Healthy Baby Practical advice for treating newborns and toddlers.

Simple Checklist for the Full- Term Healthy Newborn Visit Stan L. Block, MD, FAAP

hen I am in the nursery dis- kind of event for which child protective Pacifiers cussing routine newborn services have been known to remove Although controversial, these can ac- Wcare with postpartum moth- babies from households. Also, creating tually be a soothing tool, as most babies ers, I run through a list of pertinent the baby “pillow fortress” is too risky, want more nonnutritive sucking than advice that I have developed over the as I recently explained to my daughters, the typical 7 to 10 minutes they get per years. The clinician may find the entire both of whom were new . Like- feeding. Pacifiers sure make life easier article of my essential tips helpful to use wise, I would advise to never leave a if you have a temperamental baby (per- or distribute in their own practice. baby alone high up on a changing table, sonal experience). Early pacifier use bed, sofa, etc., at any age. may reduce the risk for SIDS and likely TIPS FOR MOMS OF NEWBORNS To help condition your baby, lay her improves rates of breast-feeding.1 ‘Back’ to Sleep/Preventing Crib Death down while she’s still partially awake. A newborn should sleep on his back Breast-feeding only; no side or prone sleeping. Never Breast-feeding is the best for your let your baby sleep in your bed, espe- Bottle-fed and breast-fed baby, but pace yourself — too much too cially during the first 4 months of life babies only require small soon can create unnecessary discomfort. when the risk for sudden death By gradually increasing the feeding du- syndrome (SIDS) is many-fold higher. volumes of milk the first 3 ration during the first week, then some- Cosleeping with an older infant/child days of life. what more during the next few weeks, is also fraught with repercussions, such your breasts will have a better chance to as poor sleep for all, and in my clinical acclimate to the increasing vigorousness experience, inevitable marital discord. This will help her learn that being held of nursing. Bottle-fed babies only eat 1 Additionally, as early as 2 weeks, co- is not essential to fall sleep. Rocking the to 1 1/2 ounces per each feeding over sleeping babies are at significant risk for baby completely to sleep will usually the first few days. A breast-fed baby falling out of your bed at night (particu- become a nightly ritual that is traumatic only eats about 1/2 to 3/4 of an ounce larly if you get up to use the bathroom, to break. Sleep comes much easier for per breast per each feeding for the first even for just a few minutes) and fractur- all, if the baby eventually learns to “self- few days.2,3 Thus, both the bottle-fed and ing a major long bone or skull, just the soothe” at night. breast-fed baby only require small vol- Your baby’s crib mattress should be umes of milk the first 3 days of life. Stan L. Block, MD, FAAP, is Professor of Clinical somewhat firm with a touch of cushion- During the first 3 to 5 days of your , University of Louisville, and University of ing. Avoid blankets and pillows inside baby’s life, the milk you are producing Kentucky, Lexington, KY; President, Kentucky Pedi- the basinet or crib, etc., as these may in- is called “colostrum.” The “pins and atric and Adult Research Inc.; and general pediatri- crease the risk for crib death. needles” feeling of the breast “letdown cian, Bardstown, KY. Address correspondence to Typically, the room temperature for a reflex” usually occurs after 3 to 5 days. Stan L. Block, MD, FAAP, via email: [email protected]. sleeping baby should be less than 77°F. Not every experiences it, but if Dr. Block has disclosed no relevant financial re- Another way to gauge it is that the room you do, it is a very reassuring sign that lationships. should be comfortable enough for a par- your milk production will be adequate. doi: 10.3928/00904481-20120625-04 ent wearing light-weight clothing. After the fifth day, your full milk sup-

270 | Healio.com/Pediatrics PEDIATRIC ANNALS 41:7 | JULY 2012 Healthy Baby Image courtesy of Stan L. Block, MD. Figure 1. Be aware of the need to increase the bottle nipple size as the baby grows. ply comes in. At each feeding, about close relatives or friends who have suc- as long as you are mostly breast-feeding. 80% of the milk you produce in the first cessfully breast-fed. A recent report has documented that 5 minutes is the “fore milk,” which is Try to avoid all baby bottles until the breast-feeding mothers may safely in- lower in calories than the nutrient- and second week of life at the earliest. Oth- gest some caffeine while nursing, so feel fat-enriched “hind milk” that is deliv- erwise, your baby may refuse to breast- free to enjoy some daily coffee or tea. ered in the next 4 to 5 minutes. Thus, al- feed due to the slower flow of your milk. lowing your baby to nurse for more than Bottle Feeding 8 to 10 minutes on a single breast during Breast Care for Nursing Mothers Boiling or sterilizing bottles for for- the first week is probably unnecessary, Some experts suggest that mula feeding is unnecessary; wash your since you will not actually produce any caused by nursing may be alleviated by baby’s bottles the same way you would additional milk for the baby, but might applying warm, wet tea bags (due to tea’s your dinner dishes. Mixing tap water cause yourself unnecessary nipple pain.4 tannic acid) to the nipples. Some women with powder or concentrate formula is To avoid this, the most common reason may also find nipple pain relief by using acceptable. But if you instead choose to for breast-feeding discontinuation, try soft silicone nipple shields. Also, try fre- use bottled water products for mixing to limit nursing during the first week to quently changing the angle at which you formula, be sure to specifically purchase feeding intervals of 2.5 to 4 hours for 8 hold your child while he nurses. the “nursery water” formulations, which to 10 minutes on each breast. Routinely apply medical grade lano- have some fluoride supplementation. Be aware that during the first 24 lin cream or emollients to your nipples Introduction of an extra few ounces of hours of life, many babies are so sleepy after every feeding. Do not routinely water alone after the first week is fine. that they may eat very poorly. This com- use soap to clean the nipples; just rinse Be aware of the need to change nipple mon pattern can be extremely stressful, them with warm water. For sore, cracked sizes as the infant grows, as the size of especially for the first-time mother. The nipples, consult your doctor. the nipple controls the amount of formu- mother may think that her breasts are Ensure that the baby is properly la your baby receives with each feeding producing inadequately. However, after latched on to the areola, and that the ba- (See Figure 1). 24 hours, the baby will become more by’s suction is removed by your finger, alert and eat more. So, be patient with before latching off. Growth Spurts the breast-feeding process during the The breast-fed baby needs extra daily Nearly all full-term will ex- first few days of life. vitamin D (preferably the much more perience a growth spurt at about 2, 6, During the first few weeks, it may palatable “Just D” formulation available and 12 weeks of life. This can be alarm- also help tremendously to read books at most drug stores or Amazon.com) af- ing because it will seem as though your about breast-feeding or to talk with any ter the first week. Administer 1 cc daily baby’s appetite is almost insatiable, as

PEDIATRIC ANNALS 41:7 | JULY 2012 Healio.com/Pediatrics | 271 Healthy Baby Images courtesy of Stan L. Block, MD, FAAP. Figure 2. Newborn with flammeus nevus on the Figure 3. Two-day old infant with milia rubra. nape of the neck. One third of white newborns will have a flammeus nevus (“stork bite”).

he demands more quantity and higher Scalp Care sures will usually prevent the wet, putrid frequency of feedings for nearly a full The small “soft spot” on the top of the cord smell. week. The baby is experiencing a tem- head, called the “fontanel,” is where the porary increased need for more calories boney plates of the baby’s head remain Genitalia to grow. No need to start cereal yet. open to allow the large amount of brain Boys growth during the first years of life. This If your male infant is circumcised, Bowel Movements and Urination is a normal feature. The fontanel usually apply to the wound af- The baby usually has one or two closes after about 9 to 18 months. Do not ter every change. If uncircum- stools per day in the first 2 days. After be afraid to scrub this area gently with cised, leave it alone; do not try to forc- that, the infant typically will produce baby along with the rest of the ibly retract the foreskin. Circumcision three to eight stools per day, with the scalp several times weekly. is mostly a personal, social, or religious breast-fed infant likely having at least If your baby’s scalp is scaly or he choice, although much data support one bowel movement per every feed- has developed orange plaques of “cradle its benefits in reducing early urinary ing. This frequency is usually a good cap,” I suggest shampooing the scalp tract infections and in later life, some indicator of adequate milk intake for daily with baby shampoo, but twice sexually transmitted infections such as the bottle-fed or breast-fed infant. The weekly substituting a shampoo HPV, HIV, syphilis, and possibly oth- appearance of healthy stools may range that contains sulfide. ers. About one-quarter of circumcised from soft, seedy, to watery; they may be infants will develop some form of mild any color — even green — but not red or Umbilical Cord Care scar tissue at the head of the penis; this bloody. If that happens, time to call the About three to four times daily, use is easily removed, but only by your pe- pediatrician. By 1 week, more than six a cotton swab to apply rubbing alcohol diatrician when your baby is at least 2 wet daily is typical. under and between the cord and the skin months old. Hard balls of stool or bowel move- until the cord falls off. This will occur ments less frequently than every 48 somewhere between 2 and 10 weeks. Girls hours probably indicates constipation. Do not give your baby a full, immersion A thick, white vaginal discharge is In that case, contact your pediatrician. bath until the cord falls off. These mea- common for several months after birth.

272 | Healio.com/Pediatrics PEDIATRIC ANNALS 41:7 | JULY 2012 Healthy Baby

SIDEBAR Newborn Checklist

 Car seat  SIDS prevention  Constipation  Head • Sleep position • Baby laxative • Cradle cap • No co-sleeping (glycerin suppository) • • Falling out of bed  Parental vaccines • Soft spot • Crib mattress/no blankets • TDaP • Pacifier  Fingernails • Flu • Emery board  Breast feeding  Umbilical cord care • 1st 24 hours are slow  Skin • Alcohol/cotton swab • Pace: 7 to 10 minutes per breast • Peeling • Timing • Lanolin creams • Lotions to dry spots • Sponge bath • Nipple shield (avoid lavender/tea tree oil)  Follow-up • Medications and caffeine  Skin findings • Post-hospital • Stool frequency • Jaundice • Jaundice  Formula/Bottle • Avoid crowds  Genitalia • No boil • Extra help • Boys: circumcision? • “Nursery” water (circumcision care)  Periodic breathing • Advancing nipple size • Girls: hygiene/vaginal discharge   and rarely bleeding

Source: Stan L. Block, MD, FAAP. Used with permission.

Gently wipe it off using a tissue, cotton Skin Care lian spots, hemangiomas, milia rubra, ball, or soft, damp wash cloth. Rarely, a In the first month of life, most ba- etc. (see Figures 2 and 3, page 272). The moderate amount of brief, spontaneous bies peel and molt skin, just like snakes. duration and benign nature of these find- vaginal bleeding can occur during the Apply lotion specifically to the trouble ings can be explained to you by your pe- first 2 weeks of life; this is temporary, spots – usually wrists and ankles – sev- diatrician. normal, and due to the maternal passage eral times daily. Daily application of of hormones across the placenta. Be sure emollients or skin creams may reduce Jaundice to clean between labial folds after each atopic in eczema-prone chil- In the uterus, the baby produces ex- stool. dren. However, avoid the use of “calm- tra red blood cells to carry oxygen. Af- ing creams” or any products containing ter birth, the breakdown of these extra Fingernails tea tree oil or lavender because of their red blood cells may cause an excessive Filing your baby’s fingernails with an possible connection to the development orange skin discoloration. Occasionally, emery board every few days is the pre- of gynecomastia (breast lumps). this breakdown can lead to bilirubin ferred way to trim your baby’s nails. If (jaundice level) that is too high, requir- you use nail clippers, it’s easy to acciden- Skin Marks ing treatment with special lights. Some tally clip the skin on the fingertips; chew- Frequently, children have coinciden- doctors think that exposing the baby to ing your baby’s nails off with your teeth tal, innocuous skin spots, such as nevi, indirect sunlight (never direct sunlight!) can transmit staph or herpes infections. flammeus nevus (“stork bite”), Mongo- from a window may occasionally help

PEDIATRIC ANNALS 41:7 | JULY 2012 Healio.com/Pediatrics | 273 Healthy Baby

reduce the levels of jaundice. A heel- ceive the advice and help of a seasoned your pediatrician if the problem seems stick on the day of discharge from the mother. Asking the baby’s father to help excessive or the baby seems constantly hospital is commonly performed to de- you by changing and holding the baby fussy. termine the blood bilirubin level. Call when you need a break also gives father your pediatrician if your baby starts to and child a chance to bond. Swaddling look like a little bronzed sun-god in the Many tempermental babies respond to first few weeks. Newborn Tests swaddling, or tight blanket wrapping, of Heel-stick metabolic testing is per- the upper body. However, do not swaddle Preventing Infections formed on all newborns. Your pediatri- the legs, as this may be associated with Crowds are best avoided during the cian will call you with the results within hip dislocation. first 2 months of your baby’s life. A new- about 2 weeks. A pulse oximeter via a born with a fever is a ’s — and pe- probe is usually performed at 24 to 48 REFERENCES diatrician’s — nightmare. Contact your hours of life to screen for some serious 1. Kair L, Phillipi C. Increase in supplemental pediatrician immediately if your newborn lung and heart diseases. formula feeds observed following removal of develops a fever more than 100.5°F. pacifiers from a mother baby unit. Presented Periodic Breathing at: Pediatric Academic Society Annual Meet- Parental Vaccines In the first months of life, nearly all ing; April 30, 2012; Chicago, IL. 2. Howie PW, McNeilly AS, McArdle T, et al. Both should be vaccinated babies will have periods when they ac- The relationship between suckling induced with annual flu vaccines during the tually stop breathing for nearly 5 to 10 prolactin response and lactogenesis. J Clin season, and with TDaP (especially the seconds. The baby will then progress Endocrinol Metab. 1980;50:670. 3. Lucas A, Lucas PJ, Baum JD. Differences mother after 20 weeks of gestation but into a pattern of more rapid breathing for in the pattern of milk intake between breast before delivery to best protect the baby). 30 or so seconds. This breathing cycle and bottle fed infants. Early Human Dev. often repeats itself and is totally normal. 1981;5:195. 4. Neville MC. Determinants of milk volume and Cabin Fever However, a baby who stops breathing for composition. In Jensen RG, ed. Handbook of If allowed by your obstetrician, tak- more than 20 seconds or develops any Milk Composition. San Diego, CA: Academic ing short walks several times a week persistent blue color of the lips is cause Press; 1995. postpartum can help alleviate the stress for alarm. You should contact your doc- of round-the-clock caring for a newborn. tor or emergency services immediately. RECOMMENDED READING Especially for first-time mothers, Meek JY, ed. New Mother’s Guide to Breast Feeding, second edition. Elk Grove Vil- having a grandmother stay with you in Spitting Up lage, IL:American Academy of Pediatrics; the first weeks of a newborn’s life is usu- Nearly all babies spit up or regurgitate 2012. ally an excellent way to ensure you can some feedings. Even vomiting an entire Shelov SP, ed. Your Baby’s First Year, third take a break when you need one, and re- feeding once a day is common. Contact edition. Elk Grove Village, IL: American Academy of Pediatrics; 2010.

274 | Healio.com/Pediatrics PEDIATRIC ANNALS 41:7 | JULY 2012 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.