that brainstem abnormalities and genetic variations may contribute FIGURE 14-15 Creating a safe infant sleep environment. to SIDS (Casale et al., 2013; Machaalani & Waters, 2014). © Jones & Bartlett Learning, LLCBreastfeeding reduces the risk© ofJones SIDS by & approximately Bartlett Learning, LLC Adapted from Donohue-Carey,NOT P. Solitary FOR or shared SALE sleep: OR what’s DISTRIBUTION safe? 50 percent at all ages throughoutNOT infancy FOR (Vennemann SALE OR et DISTRIBUTION Mothering. 2002;114:44-47. Updated 2009 by Patricia Donohue-Carey. al., 2009). A baby who is not breastfed may be at greater risk, both because of the lack of immunologic protection and because of dierences in breathing and arousal pat- this habit may be difficult to break once formed. Some terns (Hauck et al., 2011). Breastfed infants arouse more fear the© motherJones could & Bartlett inadvertently Learning, roll over LLC onto the easily from active© Jones sleep at& 2 Bartlett to 3 months Learning, of age. Given LLC that infantNOT while FORshe is asleep.SALE Most OR infantsDISTRIBUTION worldwide sleep this age coincidesNOT FORwith the SALE peak incidenceOR DISTRIBUTION of SIDS, this with their parents. Some cultures have high rates of bed behavior may represent a protective mechanism of breast- sharing and low rates of SIDS, and others have high feeding. e position in which the mother places her baby rates of bed sharing and high rates of SIDS (AAP, 2011). for sleep is a major factor in the risk of SIDS. Placing the It has become a cultural norm in the United States for baby in a supine position (on his or her back) rather than © Jonesinfants & Bartlett to sleep Learning, separated from LLC their parents, not a bio- © Jonesin a prone & Bartlett position (onLearning, his or her LLCstomach) substantially NOT FORlogical SALE norm. OR DISTRIBUTION NOTreduces FOR SALEthe incidence OR DISTRIBUTION of SIDS. Breastfeeding mothers

9781284078954_CH14_293_230.indd 316 18/06/15 6:35 pm Crying and Colicky Behavior 317 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR whoSALE cosleep OR DISTRIBUTIONpredominantly put their infants on theirNOT FOR SALE OR DISTRIBUTION backs to facilitate reaching the breast. SIDS rates have declined by more than 50 percent in the United States since 1994, when the “Back to Sleep” public information campaign began. Risks for SIDS increase© Jones when &parents Bartlett smoke, Learning, put the LLC © Jones & Bartlett Learning, LLC baby to sleep in the NOTprone FORposition, SALE and doOR not DISTRIBUTION breast- NOT FOR SALE OR DISTRIBUTION feed. Sleeping prone and maternal smoking are two signi cant risk factors for SIDS. An estimated one-third of SIDS deaths could be prevented if mothers did not smoke during pregnancy (Dietz et al., 2010). Another risk factor is© the Jones baby’s &inhalation Bartlett of Learning,passive smoke. LLC Parents who © Jones & Bartlett Learning, LLC smokeNOT around FOR their SALE baby ORneed DISTRIBUTION to be educated about the NOT FOR SALE OR DISTRIBUTION dangers to their baby. Small-at-birth infants who sleep in a separate room are FIGURE 14-16 A crying infant needs to be settled before at increased risk for SIDS compared with similar infants being put to the breast. who sleep in the same room with their parents (Blair et Printed with permission of Kori Martin. © Jones &al., Bartlett 2006). Keeping Learning, the baby LLC in the parents’ room (room© Jones & Bartlett Learning, LLC NOT FOR sharing)SALE ORmay DISTRIBUTIONreduce the risk of SIDS by as much as 50NOT FOR SALE OR DISTRIBUTION percent (Mitchell & ompson, 1995; Tappin et al., 2005). Children who cosleep in their parents’ room have lower inhalation-exhalation pattern. eir cry is a full octave cortisol levels, which translates to lower tension and stress higher than that of a full-term infant, signaling a greater (Waynforth, 2007). Sofas are not safe sleep surfaces for an urgency. Crying for a preterm infant requires great eort, infant. Sleeping on sofas© Jones increases & Bartlettthe risk of Learning, SIDS and LLCwhich can cause distress and© Jones lower blood & Bartlett oxygenation. Learning, LLC comprises almost 13 percentNOT FOR of infant SALE sleep-related OR DISTRIBUTION deaths Preterm infants have beenNOT found FOR to fuss SALE and cryOR more DISTRIBUTION (Rechtman et al., 2014). Bed sharing should be avoided if frequently when they reach term-adjusted age (Shinya parents consume alcohol, smoke or take drugs, or if the et al., 2014). infant is born preterm (Blair et al., 2014). e AAP Task Force on SIDS states that using a paci er Parental Reactions to Crying to go© toJones sleep may & Bartlettbe protective Learning, against SIDS LLC and recom- © Jones & Bartlett Learning, LLC mendsNOT that FOR all babies SALE be putOR to DISTRIBUTION sleep with paci ers. is New parentsNOT envision FOR SALE a baby OR who DISTRIBUTION smiles, coos, and recommendation, however, is based on studying babies snuggles, not one who is fussy and cries. As a conse- who typically used paci ers and were more at risk for quence, they may worry that crying is a reection of SIDS if they did not use one. Breastfed babies who suck to their parenting. You can help them recognize that babies sleep at the breast do not t that pro le. fuss and cry because of their needs, not because of the © Jones & Bartlett Learning, LLC © Jonesparents’ & Bartlett actions. EncourageLearning, parents LLC to focus on the posi- NOT FOR SALE OR DISTRIBUTION NOT FORtive attributes SALE ORof this DISTRIBUTION behavior—that a fussy baby is very alert, responsive to the environment, and a good com- Crying and Colicky Behavior municator—rather than considering their baby to be Crying is an infant’s rst language, used to communicate dicult or spoiled. distress and to elicit help from caregivers. In response to Mothers are vulnerable to reacting negatively to their her baby’s cry, the mother’s© Jones heart & beats Bartlett louder, Learning, her blood LLCcrying baby. During pregnancy,© Jones the mother & Bartlett was in control Learning, LLC pressure increases, andNOT the FORtemperature SALE increases OR DISTRIBUTION in her and was the center of attention.NOT Now FOR it may SALE seem OR that DISTRIBUTIONthe breasts. e sound of a crying infant is disturbing and baby has both the attention and the control. When others aggravating (see Figure 14-16)—a sound designed to stare at the parents of a crying baby or make rude or per- ensure that the newborn receives the attention he or she sonal comments, the parents may feel out of control or needs. Crying is meant to get attention! e decibel level judged. Many times the problem lies in the parents’ expec- of a© baby’s Jones cry is& actually Bartlett higher Learning, than street LLC noise and can tations of© what Jones parenting & Bartlett will be like. Learning, LLC be NOT20 decibels FOR louder SALE than OR normal DISTRIBUTION speech. Table 14-9 ParentsNOT are oen FOR advised SALE not OR to DISTRIBUTIONpick up their crying describes several combinations of temperament that can infant and are encouraged to let the child “cry it out.” aect a baby’s disposition. See Chapter 15 for a discussion (See Chapter 20 for a discussion of such “baby training” of the baby who is fussy at the breast. and its impact on breastfeeding.) In reality, infant cry- e crying pattern for a preterm infant is dierent ing is a powerful communication tool used by the baby © Jones &from Bartlett that of Learning, a full-term LLCinfant (Manfredi et al., 2008).© Jonesto interact & Bartlett with theLearning, external environment.LLC In a cause- NOT FOR PretermSALE ORinfants DISTRIBUTION have a dierent rhythm, pause, andNOT FORand-eect SALE relationship, OR DISTRIBUTION babies learn that crying elicits

9781284078954_CH14_293_230.indd 317 18/06/15 6:35 pm 318 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORTABLE SALE 14-9 OR Influences DISTRIBUTION on Baby’s Disposition NOT FOR SALE OR DISTRIBUTION Baby’s Disposition Mother’s Disposition Probable Outcome Easy baby Responsive mother This is a predictable and cuddly baby whose mother is in tune with him. The mother feels good about her parenting based on the positive interactions with her baby. Easy baby Restrained© Jones mother & Bartlett This babyLearning, is not very LLC demanding, and such behavior© may Jones lead the & mother Bartlett to feel Learning, LLC NOT FOR SALE ORsomewhat DISTRIBUTION unnecessary. The mother initially may notNOT develop FOR comfort SALE skills, OR DISTRIBUTION believing they are unnecessary. She may divert her energies elsewhere, and her baby may, in time, exhibit more fussy behavior. High-need baby with Responsive mother The mother cannot ignore the needs of her baby and responds to him. She is good attachment- rewarded with occasional satised responses from her baby. She will continue to promoting© Jones & Bartlett Learning, LLCexplore alternative responses until© Jonesshe nds one& Bartlett that reaches Learning, her baby. Because LLC behaviorsNOT FOR SALE OR DISTRIBUTIONof his mother’s responsiveness,NOT the baby FOR will also SALE ne-tune OR his DISTRIBUTION attachment- promoting skills, resulting in a parent–child relationship of mutual sensitivity. High-need baby with Responsive mother This type of baby often is referred to as slow to warm up. He shows little or no poor attachment- effort to respond to or be comforted by his mother’s efforts. The mother’s promoting skills nurturing responses are ne-tuned by her baby’s responses. When the baby’s © Jones & Bartlett Learning, LLC responsiveness© Jones is lacking, & this Bartlett may seriously Learning, jeopardize LLC the mother–baby rela- NOT FOR SALE OR DISTRIBUTION tionship. In someNOT situations, FOR SALE it is helpful OR for DISTRIBUTION the mother to seek assistance from a professional who is trained in interaction counseling. High-need baby Restrained mother This situation places the mother–baby relationship at risk. Often, the mother has been advised to let the baby cry it out or to not spoil him. Continued lack of response to his needs will lead this baby to one of two outcomes. He will inten- © Jones & Bartlettsify Learning, his high-need LLCbehaviors, or he will give up. The© baby Jones who gives& Bartlett up essen- Learning, LLC tially shuts down his communication and withdraws into himself. He is prone to NOT FOR SALE ORattach DISTRIBUTION to objects rather than persons. NOT FOR SALE OR DISTRIBUTION Adapted from Sears W, Sears M. The Fussy Baby Book: Parenting Your High-Need Child from Birth to Age Five. New York: Little Brown & Company; 1996.

parental© Jonesresponse & to Bartlett meet their Learning, needs. is LLC enhances oxygenated ©blood Jones ows &back Bartlett into circulation Learning, rather LLC than attachmentNOT to FOR the parents,SALE developsOR DISTRIBUTION trust more readily, into the lungs.NOT Large FOR uctuations SALE ORin blood DISTRIBUTION ow increase and reduces crying. In contrast, babies repeatedly le to cerebral blood volume and decrease cerebral oxygenation, cry alone learn that their needs will not be met. Failing to increasing the risk of respiratory diculty. understand or respond to infants’ messages can compro- Metabolically, crying leads to increased glucose expen- mise their care as well as parental eectiveness, thereby diture, which, in the immediate postpartum period, could © Jonesundermining & Bartlett theLearning, budding relationship LLC between parents © Jonesresult &in Bartletthypoglycemia. Learning, Crying LLCalso increases gastric NOT FORand SALE their baby. OR DISTRIBUTION NOTdistention FOR SALE and may OR result DISTRIBUTION in a very discontented baby Mothers who are restrained in their response to crying because of gas pain. In addition, crying raises infants’ abandon breastfeeding earlier and have infants who cry levels of cortisol, a stress hormone. Continually elevated more overall. ey may perceive infant fussiness as dis- stress hormone levels are believed to contribute to infant satisfaction with breastfeeding and conclude that supple- illness (Mörelius et al., 2009; Shah et al., 2012). Crying also menting with formula or© cerealJones will & provideBartlett a solution. Learning, decreasesLLC the absorption of inhalant© Jones medications, & Bartlett which Learning, LLC Short breastfeeding durationNOT orFOR formula SALE use ORfrom DISTRIBUTION birth preterm babies frequently receiveNOT (Iles FOR et al., SALE 1999). BabiesOR DISTRIBUTION is signi cantly associated with low nurturance levels and who have been crying have diculty breastfeeding. ey high anxiety levels. Longer breastfeeding duration is asso- are oen unable to organize themselves and their behav- ciated with mothers responding to and following infant ior for a period aer the crying spell. cues (Brown & Arnott, 2014). Educating parents that crying is a baby’s method of communicating with the world © Jones & Bartlett Learning, LLC Identifying© the Jones Cause & of Bartlett Crying Learning, LLC will helpNOT prevent FOR mothers SALE from OR giving DISTRIBUTION up on breastfeeding NOT FOR SALE OR DISTRIBUTION prematurely. A baby’s cry usually indicates some form of physical discomfort. As parents become accustomed to their baby, they The Effect of Crying on the Infant will learn to distinguish among dierent types of cries. An infant’s cry may indicate hunger, pain, or a reaction to the © JonesCrying & Bartlett increases Learning, the newborn’s LLC heart rate and blood pres- © Jonesexternal & environment. Bartlett Learning, Too oen, LLCa mother immediately NOT FORsure, SALE which ORin turn DISTRIBUTION increases intracranial pressure. Poorly NOTassumes FOR SALEthat hunger OR is DISTRIBUTION the cause and may blame low milk

9781284078954_CH14_293_230.indd 318 18/06/15 6:35 pm Crying and Colicky Behavior 319 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR productionSALE OR or DISTRIBUTION the quality of her milk for her baby’s fussyNOT FORfor comforting SALE OR a colicky DISTRIBUTION baby described later in this chap- disposition. If the baby has nursed recently and does not ter. Additionally, some babies take in more milk than appear to be hungry, you can encourage parents to inves- they are able to handle. Such overfeeding causes pres- tigate other causes for crying. As parents become better sure, which in turn can produce discomfort. Nursing long acquainted with their baby’s particular communication, enough for the baby to drain one breast before oering the they will learn to distinguish© Jones the &causes Bartlett of the crying.Learning, LLCother one will help avoid ingesting© Jones excessive & Bartlett amounts Learning, of LLC NOT FOR SALE OR DISTRIBUTIONmilk at a feeding. NOT FOR SALE OR DISTRIBUTION Crying from Hunger Crying from External Stimuli In the early weeks aer birth, it is common for the baby to When parents have tended to the physical needs of their require frequent feedings and to sleep for short, frequent baby and the child continues to cry, they will want to look periods. e mother will learn to recognize a hunger cry © Jones & Bartlett Learning, LLC for an external© Jones cause for& theBartlett crying. Learning,Babies may startle LLC and as she tunes into her baby’s pattern of sleeping and waking. cry in reaction to sudden movement, touch, smell, light, She NOTcan consider FOR howSALE recent OR and DISTRIBUTION long the previous feeding NOT FOR SALE OR DISTRIBUTION noise, or excessive handling. is factor oen accounts for was, her baby’s hunger cues and general disposition, and the initial fussiness babies demonstrate when transition- whether her baby can be soothed easily or with diculty. ing from hospital to home. Constant so, soothing noise A newborn may cry from hunger approximately 1½ to 2 can be an eective comfort measure. e steady move- hours or more aer a feeding. A hunger cry may be more © Jones & Bartlett Learning, LLC © Jonesment & of Bartlett being rocked Learning, is comforting, LLC as is the motion of a prevalent in the evening hours when the mother’s milk car ride. Recreating the sounds and feeling of the womb NOT FOR productionSALE OR seems DISTRIBUTION lowest and the environment feels harNOT- FOR SALE OR DISTRIBUTION comforts a newborn. ried. Because of this, it is common for babies to cluster Some babies respond well to swaddling, which reduces their feedings in the early evening. Mothers who respond the amount of movement the baby can make and, there- to hunger cries by nursing their babies will most likely fore, the amount of stimulation experienced from move- have more contented babies. ese babies will cry less © Jones & Bartlett Learning, LLCment. Con ning the arms© and Jones legs prevents& Bartlett the infantLearning, LLC frequently than those whose mothers maintain a strict from startling and provides a feeling of warmth, security, feeding schedule andNOT disregard FOR their SALE babies’ OR cries. DISTRIBUTION You can NOT FOR SALE OR DISTRIBUTION and constant touch stimulation. Although this practice teach mothers to recognize and respond to hunger cues may increase the time a baby sleeps and decrease time rather than waiting until the baby cries. spent crying, it does not necessarily do so at the expense Crying from Body Discomfort of time spent quietly awake. Swaddling should be done © Jones & Bartlett Learning, LLC with the baby’s© Jones legs together & Bartlett in normal Learning, exion to LLC prevent WetNOT or soiled FOR diapers SALE by themselves OR DISTRIBUTION may not be sucient hip dysplasiaNOT (Loder FOR &SALE Skopelja, OR 2011). DISTRIBUTION Swaddling and to cause crying. However, when the diaper cools, the drop putting a baby down to sleep in a prone position increases in temperature can cause discomfort, thus making the the risk of SIDS. Parents should be wary of commercial baby more responsive to stimulation and more likely to swaddlers and wearable blankets because injuries and cry for other reasons. Babies also may cry from excessive deaths have been reported with these. SIDS researchers © Jones &heat. Bartlett First-time Learning, parents tend LLC to overdress a new baby even© Jonesrecommend & Bartlett that parentsLearning, discontinue LLC swaddling as soon NOT FOR onSALE the hottest OR DISTRIBUTION summer day, fearing that the child mayNOT FORas an SALEinfant’s ORearliest DISTRIBUTION attempts to roll over are observed become chilled. In warm weather and cold weather alike, (McDonnell & Moon, 2014). healthy, full-term babies can be dressed in the same type Parents learn quickly what their baby prefers. Some of clothing that an adult would wear. babies dislike being swaddled and will cry or squirm Even when temperature is controlled, babies may cry when they are wrapped or held too tightly. Such a baby when they are undressed© Jones and lose & the Bartlett warm, secure Learning, feel- LLCmay push away from the ©breast Jones when & heldBartlett too closely Learning, LLC ing of clothing and NOTblankets. FOR A babySALE who OR is especiallyDISTRIBUTION and may prefer a positionNOT that allowsFOR bodySALE movement. OR DISTRIBUTION sensitive to this eect may bene t from swaddling. e e mother can lie on her side to nurse while lightly texture of the cloth that touches the child’s body is impor- supporting the baby from behind with her hand or a pil- tant. For example, plastic or rubber is more irritating than low. She could also lower her breast while leaning above so toweling or blanketing. Other skin irritations such as her reclining infant. heat© rash Jones or diaper & Bartlett rash can beLearning, a cause of a LLC baby’s cries. A Figure ©14-13 Jones shows & a comfortingBartlett Learning,technique of “wearing”LLC babyNOT may FORalso nd SALE comfort OR in DISTRIBUTION close skin-to-skin contact the baby inNOT a sling. FOR is SALEpractice providesOR DISTRIBUTION the infant with the with the parents. e mother or father can lie with the secure feeling of swaddling, with the added bene t of close- baby in bed or a bathtub. ness to the person who wears the sling. Infant deaths have A baby may cry from internal discomfort such as gas or occurred in slings, either by compression of the baby into overfullness. A baby who is constantly fussy during feed- a forward-exed position or by direct suocation. us, it © Jones &ings Bartlett may need Learning, to bring up LLCa bubble of air. Parents can help© Jonesis important & Bartlett that theLearning, parent keep LLC the baby upright and the NOT FOR theSALE baby ORpass DISTRIBUTIONgas in the intestines by using the techniquesNOT FORbaby’s SALE head clear OR of DISTRIBUTIONthe material (Madre et al., 2013).

9781284078954_CH14_293_230.indd 319 18/06/15 6:35 pm 320 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORA SALE baby receivesOR DISTRIBUTION important information about the NOTenergetic, FOR SALE excitable, OR and DISTRIBUTION easily startled—with clenched surrounding world through touch. A mother whose sts and a facial grimace. Continuous crying can cause the touch is tentative and light may irritate the baby. With baby to swallow air and further aggravate the discomfort. a rm touch, a mother communicates that she is con - e exact cause of colicky behavior has not been deter- dent, which allows her baby to relax and trust her. Gen- mined medically. In fact, researchers do not even agree tly stroking the baby’s© body Jones during & Bartletta feeding—called Learning, LLCabout the true incidence of© colic. Jones Colic & Bartlettstudies have Learning, LLC grooming—increases theNOT mother’s FOR prolactin SALE ORlevel. DISTRIBUTION Such not dierentiated well betweenNOT bottle-fed FOR SALE and breast OR -DISTRIBUTION quiet, gentle touching does not usually interfere with fed infants. Colic does seem to be more common when feedings. However, poking or jiggling the baby during infants are fed solid foods while they are younger than nursing could make it dicult for the baby to relax and 3 months of age. result in crying. Some theories relate colic to stress and tension in the Overhandling© Jones by & well-meaning Bartlett Learning, adults can cause LLC a baby mother and ©child Jones during & pregnancy Bartlett andLearning, lactation. LLCColic to cry NOTas a plea FOR to “pleaseSALE leaveOR DISTRIBUTIONme alone!” Sometimes has been foundNOT in higherFOR proportionsSALE OR in DISTRIBUTION families with less babies may prefer to lie quietly in their cribs and will react education, smoking mothers, domestic violence, impaired unhappily when picked up. is occurs especially if the bonding, hostility, and postpartum depression (Yalçin baby has been overstimulated by lights, noise, interrup- et al., 2010). Others believe the cause to be an immature tions to nursing or napping, and the attention of too many digestive and intestinal system or allergies. © Jonesvisitors. & Bartlett Some babiesLearning, become LLC agitated when they are tired © Jones & Bartlett Learning, LLC NOT FORand SALE might cryOR themselves DISTRIBUTION to sleep. NOTImmature FOR SALE Gastrointestinal OR DISTRIBUTION and Neurologic Systems If parents have ruled out hunger and discomfort, their Compared with other young mammals, a human baby is baby may settle aer a few minutes. Focusing on the cues born in an extremely immature state—essentially neu- their baby gives in response to their parenting approach rologically incomplete. At 1 month, the infant’s stomach will help them know how to proceed. If their baby is 1 © Jones & Bartlett Learning, capacityLLC is ∕10 the size of an ©adult Jones stomach. & Bartlett Moreover, Learning, a LLC responding positively to a technique, it can be encouraged. newborn has only minimal gastric glands that secrete If their baby exhibits withdrawalNOT FOR or avoidance SALE OR behaviors, DISTRIBUTION digestive enzymes. e muscleNOT layers FOR surrounding SALE OR the DISTRIBUTION they will want to try a new approach. newborn’s stomach and intestines are thin and weak, and the intestines lack the ridges and hairlike laments that Colicky Behavior help process food. Much of© theJones extreme & infantBartlett fussiness Learning, that occurs LLC is actually Colicky infants© Jones may &have Bartlett more permeable Learning, intestinal LLC linings (Saavedra & Dattilo, 2012). In these children, colic-likeNOT behavior FOR rather SALE than OR true DISTRIBUTION colic. e term “colic” NOT FOR SALE OR DISTRIBUTION derives from the Greek word kolikos, an adjective derived peristalsis (wavelike rhythmic contractions of smooth from kolon, meaning “large colon.” In de ning colic, dura- muscle) may be irregular, faint, forceful, or spasmodic. tion is more signi cant than frequency. Colic is classically Additionally, lack of muscle tone can cause food to move de ned by the “rule of threes,” characterized by inconsol- up out of the stomach as well as down into the intestines. able crying for which no physical cause can be found that e colons of colicky infants may contract violently dur- © Jones & Bartlett Learning, LLC © Jonesing feedings. & Bartlett Whereas Learning, the colon inLLC normal infants takes NOT FORlasts SALE more thanOR 3DISTRIBUTION hours per day, occurs at least 3 days per NOT FOR SALE OR DISTRIBUTION week, and continues for at least 3 weeks. e baby expe- several hours to empty, for some colicky infants, the colon riences spasmodic contractions of the smooth muscle, may empty very quickly. causing pain and discomfort (Wessel et al., 1954). Symp- Hormones toms typically subside by 16 weeks of age in the majority of infants. © Jones & Bartlett Learning, BabiesLLC have high levels of progesterone© Jones &at Bartlettbirth, which Learning, LLC Colicky behavior is quiteNOT dierentFOR SALE from theOR pattern DISTRIBUTION helps relax the muscles of theirNOT intestines. FOR SALE e proges OR -DISTRIBUTION of one or two fussy periods a day experienced by most terone level drops 1 to 2 weeks aer birth, which may infants. A crying infant who is willing to be soothed by account for the increase in colic symptoms at that time. going to the breast usually does not have colic. A colicky Infants with colic-like behavior have high levels of baby exhibits unexplained fussiness, fretfulness, and irri- motilin—a digestive hormone that stimulates muscle tability.© e Jones baby &appears Bartlett to suer Learning, from severe LLC discom- contractions—from© Jones the & rst Bartlett day of Learning, life. Human LLC milk fort duringNOT the FOR colicky SALE period, OR with DISTRIBUTION cries that are piercing, has high levelsNOT of FORmany enzymesSALE OR that DISTRIBUTION are necessary for explosive attacks. A rumbling sound may be audible in the digestion and therefore may aid in reducing the inten- baby’s gut. Excessive atulence (gas) and apparent abdom- sity of colic in some infants. Cholecystokinin (CCK), a inal pain may cause the baby’s legs to draw up sharply into digestive hormone abundant in milk, has been shown to the abdomen, or the baby’s body to stien and twist. e be present in lower levels in infants suering from colic. © Jonesbaby & Bartlett may awaken Learning, easily and frequently LLC and appear intense, © JonesCortisol, & theBartlett stress hormone, Learning, is also LLC thought to be a factor NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 320 18/06/15 6:35 pm Crying and Colicky Behavior 321 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC in the development of colic. A possible self-reinforcing NOT FOR SALE OR DISTRIBUTION NOT FOR• SALEA stuffy or OR drippy DISTRIBUTION nose without any other sign of having loop of stress may lead to crying and to more stress. a cold • Frequently pulling off the breast and arching and crying Intrauterine and Birth-Related Factors while feeding Preterm infants and those born small for gestational age • An itchy nose © Jones & Bartlett Learning, LLC • A red, scaly, oily rash on© the Jones forehead &or eyebrows,Bartlett in theLearning, LLC have higher risks for colic (Milidou et al., 2014). Increased NOT FOR SALE OR DISTRIBUTION hair, or behind the ears NOT FOR SALE OR DISTRIBUTION excitability and fussiness are seen in infants whose • Eczema mothers were hypertensive (high blood pressure) or who • A red rectal ring experienced distress during pregnancy. To relieve infant • Fretful sleeping or persistent sleeplessness colic, many parents seek help from chiropractic care, mas- • Frequent spitting up or vomiting sage© therapy, Jones acupuncture, & Bartlett or Learning,craniosacral therapy.LLC • Diarrhea© Jones or green &stools, Bartlett perhaps Learning,with blood in them LLC • Wheezing DrugsNOT FOR SALE OR DISTRIBUTION • Colic-likeNOT symptoms FOR SALE and behaviors OR DISTRIBUTION Prenatal maternal abuse of heroin, marijuana, barbitu- rates, or cocaine can result in colic-like behavior in the FIGURE 14-17 Signs of food sensitivity in the infant. infant. If you work in a hospital setting, medical oce, © Jones &or Bartlett clinic, you Learning, are likely to LLC encounter these mothers and© Jones & Bartlett Learning, LLC their babies. Infants of substance abusers oen exhibit NOT FOR SALE OR DISTRIBUTION NOT FORdiagnosed SALE with OR food DISTRIBUTION allergy by the age of 2 years received signs of nervous system instabilities. Symptoms may not solids at less than 16 weeks of age and were less likely to appear until a week or more aer birth. ey can include be receiving breastmilk when cow’s milk protein was rst excitability, trembling, restlessness, ravenous appetite, introduced into their diet (Grimshaw et al., 2013). jitteriness, hyperactivity, shrill scream, feeding problems, and either hypertonia© Jones or &hypotonia. Bartlett See Learning, Chapter LLCCow and Soy Milk Intolerances© Jones & Bartlett Learning, LLC 11 for more informationNOT on FOR the eects SALE of street OR DISTRIBUTIONdrugs on NOT FOR SALE OR DISTRIBUTION the newborn. Cow’s milk protein is a common cause of intolerance in infants. Almost all mammal milks contain immu- Nicotine noglobulin G (IgG). Mothers of colicky babies have higher levels of bovine IgG in their milk than the level ere is a clear correlation between infant fussiness and © Jones & Bartlett Learning, LLC found in© the Jones milk of & noncolicky Bartlett Learning,babies (Clyne LLC & Kul- parental intake of nicotine. Exclusive breastfeeding is czycki, 1991). Levels in human milk range from 0.1 to protectiveNOT FORagainst SALE colic, includingOR DISTRIBUTION for infants of smok- NOT FOR SALE OR DISTRIBUTION 8.5 mg/mL compared with 0.6 to 128 mg/mL in cow’s ing mothers. Infants of smokers are more excitable and milk formulas. e highest levels in formula are in the hypertonic than other infants. ey require more careful powdered form and the lowest levels are in concentrate. handling, show more signs of stress and abstinence, and Bovine IgG levels can be so high or the half-life so long have more diculty with self-regulation. © Jones & Bartlett Learning, LLC © Jonesthat & trials Bartlett of 2 to Learning, 7 days on aLLC diet free of cow’s milk may not be long enough to produce positive results in a NOT FOR FoodSALE Sensitivity OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION colicky child. A 14-day trial may be necessary to obtain An infant who reacts to something in the mother’s diet valid results. ere is no bovine IgG in soy or amino is typically calm at the start of a feeding and then begins acid formulas. to pull o the breast, stiens his or her body, cries, and Colic-like behavior in breastfed infants is sometimes then reattaches. e infant© Jones may repeat & Bartlett this pattern Learning, several LLCthought to be due to cow’s© milkJones protein & Bartlett intolerance. Learning, A LLC times during the feeding.NOT Symptoms FOR SALE can be ORcontinuous DISTRIBUTION or mother who suspects that NOTher baby FOR is intolerant SALE ORto cow’s DISTRIBUTION can start aer a feeding. It is rare for symptoms of a food milk might try eliminating dairy foods from her diet for sensitivity to show up before 3 weeks. See Figure 14-17 2 weeks. If cow’s milk is the cause of her infant’s colic-like for signs of food sensitivity. behavior, she may see some improvement in 48 hours. Avoiding exposure to food allergens in the infant’s Full resolution of the symptoms could take several days. diet© before Jones the &age Bartlett of 3 to 6 monthsLearning, is protective LLC against e mother© Jones can then & reintroduce Bartlett Learning, dairy slowly LLCinto her becomingNOT FORsensitized SALE or developing OR DISTRIBUTION food hypersensitivity. diet. Ideally,NOT she FOR will startSALE with OR hard DISTRIBUTION cheeses or yogurt Exclusive breastfeeding to the age of 6 months provides the rst week, add so cheeses in the second week, butter the necessary protection. Weaning age may inuence the and ice cream in the third week, and cow’s milk in small development of sensitization to food allergens or food quantities in the fourth week. If her baby becomes fussy hypersensitivity (Venter, 2009). Maternal dietary intake or other symptoms return, the mother can once again © Jones &during Bartlett pregnancy Learning, does not LLC appear to have an eect. Infants© Jonesreduce & Bartletther intake Learning, of dairy products. LLC In a completely NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 321 18/06/15 6:35 pm 322 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORmilk-free SALE diet, OR the DISTRIBUTION mother takes in no milk, whey, casein, NOTgain, FOR a bloatedSALE abdomen,OR DISTRIBUTION and a great deal of gas are or sodium caseinate. Consumption of lactose is accept- also symptoms and are very similar to the symptoms of able because it is a sugar and not a cow’s milk protein. food intolerance. Caution mothers who use a dairy elimination diet to read Lactose overload can result from an overactive letdown, food labels because casein is used as a binder in many overabundant milk production, or insucient hindmilk processed foods. © Jones & Bartlett Learning, LLCintake. e amount of lactose ©in humanJones milk & Bartlettis not depen Learning,- LLC NOT FOR SALE OR DISTRIBUTIONdent on the mother’s diet. AlthoughNOT theFOR amount SALE of lactose OR DISTRIBUTION Other Factors in the Mother’s and Infant’s Diets is the same in both foremilk and hindmilk, fat concentrations are low in foremilk and high in hindmilk. An infant Removal of possible sources of intolerance may provide who receives an unbalanced feeding gets a higher percent- relief to a colicky baby. First, the mother should feed the age of lactose in comparison with the percentage of fat. baby only her milk. Even vitamins, uoride, and iron © Jones & Bartlett Learning, LLC e excess lactose© Jones then ferments& Bartlett in the Learning, baby’s gut, whichLLC supplements can be a source of discomfort. Babies who can lead to gassiness and fussiness. receiveNOT antibiotics FOR may SALE be at OR a greater DISTRIBUTION risk for develop- NOT FOR SALE OR DISTRIBUTION A mother who places limits on her baby’s time at the ing food allergies. Antibiotics are linked to leaky gut breast may end a feeding from one breast before letdown syndrome, a condition in which the intestinal lining rst has occurred or before her baby has been able to obtain becomes inamed, and then thin and porous. Proteins the amount of hindmilk needed. is practice results in that are not completely digested may cross from the © Jones & Bartlett Learning, LLC © Jonesthe baby & ingestingBartlett a Learning, larger ratio ofLLC foremilk on the rst intestines into the bloodstream. Leukocytes attack such breast and then lling up on foremilk again on the second NOT FORproteins SALE and OR lead DISTRIBUTION to an antigen–antibody reaction, which NOT FOR SALE OR DISTRIBUTION breast. Fat intake varies between feedings, and the emp- manifests itself as an allergic reaction on subsequent tier the breast, the higher the fat content. us, allowing exposure to that protein. the baby to remain on a breast long enough to drain it Babies usually are not bothered by foods in their moth- will ensure adequate fat intake. Some babies may need to ers’ diets. A mother with a highly sensitive baby may want © Jones & Bartlett Learning, nurseLLC repeatedly on the same© breastJones before & Bartlett they switch Learning, LLC to monitor her food intake. Medications, vitamin supple- to the other breast. See Chapter 9 for more discussion on ments, caeine, high-proteinNOT foods,FOR milk,SALE wheat, OR chocoDISTRIBUTION- NOT FOR SALE OR DISTRIBUTION milk composition. late, eggs, and nuts are all potential sources of discomfort If the mother has overabundant milk production, she to an intolerant baby. Many mothers report that foods that might try nursing on one breast for several feedings before make them gassy (e.g., cabbage, beans, and broccoli) also switching. is should be recommended only aer a full make their babies gassy, especially in the early days aer © Jones & Bartlett Learning, LLC feeding assessment© Jones that includes& Bartlett before- Learning, and aer-feeding LLC birth. Because colicky babies can become food-intoler- (ac/pc) weights measured on a digital scale. is inter- ant children,NOT FORthere maySALE be some OR validityDISTRIBUTION to the theory of NOT FOR SALE OR DISTRIBUTION vention may be combined with pumping residual milk. allergy as a cause of colic-like behavior. For example, a baby might present with the markers for Lactose Overload overabundant milk production, but when ac/pc weights are done, the baby will have had an intake of only 2 or © JonesYou & Bartlettmay encounter Learning, a mother LLCwho says her baby is “lactose © Jones3 ounces. & BartlettIn this case, Learning, the fussy behaviorLLC may be unre- NOT FORintolerant.” SALE ORis DISTRIBUTIONis a misconception propagated by super- NOTlated FOR to nursing.SALE IfOR the DISTRIBUTION mother were to down-regulate her cial media and formula companies with “lactose-free” milk production in this instance, breastfeeding could be products to sell. Lactose is the sugar in human milk, and harmed. it is crucial for brain development. Approximately 20 per- Lactose overload should not be confused with lactose cent of lactose passes undigested into the large intestine, intolerance. Lactose intolerance occurs when a person where it promotes the ©proliferation Jones & of Bartlett healthy bacteriaLearning, doesLLC not produce enough lactase—the© Jones enzyme & Bartlett required Learning, LLC (Mikkelsen, 2014). LactaseNOT is FOR the enzyme SALE thatOR breaksDISTRIBUTION to digest lactose—and thereforeNOT cannot FOR digestSALE lactose. OR DISTRIBUTION down lactose. us, lactose intolerance is a result of insucient lactase, Colic-like symptoms can occur when a baby con- not a condition in and of itself. As people age, their bod- sumes an unbalanced amount of foremilk and hind- ies begin to produce less lactase. Up to 70 percent of the milk, receiving too much lactose and too little fat. In world’s population has lactase deciency, or lactase non- addition,© Jones gut lining & Bartlettdamage from Learning, the infant LLC receiving persistence.© is Jones is indicative & Bartlett of the body’s Learning, maturation LLC as cow’s milkNOT protein FOR maySALE compromise OR DISTRIBUTION lactase production a child maturesNOT and FOR weans SALE from human OR DISTRIBUTION milk. It is rare for (De Koker et al., 2014). Or, the increase in the amount children to have primary lactase de ciency before 3 years of lactose may be too rapid for the lactase to break of age, even in populations with genetic propensities for down the lactose, resulting in lactose overload symp- it, such as Asians, South Americans, and Africans (De toms. An infant with lactose overload may produce Koker et al., 2014). is is also reective of the biologically © Jonesgreen, & Bartlett frothy, Learning,loose, and frequent LLC stools. Poor weight © Jonesnormal & ages Bartlett for weaning. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 322 18/06/15 6:35 pm Crying and Colicky Behavior 323 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR TreatmentSALE OR of DISTRIBUTION Colic-like Symptoms NOT FORabound SALE on the OR Internet, DISTRIBUTION through community classes, and in the form of books. Resources from the International Treatments for colic over the years have ranged from folk Association of Infant Massage (IAIM, 2014) can be help- remedies to prescription medication. Successful calming ful for parents. techniques for fussiness include holding, breastfeeding, Many cultures promote home remedies such as cham- walking, and rocking. Mothers of infants with a diagno- © Jones & Bartlett Learning, LLComile, catnip, fennel, dill, ©and Jones anise for& Bartlettcolic symptoms Learning, LLC sis of colic may not regard breastfeeding as an eective (Humphrey, 2003). An herbal tea containing chamomile, method of infant comforting.NOT FOR In fact, SALE a diagnosis OR DISTRIBUTION of colic NOT FOR SALE OR DISTRIBUTION vervain, licorice, fennel, and balm mint is reportedly correlates with a shorter duration of full breastfeeding. eective, but the volume necessary for treatment limits Giving anticipatory guidance to parents about infant feed- its usefulness (Crotteau et al., 2006). Fennel oil has also ing, colic, and recommended breastfeeding duration may historically been used (Gori et al., 2012). Caution par- be helpful in ensuring that they maintain breastfeeding as © Jones & Bartlett Learning, LLC ents to discuss© Jones their &options Bartlett with Learning,their baby’s caregiverLLC long as possible. before they use any over-the-counter, herbal, or folk rem- OneNOT theory FOR holds SALE that ORcolic DISTRIBUTIONindicates an overreactive NOT FOR SALE OR DISTRIBUTION edy. Such treatments may even be dangerous. Japanese nervous system. According to this hypothesis, a colicky star anise, used for colic, has resulted in infant poisoning baby tenses easily and reacts with discomfort to most (Madden et al., 2012). Prescription medication is avail- stimuli, including parental handling. e mother may able for relieving colic symptoms. Dicyclomine, an anti- interpret her baby’s crying and pushing away as a sign © Jones & Bartlett Learning, LLC © Jonescholinergic & Bartlett agent Learning,used to treat LLCthe symptoms of irritable of rejection. She needs to learn that these reactions do bowel syndrome, relieves muscle spasms in the gastro- NOT FOR notSALE indicate OR DISTRIBUTIONrejection, but rather the need for soothNOT- FOR SALE OR DISTRIBUTION intestinal tract. Some caregivers prescribe simethicone ing. Babies are better able to self-regulate when parents (Mylicon) drops for colic due to gas or cimetropium establish regularity and uniformity in their daily care. bromide (Savino et al., 2014). Other parents use homeo- Predictability improves the baby’s sleep-wake rhythm, pathic preparations. thereby avoiding overtiredness and excessive crying © Jones & Bartlett Learning, LLCA new trend for the treatment© Jones of & infantile Bartlett colic Learning, is LLC (Blom et al., 2009). the use of probiotics, medicine’s most recent “ham- Many parents seekNOT help fromFOR chiropractic SALE OR care, DISTRIBUTION mas- NOT FOR SALE OR DISTRIBUTION mer looking for a nail” (Bennett, 2014). Aer several sage therapy, or craniosacral therapy. Referral by the small industry-funded trials, a large cohort was stud- family’s primary care provider to occupational or physi- ied. Researchers concluded that treatment with Lacto- cal therapy may also be helpful in reducing maternal dis- bacillus reuteri (the probiotic) did not reduce crying or tress by addressing the baby’s symptoms. Chiropractic © Jones & Bartlett Learning, LLC fussing. It© was Jones also ineective & Bartlett in improving Learning, infant LLC sleep, care involves gentle pressure to relieve nerve compres- maternal mental health, family or infant functioning, sionNOT that impairsFOR SALE the aected OR DISTRIBUTION system. e majority of NOT FOR SALE OR DISTRIBUTION or quality of life (Sung et al., 2014). Although interven- parents nd an improvement in symptoms. Massage has tions can be of limited value, some parents nd one that relaxing eects on both the baby and parent, enhances works much better for their baby, while others keep a mother–infant interaction and infant sleep, and lowers repertoire handy for this purpose. When crying stops levels of stress hormones. Massage on preterm babies temporarily, parents cannot necessarily assume the © Jones &in Bartlett the neonatal Learning, intensive LLC care unit is linked to greater© Jones & Bartlett Learning, LLC cause is clear. Table 14-10 identi es some interventions NOT FOR weightSALE gain,OR DISTRIBUTIONearlier discharge, and increased developNOT- FOR SALE OR DISTRIBUTION parents may wish to try. One of the techniques, shown mental scores. in Figure 14-19, is for the mother to place her baby See Figure 14-18 for one eective technique for infant across her lap. If all measures used to comfort the baby massage. Sometimes the baby will cry throughout the fail, the parents should consult their baby’s caregiver to massage but be calm by the end. Other infants may © Jones & Bartlett Learning, LLCrule out a medical condition.© Jones e potential & Bartlett harm assoLearning,- LLC respond immediately. Many resources for infant massage NOT FOR SALE OR DISTRIBUTIONciated with diagnosis andNOT treatment FOR is SALElikely to OR surpass DISTRIBUTION any harm from the colic. Families will bene t from reassurance, family social support, and the tincture of time (Bennett, 2014). • Hold the naked baby on the parent’s lap, supine, with the baby’s head resting on the parent’s knees. ©• JonesGently massage & Bartlett the baby’s Learning, stomach, shoulders, LLC head, Supporting© Jones the Parents & Bartlett of a Colicky Learning, Baby LLC NOThands, FOR and feet.SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Turn the baby over and massage the back. When a baby experiences colic-like symptoms, parental • Hold and soothe the baby against the parent’s shoulder stress and concern naturally increase. Colic seems severe until the crying ceases. enough to some parents that they visit the hospital emer- gency department. Parents of a colicky baby will need © Jones &FIGURE Bartlett 14-18 Learning, Technique LLC for infant massage. © Jonessupport, & Bartlett frequent Learning, contact, and LLC reassurance. Depending NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 323 18/06/15 6:35 pm 324 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORTABLE SALE 14-10 OR MeasuresDISTRIBUTION for Comforting a Colicky Baby NOT FOR SALE OR DISTRIBUTION Holding techniques “Wear” the baby around the house in a cloth baby sling, walking and dancing in a soothing manner (make sure the baby’s breathing is not blocked). Hold the baby upright against the parent’s shoulder near the neck. Place the baby on his or her stomach across the parent’s lap or knees. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Carry the baby against the parent’s hip. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Lay the baby face down on the parent’s chest. Lay the baby face down on the inside of the parent’s forearm with the baby’s head held in the crook of the parent’s arm. The pressure on the stomach feels good, and the parent can use the free hand to pat and rub the baby’s back. © Jones & PickBartlett up the Learning,baby as soon asLLC he or she starts to fuss. This will© Jonesdecrease &the Bartlett length of time Learning, the baby is LLCfussy NOT FOR SALEand prevent OR DISTRIBUTION it from escalating. NOT FOR SALE OR DISTRIBUTION Sounds and motion Provide a steady noise from a vacuum, clothes dryer, music, humming, or tapes of the mother’s heartbeat. Play a recording of the baby’s own cry. Speak closely and softly in whispers. © Jones & Bartlett Learning,Position LLCbaby to look at the mother’s and© father’s Jones face. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONProvide an unexpected distraction to startleNOT the FOR baby to SALE cease crying. OR DISTRIBUTION Take the baby for a car ride to provide soothing, rhythmic motion. Bounce, swing, rock, and walk in slow, rhythmical movements. Security and Place the baby in a warm bath. warmth Check© Jones for any rashes & Bartlett that could Learning, indicate reaction LLC to the ber or detergent in clothing© Jones or blankets. & Bartlett Learning, LLC SwaddleNOT theFOR baby SALE to provide OR closeness DISTRIBUTION and security, or unswaddle him or herNOT if the blanketFOR seemsSALE too OR DISTRIBUTION constricting. Check the diaper for dampness and keep the baby warm with sweaters or blankets. Place a warmed hot water bottle against the baby’s stomach area to help him or her release tension and thereby encourage the passing of gas. © Jones & BartlettFold the baby’s Learning, legs up to hisLLC or her stomach in a bicycle motion© Jones to help & eliminate Bartlett gas. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

on their reading level and desire, you can suggest appro- Caring for an infant with unexplained, persistent cry- priate resources to assist them in caring for their colicky ing is one of the most stressful and common concerns © Joneschild. & Bartlett Many Internet Learning, and parenting LLC support forums are © Jonesfor new & parents. Bartlett Interaction Learning, between LLC parents and their NOT FORavailable. SALE Breastfeeding OR DISTRIBUTION support groups and online meet- NOTcolicky FOR infantSALE is ORcompromised, DISTRIBUTION and tension can further ings can also provide a support network to help families aggravate a baby’s colicky condition. e mother will get through this very intense and dicult beginning to need an avenue for venting her anger and frustration. their baby’s life. She will bene t from the support of someone who is The mother of a colicky baby may experience frustra- receptive, caring, and reassuring. Parents may need to tion and guilt for resenting© Jones her child. & Bartlett Physical exhausLearning,- takeLLC a break and spend some© time Jones away & from Bartlett the baby Learning, LLC tion is common from constantlyNOT FOR trying SALE to sootheOR DISTRIBUTION and when necessary to keep theirNOT perspective. FOR SALE Encourage OR DISTRIBUTION comfort a crying baby. A baby may sense the mother’s them to seek help if they feel they cannot cope with emotional state and be comforted immediately when their baby’s crying. Home-based healthcare interven- another person picks the child up. This can further add tion and support, when available, helps reduce parent- to the mother’s feelings of guilt and inadequacy. She ing stress and improves interactions between parents may feel© Jonesthat her &baby Bartlett is rejecting Learning, her and LLCthat she is and their infants.© Jones & Bartlett Learning, LLC the causeNOT of FORher baby’s SALE colic-like OR DISTRIBUTION behavior. During this Support forNOT parents FOR is especiallySALE OR critical DISTRIBUTION in preventing time, the mother will need a great deal of emotional a reaction of shaking the baby in frustration. Parents and support. It is not surprising that mothers of colicky caregivers need to be educated about the causes and dan- babies often experience postpartum depression and gers of shaken baby syndrome and know to never shake or insecure maternal attachment (Hiscock et al., 2014; handle the baby roughly. Shaking can cause brain damage, © JonesRadesky & Bartlett et al., Learning,2013). LLC © Jonesblindness, & Bartlett and death Learning,(CDC, 2012). LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 324 18/06/15 6:35 pm What You Learned—At a Glance 325 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORWhat SALE You Learned—At OR DISTRIBUTION a Glance

Elements of newborn assessment • Body tone can indicate possible congenital anomalies © Jones & Bartlett Learning, LLCor the need for assistance© with Jones positioning & Bartlett for feedings. Learning, LLC NOT FOR SALE OR DISTRIBUTION• Skin turgor indicates adequateNOT FOR hydration SALE from OR milk DISTRIBUTION transfer. • Severe caput succedaneum or cephalhematoma can lead to feeding diculties or jaundice. © Jones & Bartlett Learning, LLC • Facial asymmetry© Jones or & torticollis Bartlett is Learning,a marker for potentialLLC latch and sucking diculty. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Low fat buccal pads indicate a possible need to assist with latch. • Short tongue, tight frenulum or frenum, or other inabil- ity to extend the tongue over the alveolar ridge could © Jones & Bartlett Learning, LLC © Jonesinterfere & Bartlett with latch Learning, and cause LLC nipple damage. NOT FOR SALE OR DISTRIBUTION NOT FOR• High SALE palate ORor palatal DISTRIBUTION defects such as a cle of the so palate, a submucosal cle, or a bifurcated (bi d) uvula could interfere with latch or sucking. • Fractured clavicle or sensitivity from forceps or vacuum © Jones & Bartlett Learning, LLCcan cause feeding discomfort© Jones or impairment. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Nutritive and nonnutritiveNOT sucking FOR indicateSALE ORwhether DISTRIBUTION the baby is receiving milk.

Digestion FIGURE 14-19 Placing the baby on his or her stomach across© Jonesthe parent’s & Bartlettlap can help Learning, relieve colic symptoms.LLC • Burping© decreases Jones gas& Bartlett pain and reducesLearning, spitting LLC up. • When a baby spits up, the amount, frequency, and force PrintedNOT with permissionFOR SALE of Nelia OR Box. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION indicate possible need for a change in breastfeeding management. • Spitting up multiple times in one day can be a sign of Summary GER. © Jones &Infant Bartlett assessment Learning, is a signi cant LLC part of the lactation© Jones• GERD & Bartlett is associated Learning, with esophagitis, LLC low weight gain, NOT FOR consultant’sSALE OR role DISTRIBUTION in caring for breastfeeding families. RecNOT- FORfailure SALE to thrive, OR andDISTRIBUTION respiratory disorders. ognizing deviations from normal in the infant’s body, • Monitoring voids and stools indicates adequate posture, skin, head, and reexes provides important clues nourishment. about the child’s condition. Assessment of the infant’s oral structure and elimination patterns will help the lactation • Recognizing normal stool consistency helps mothers consultant determine© whether Jones changes & Bartlett are needed Learning, in the LLCrule out constipation or diarrhea.© Jones & Bartlett Learning, LLC breastfeeding approach.NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION As a lactation consultant, you have the opportunity to Infant communication and behavior educate parents about normal baby behavior. Many par- • Infants communicate through approach and avoidance ents will have never been around babies or even held a behaviors. baby until they hold their own child. Your experience with • Hunger cues are most evident when the baby is in a many© healthyJones babies & Bartlett at dierent Learning, developmental LLC stages will © Jones & Bartlett Learning, LLC light sleep, drowsy, and quietly alert. helpNOT you FOReducate SALE parents OR about DISTRIBUTION normal healthy infant NOT FOR SALE OR DISTRIBUTION behavior. Teaching parents how to recognize and inter- • If hunger cues are unheeded, the baby may cry or fall pret infant signals helps them tune into their baby’s needs. back asleep. As parents learn about normal infant behavior, growth, • Breastfeeding management may need to accommodate sleeping, crying, and digestion patterns, they become pro- the infant’s behavior pattern, which ranges from easy- © Jones & cient Bartlett in interpreting Learning, their LLC own babies’ behaviors. © Jonesgoing & Bartlett and undemanding Learning, to active LLC and fussy. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 325 18/06/15 6:35 pm 326 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR• Knowing SALE ORhow DISTRIBUTIONto stimulate a sleepy or undemanding NOTReferences FOR SALE OR DISTRIBUTION baby and comfort a fussy baby will help mothers ensure the baby’s adequate nourishment. Academy of Breastfeeding Medicine (ABM). Clinical protocol #6: Guideline on co-sleeping and breastfeeding revision. March 2008. http://www.bfmed.org Infant growth Academy of Breastfeeding Medicine (ABM). Clinical protocol #11: © Jones & Bartlett Learning, LLCGuidelines for the evaluation© and Jones management & Bartlett of neonatal Learning, LLC • Healthy, full-term infantsNOT self-regulate FOR SALE their foodOR intake.DISTRIBUTIONankyloglossia and its complicationsNOT FOR in the SALE breastfeeding OR DISTRIBUTION • Newborns may lose up to 7 to 10 percent of birth weight dyad. 2009. http://www.bfmed.org/Resources/Protocols due to passage of meconium and urine. .aspx • Weight loss over 10 percent is outside normal limits and Allen LM, Spadola AC. Prenatal detection of ankyloglossia in a 22-week fetus. 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Late onset necrotizing enterocolitis in infants fol- • Sleeping prone and maternal smoking are risk factors lowing use of a xanthan gum-containing thickening agent. for SIDS.© Jones & Bartlett Learning, LLC J Pediatr©. 2012;161(2):354-356. Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Bennett WENOT Jr. Probiotics FOR SALE and infant OR DISTRIBUTIONcolic. BMJ. April Crying and colicky behavior 2014;348:g2286. Bergman NJ. Neonatal stomach volume and physiology suggest • Infants’ crying is a form of communication to elicit feeding at 1-h intervals. Acta Paediatrica. 2013;102(8):773-777. parental response to meet their needs. Blackburn ST. Maternal, Fetal, & Neonatal Physiology: A Clin- © Jones• &A Bartlettnewborn mayLearning, cry from LLChunger approximately 1½–2 © Jonesical & Perspective Bartlett. 4th Learning, ed. Maryland LLC Heights, MO: Elsevier hours or more aer a feeding. Saunders; 2013. NOT FOR SALE OR DISTRIBUTION NOTBlair FOR P, et SALE al. Sudden OR infant DISTRIBUTION death syndrome and sleeping posi- • Some babies settle when swaddled or carried in a sling. tion in pre-term and low birth weight infants: an opportu- • A colicky baby has severe abdominal discomfort, pierc- nity for targeted intervention [published online ahead of ing cries, and explosive attacks. print May 24, 2005]. Arch Dis Child. 2006;91(2):101-106. Blair PS, et al. Bed-sharing in the absence of hazardous circum- • Infants born preterm and© Jones small for & gestational Bartlett ageLearning, have LLCstances: Is there a risk of sudden© Jones infant &death Bartlett syndrome? Learning, LLC higher risks for colic. NOT FOR SALE OR DISTRIBUTIONAn analysis from two case-controlNOT studies FOR conducted SALE OR in the DISTRIBUTION • Prenatal maternal abuse of heroin, marijuana, barbitu- UK. PLoS One. 2014;9(9):e107799. rates, or cocaine can cause colic-like behavior. Blom MA, et al. 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9781284078954_CH14_293_230.indd 326 18/06/15 6:35 pm References 327 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR CampanozziSALE OR A, DISTRIBUTION et al. Prevalence and natural history of gasNOT- FORas SALE imaged byOR ultrasound DISTRIBUTION [published online ahead of print troesophageal reux: pediatric prospective survey. Pediat- June 23, 2008]. Pediatrics. 2008;122(1):e188-e194. rics. 2009;123(3):779-783. Genna CW. Supporting Sucking Skills in Breastfeeding Infants. Carrascoza K, et al. Consequences of bottle-feeding to the oral Sudbury, MA: Jones and Bartlett; 2008. facial development of initially breastfed children [pub- Gettler LT, McKenna JJ. Evolutionary perspectives on mother- lished online ahead© of Jones print September & Bartlett 21, 2006]. Learning, J Pediatr LLC infant sleep proximity and© Jones breastfeeding & Bartlett in a laboratory Learning, LLC (Rio J.) 2006;82(5):395-397. setting. Am J Phys Anthropol. 2011;144(3):454-462. Casale V, et al. InvestigationNOT of FOR 5-HTT SALE expression OR using DISTRIBUTION quan- Goetzinger KR, Macones GA.NOT Operative FOR SALE vaginal ORdelivery: DISTRIBUTION titative real-time PCR in the human brain in SIDS Italian current trends in obstetrics. Women’s Health (Lond). cases. Exp Mol Pathol. 2013;94(1):239-242. 2008;4(3):281-290. Centers for Disease Control and Prevention (CDC). Injury Gori L, et al. Can estragole in fennel seed decoctions really Prevention & Control: Traumatic Brain Injury. Heads Up: be considered a danger for human health? A fennel ©Prevent Jones Shaken & BartlettBaby Syndrome. Learning, March 9, LLC2012. www.cdc safety© update. Jones Evid & BartlettBased Complement Learning, Alternat LLC Med. NOT.gov/concussion/HeadsUp/sbs.html FOR SALE OR DISTRIBUTION 2012;2012:860542.NOT FOR SALE OR DISTRIBUTION Centers for Disease Control and Prevention (CDC). About Grimshaw KE, et al. Introduction of complementary foods and sudden unexpected infant death and sudden infant death the relationship to food allergy. Pediatrics. 2013;132(6):e15 syndrome. September 29, 2014. http://www.cdc.gov/sids 29-e1538. /aboutsuidandsids.htm Han SH, et al. A study on the genetic inheritance of anky- © Jones &Clyne Bartlett P, Kulczycki Learning, A. Human LLC breast milk contains bovine IgG:© Jones &loglossia Bartlett based Learning, on pedigree LLCanalysis. Arch Plast Surg. relationship to infant colic? Pediatrics. 1991;87:439-444. 2012;39(4):329-332. NOT FOR CrotteauSALE C,OR et al.DISTRIBUTION Clinical inquiries: what is the best treatmentNOT FORHauck SALE FR, et ORal. Breastfeeding DISTRIBUTION and reduced risk of sud- for infants with colic? J Fam Pract. 2006;55(7):634-636. den infant death syndrome: a meta-analysis. Pediatrics. Das A, Das NK. Cradle cap. Indian Pediatr. June 2014;51(6): 2011;128(1):103-110. 509-510. Hester SN, et al. Is the macronutrient intake of formula-fed De Koker CE, et al. e dierences between lactose intoler- infants greater than breast-fed infants in early infancy? ance and cow’s milk© Jonesprotein allergy. & Bartlett J Fam Health Learning, Care. LLC J Nutr Metab. 2012;2012:891201.© Jones & Bartlett Learning, LLC January-February NOT2014;24(1):14-18, FOR SALE 20. OR DISTRIBUTIONHiscock H, et al. Preventing earlyNOT infant FOR sleep SALE and crying OR prob DISTRIBUTION- DeMuth K, et al. Relationship between treatment with antacid lems and postnatal depression: a randomized trial. Pediat- medication and the prevalence of food allergy in children. rics. 2014;133(2):e346-e354. Allergy Asthma Proc. 2013;34(3):227-232. Honein MA, Cragan JD. Balancing competing risks: perina- De Santis D, et al. Lingual frenectomy: a comparison between tal exposure to macrolides increases the risk of infantile the conventional surgical and laser procedure. Minerva hypertrophic pyloric stenosis. Evid Based Med. August ©Stomatol Jones. August & Bartlett 1, 2013. [Epub Learning, ahead of print]LLC 2014.© pii: Jones ebmed-2014-110015 & Bartlett Learning, LLC DeweyNOT K. Nutrition,FOR SALE growth OR and DISTRIBUTION complementary feeding of Hong P, etNOT al. De ning FOR ankyloglossia: SALE OR a DISTRIBUTION case series of anterior the breastfed infant. In Hale T, Hartmann P. (eds.), Hale & and posterior tongue ties. Int J Pediatr Otorhinolaryngol. Hartmann’s Textbook of Human Lactation. Amarillo, TX: 2010;74(9):1003-1006. Hale Publishing; 2007; 415-423. Huang Y, et al. Inuence of bedsharing activity on breast- Dias CC, Figueiredo B. Breastfeeding and depression: Asystem- feeding duration among U.S. mothers. JAMA Pediatr. © Jones & Bartlettatic review Learning, of the literature. LLC J Aect Disord. September 2014;© Jones &2013;167(11):1038-1044. Bartlett Learning, LLC 171C:142-154. Humphrey S. e Nursing Mother’s Herbal. Minneapolis, MN: NOT FOR DietzSALE PM, OR et al. DISTRIBUTION Infant morbidity and mortality attributable NOTto FORFairview SALE Press; OR 2003. DISTRIBUTION prenatal smoking in the U.S. Am J Prev Med. 2010;39(1): Ikeda K, et al. Importance of evaluating for cow’s milk allergy 45-52. in pediatric surgical patients with functional bowel symp- Doan T, et al. Nighttime breastfeeding behavior is associated toms. J Pediatr Surg. 2011;46(12):2332-2335. with more nocturnal sleep among rst-time mothers at one Iles R, et al. Crying signi cantly reduces absorp- month postpartum.© JJones Clin Sleep & Med Bartlett. March Learning,2014;10(3): LLC tion of aerosolised drug© Jonesin infants. & BartlettArch Dis ChildLearning,. LLC 313-319. NOT FOR SALE OR DISTRIBUTION1999;81(2):163-165. NOT FOR SALE OR DISTRIBUTION Doumouchtsis SK, Arulkumaran S. Head trauma aer instru- International Association of Infant Massage (IAIM). 2014. mental births. Clin Perinatol. 2008;35(1):69-83, viii. http://www.iaim.net Edmunds J, et al. Tongue-tie and breastfeeding: a review of the International Chiropractic Pediatric Association (ICPA). literature. Breastfeed Rev. March 2011;19(1):19-26. Review. Advancing the family wellness lifestyle. 2014. http://www Edmunds© Jones J, et al. &Tongue-tie. Bartlett J Hum Learning, Lact. 2012;28(1):14-17. LLC .icpa4kids.org© Jones & Bartlett Learning, LLC Eghbalian F, Monsef A. Congenital epulis in the newborn: Jain S. “Witch’s milk” and 99mTc-pertechnetate uptake in neo- NOTreview FOR of the literatureSALE andOR a caseDISTRIBUTION report. J Pediatr Hematol natal NOTbreast tissue:FOR an SALE uncommon OR but DISTRIBUTION not unexpected nd- Oncol. 2009;31(3):198-199. ing. Clin Nucl Med. July 2013;38(7):586-587. Garbin CP, et al. Evidence of improved milk intake aer freno- Jung WJ, et al. e ecacy of the upright position on gastro- tomy: a case report. Pediatrics. 2013;132(5):e1413-e1417. esophageal reux and reux-related respiratory symptoms Geddes D, et al. Frenulotomy for breastfeeding infants with anky- in infants with chronic respiratory symptoms. Allergy © Jones & Bartlettloglossia: Learning, Eect on milk LLC removal and sucking mechanism© Jones &Asthma Bartlett Immunol Learning, Res. 2012;4(1):17-23. LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

9781284078954_CH14_293_230.indd 327 18/06/15 6:35 pm 328 CHAPTER 14 Infant Assessment and Development © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORJunqueira SALE MA, OR et DISTRIBUTIONal. Surgical techniques for the treatment of NOTMcDonnell FOR SALE E, Moon OR RY. DISTRIBUTION Infant deaths and injuries associated ankyloglossia in children: a case series. J Appl Oral Sci. with wearable blankets, swaddle wraps, and swaddling. 2014;22(3):241-248. J Pediatr. 2014;164(5):1152-1156. Kanada KN, et al. A prospective study of cutaneous ndings McKenna J, et al. Mother-infant cosleeping, breastfeed- in newborns in the United States: correlation with race, ing and sudden infant death syndrome: what biologi- ethnicity, and gestational© Jones status &using Bartlett updated Learning, classi - LLCcal anthropology has discovered© Jones about & normalBartlett infant Learning, LLC cation and nomenclature. J Pediatr. August 2012;161(2): sleep and pediatric sleep medicine. Am J Phys Anthropol. 240-245. NOT FOR SALE OR DISTRIBUTION2007;45(suppl):133-161. NOT FOR SALE OR DISTRIBUTION Kent J, et al. Volume and frequency of breastfeedings and fat Mikkelsen A. Children’s hypersensitivity to cow’s milk. Pub- content of breast milk throughout the day. Pediatrics. lic health aspects and impact on families. Public Health 2006;117(3):e387-e395. Epidemiology Unit. Institute of Medicine Sahlgrenska Kochanska G, et al. Mother-child and father-child mutually Academy at University of Gothenburg. Gothenburg, responsive© Jones orientation & Bartlett in the Learning, rst 2 years and LLC children’s Sweden; ©2014. Jones & Bartlett Learning, LLC outcomesNOT FORat preschool SALE age: ORmechanisms DISTRIBUTION of inuence. Child Milidou I, etNOT al. FORGestational SALE age, OR small DISTRIBUTION for gestational Dev. 2008;79(1):30-44. age, and infantile colic. Paediatr Perinat Epidemiol. Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;28(2):138-145. 2014;134(2):e547-e561. Review. Mitchell EA, ompson JMD. Co-sleeping increases the risk Kotlow LA. e inuence of the maxillary frenum on the devel- of SIDS, but sleeping in the parents’ bedroom lowers it. © Jones & Bartlettopment and Learning, pattern of dental LLC caries on anterior teeth in © JonesIn &Rognum Bartlett TO, ed.Learning, Sudden Infant LLC Death Syndrome: New breastfeeding infants: prevention, diagnosis, and treat- Trends in the Nineties. Scandinavian University Press: Oslo; NOT FOR SALEment. J HumOR LactDISTRIBUTION. 2010;26(3):304-308. NOT FOR1995:266-269. SALE OR DISTRIBUTION Kotlow L. Diagnosis and treatment of ankyloglossia and tied Moimaz SA, et al. Longitudinal study of habits leading to mal- maxillary fraenum in infants using Er:YAG and 1064 occlusion development in childhood. BMC Oral Health. diode lasers. Eur Arch Paediatr Dent. 2011;12(2):106-112. August 2014;14:96. Review. Monk C, et al. e relationship between women’s attachment Kumar M, Kalke E. Tongue-tie,© Jones breastfeeding & Bartlett diculties Learning, and the LLCstyle and perinatal mood ©disturbance: Jones &implications Bartlett forLearning, LLC role of Frenotomy. ActaNOT Paediatrica FOR. 2012;101(7):687-689.SALE OR DISTRIBUTIONscreening and treatment. NOTArch Women’sFOR SALE Ment HealthOR DISTRIBUTION. La Leche League International (LLLI). How do I position my 2008;11(2):117-129. baby to breastfeed? February 11, 2013. http://www.llli.org Mörelius E, et al. Stress at three-month immunization: parents’ Leibovitch L, et al. Short-term neonatal outcome among term and infants’ salivary cortisol response in relation to the use infants aer in utero exposure to serotonin reuptake inhib- of paci er and oral glucose. Eur J Pain. 2009;2:202-208. itors. Neonatology. 2013;104(1):65-70. Moses S. Family Practice Notebook. Skin turgor. June 1, 2013. Lewis ML.© Jones A comprehensive & Bartlett newborn Learning, exam: part LLC I. General, http://www.fpnotebook.com/ER/Exam/SknTrgr.htm© Jones & Bartlett Learning, LLC headNOT and FOR neck, SALEcardiopulmonary. OR DISTRIBUTION Am Fam Physician. Mosko S, et al.NOT Maternal FOR sleep SALE and arousals OR DISTRIBUTION during bedsharing September 2014a;90(5):289-296. with infants. Sleep. 1997;201(2):142-150. Lewis ML. A comprehensive newborn exam: part II. Skin, trunk, Mulder PJ, et al. Excessive weight loss in breastfed infants dur- extremities, neurologic. Am Fam Physician. September ing the postpartum hospitalization. J Obstet Gynecol Neo- 2014b;90(5):297-302. natal Nurs. 2010;39(1):15-26. © JonesLindau & Bartlett JF, et al. DeterminantsLearning, ofLLC exclusive breastfeeding cessa- © JonesNeu M, & et Bartlettal. A review Learning, of nonsurgical LLC treatment for the symp- tion: identifying an “at risk population” for special support. tom of irritability in infants with GERD. J Spec Pediatr NOT FOR SALEEur J Pediatr OR. DISTRIBUTIONOctober 14, 2014. NOT FORNurs .SALE 2012;17(3):177-192. OR DISTRIBUTION Loder RT, Skopelja EN. e epidemiology and demographics of O’Callahan C, et al. e eects of oce-based frenotomy for hip dysplasia. ISRN Orthop. October 10, 2011;2011:238607. anterior and posterior ankyloglossia on breastfeeding. Int J Lund M, et al. Use of macrolides in mother and child and risk of Pediatr Otorhinolaryngol. 2013;77(5):827-832. infantile hypertrophic pyloric stenosis: nationwide cohort Oji T, et al. A 25-year review of cases with submucous cle palate. study. BMJ. 2014;348:g1908.© Jones & Bartlett Learning, LLCInt J Pediatr Otorhinolaryngol©. JulyJones 2013;77(7):1183-1185. & Bartlett Learning, LLC Lykoudis E, et al. AlopeciaNOT associated FOR with SALE birth injury. OR DISTRIBUTIONObstet Paddack A, et al. Food hypersensitivityNOT FOR and otolaryngologicSALE OR DISTRIBUTION Gynecol. 2007;110(2 Pt 2):487-490. conditions in young children. Otolaryngol Head Neck Surg. Mabula JB, et al. Hirschsprung’s disease in children: a ve year 2012;147(2):215-220. experience at a university teaching hospital in northwest- Parlade M, et al. Anticipatory smiling: linking early aective ern Tanzania. BMC Res Notes. 2014;7:410. communication and social outcome [published online Machaalani© Jones R, Waters & KA.Bartlett Neurochemical Learning, abnormalities LLC in the ahead of© printJones October & Bartlett 31, 2008]. Learning, Infant Behav LLC Dev. brainstem of the sudden infant death syndrome (SIDS). 2009;32(1):33-43. PaediatrNOT RespirFOR Rev SALE. September OR 19,DISTRIBUTION 2014. Perme T, et al.NOT Prolonged FOR prostaglandin SALE OR E1 therapyDISTRIBUTION in a neonate Madden GR, et al. A case of infantile star anise toxicity. Pediatr with pulmonary atresia and ventricular septal defect and the Emerg Care. 2012;28(3):284-285. development of antral foveolar hyperplasia and hypertro- Madre C, et al. Infant deaths in slings. Eur J Pediatr. December phic pyloric stenosis. Ups J Med Sci. 2013;118(2):138-142. 18, 2013. [Epub ahead of print] Ponizovsky AM, Drannikov A. Contribution of attachment © JonesManfredi & Bartlett C, et al. Learning, High-resolution LLC cry analysis in preterm new- © Jonesinsecurity & Bartlett to health-related Learning, quality LLC of life in depressed NOT FOR SALEborn infants. OR MedDISTRIBUTION Eng Phys. 2008;31(5):528-532. NOT FORpatients. SALE World OR J Psychiatry DISTRIBUTION. 2013;3(2):41-49.

9781284078954_CH14_293_230.indd 328 18/06/15 6:35 pm References 329 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR QuitadamoSALE OR P, etDISTRIBUTION al. European pediatricians’ approach to chilNOT- FORTollefson SALE MM, ORFrieden DISTRIBUTION IJ. Early growth of infantile heman- dren with GER symptoms: survey of the implementation giomas: what parents’ photographs tell us. Pediatrics. of 2009 NASPGHAN-ESPGHAN guidelines. J Pediatr Gas- 2012;130(2):e314-320. troenterol Nutr. 2014;58(4):505-509. Trikha A, et al. Development of food allergies in patients Radesky JS, et al. Inconsolable infant crying and maternal post- with gastroesophageal reux disease treated with gastric partum depressive© symptoms.Jones & PediatricsBartlett. 2013;131(6):Learning, LLC acid suppressive medications.© Jones Pediatr & AllergyBartlett Immunol Learning,. LLC e1857-e1864. 2013;24(6):582-588. Rechtman LR, et al. NOTSofas andFOR infant SALE mortality. OR DISTRIBUTIONPediatrics. Tunc V. Factors associated withNOT defecation FOR patterns SALE in 0-24-month- OR DISTRIBUTION 2014;134(5):e1293-1300. old children. Eur J Pediatr. 2008;167(12):1357-1362. Reddy NR, et al. Clipping the (tongue) tie. J Indian Soc Peri- Umeda S, et al. Impact of cow’s milk allergy on enterocolitis odontol. 2014;18(3):395-398. associated with Hirschsprung’s disease. Pediatr Surg Int. Ricke L, et al. Newborn tongue-tie: prevalence and eect on 2013;29(11):1159-1163. ©breast-feeding. Jones & JBartlett Am Board FamLearning, Pract. 2005;18(1):1-7. LLC van Dijk C,© InnisJones S. Growth-curve & Bartlett standards Learning, and the LLC assess- SaavedraNOT JM, FOR Dattilo SALE AM. OREarly DISTRIBUTION development of intestinal ment NOTof early FOR excess SALE weight ORgain DISTRIBUTIONin infancy. Pediatrics. microbiota: implications for future health. Gastroenterol 2009;123(1):102-108. Clin North Am. 2012;41(4):717-731. Vandenplas Y. Management of paediatric GERD. Nat Rev Gas- Sánchez CL, et al. e possible role of human milk nucleotides troenterol Hepatol. 2014;11(3):147-157. as sleep inducers. Nutr Neurosci. 2009;12(1):2-8. Vandenplas Y, et al. Gastrointestinal manifestations of cow’s © Jones &Savino Bartlett F, et al. Learning, Looking for new LLC treatments of infantile colic. Ital© Jones &milk Bartlett protein allergy Learning, and gastrointestinal LLC motility. Acta Pae- J Pediatr. June 2014;40:53. diatrica. November 2012;101(11):1105-1109. NOT FOR SchertzSALE M, OR et al.DISTRIBUTION Long-term neurodevelopmental follow-up NOTof FORVennemann SALE M, ORet al. DISTRIBUTIONDoes breastfeeding reduce the risk of sud- children with congenital muscular torticollis. J Child Neu- den infant death syndrome? GeSID Study Group. Pediat- rol. 2013;28(10):1215-1221. rics. 2009;123(3):e406-e110. Semeniuk J, et al. Serum interleukin—4 and tumor necro- Venter C. Factors associated with maternal dietary intake, feed- sis factor alpha concentrations in children with primary ing and weaning practices, and the development of food acid gastroesophageal© Jones reux &and Bartlett acid gastroesopha Learning,- LLC hypersensitivity in the ©infant. Jones Pediatr & AllergyBartlett Immunol Learning,. LLC geal reux secondaryNOT to cow’sFOR milk SALE allergy. OR Adv DISTRIBUTION Med Sci. 2009;20:320-327. NOT FOR SALE OR DISTRIBUTION 2012;57(2):273-281. Vipulananthan N, et al. Primary aerodigestive presentations of Shah P, et al. Breastfeeding or breast milk for proce- Pierre Robin sequence/complex and predictive factors of dural pain in neonates. Cochrane Database Syst Rev. airway type and management. Int J Pediatr Otorhinolaryn- 2012;12:CD004950. gol. October 2014;78(10):1726-1730. Shapiro-Mendoza CK, et al. Classi cation system for the Sud- Volpe J. Neurology of the Newborn. 5th ed. 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Int J Pediatr Wilson-Clay B, Hoover K. e Breastfeeding Atlas. 5th ed. Otorhinolaryngol. September 2012;76(9):1236-1240. Austin, TX: Lactnews Press; 2013. Sung V et al. Treating infant colic with the probiotic Lactoba- Woods CW, et al. Development of necrotizing enterocolitis in cillus reuteri: double blind, placebo controlled randomised premature infants receiving thickened feeds using Sim- ©trial. Jones BMJ. 2014;348:g2107. & Bartlett Learning, LLC plyick®.© Jones J Perinatol & .Bartlett 2012;32(2):150-152. Learning, LLC Tappin D, et al. Bedsharing, roomsharing, and sudden infant World Health Organization (WHO). WHO Multicentre Growth NOTdeath syndromeFOR SALE in Scotland: OR aDISTRIBUTION case-control study. J Pediatr. ReferenceNOT Study FOR Group: SALE WHO OR child DISTRIBUTION growth standards. 2005;147(1):32-37. Geneva: World Health Organization; 2006. http://www Tarang G, Anupam V. Incidence of vesicobullous and erosive dis- .who.int/childgrowth/standards/en orders of neonates. J Dermatol Case Rep. 2011;5(4):58-63. Yalçin SS, et al. Why are they having infant colic? A nested case- ten Dam E, et al. Age of diagnosis and evaluation of conse- control study. Paediatr Perinat Epidemiol. 2010;24(6):584-596. © Jones & Bartlettquences Learning,of submucous cleLLC palate. Int J Pediatr Otorhino©- JonesZuniga & BartlettR, Nguyen T.Learning, Skin conditions: LLC common skin rashes in NOT FOR SALElaryngol OR. June DISTRIBUTION 2013;77(6):1019-1024. NOT FORinfants. SALE FP OREssent DISTRIBUTION. 2013;407:31-41.

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