LITTLE THINGS LITTLE THINGS M MMY SHOULD KNOW SHOULD KNOW Issued in the public interest. Pfizer Limited. The Capital, 1802/1901, Plot No. C-70 G Block, Bandra-Kurla Complex September 2020 Bandra (East), Mumbai 400 051, India. nd POST Disclaimers: 1. This booklet content is issued by Pfizer in public interest. 2. The content of this booklet is meant for informational and awareness purpose only and should not be construed as a substitute for medical advice. 3. Consult your NATAL pediatrician for guidance on the information stated herein or further information on the subject. 4. While due care and caution has been taken to ensure that the content here is free from mistakes or omissions, Pfizer makes no representations CARE or warranties of any kind, expressed or implied; as to the accuracy, completeness or adequacy of its contents and will not

be liable for any damages, adverse events, and personal liability arising therefrom. PP-PNP-IND-0421, 22 Images for representation purpose only LITTLE THINGS M MMY SHOULD KNOW

CONTENTS

New Mom 04

Pregnancy is a time of great happiness for any couple. Your New-born 09 Every wishes to do everything possible to ensure a smooth pregnancy and a healthy baby and How to Breastfeed 14 . However, it is also a time when you are full of questions. It is important to follow your judgement - Are You Finding It Di cult? 21 along with the doctor's advice to keep an eye out for any problems occurring during pregnancy. Growth Chart and Baby Development 23

Shield Your Baby 32 POST NATAL CARE

NEW MOM b. Using the washroom • In case of di culty in passing urine, contact your doctor. Becoming a mother is an emotional and life altering experience. For many • Eat a balanced diet and drink plenty of water to prevent constipation. , the excitement and joy of holding the new baby far outweighs the c. Bleeding challenges that taking care of a newborn • Initially, bleeding continues for the next few days after brings. . This is normal and termed as lochia. However, as a new mom, there are a few • The lochia changes from red to white in color in 2-3 weeks, essential aspects that one must know to reduces in quantity and eventually stops. enter smoothly this new phase of life. • Do not use tampons for this as they can cause infections. • Losing blood in the form of large clots needs medical attention. Things One Must Know Before Leaving • If the bleeding starts to increase again, then report this to the Hospital your doctor. • On noticing any of these signs or symptoms, immediately a. Care of stitches contact the nearest doctor or gynaecologist. • In case the stitches are sore and uncomfortable, contact your doctor.

Pain in the lower abdomen Shortness of breath

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a. Diet Eat a varied, healthy and balanced diet. • Have lots of water before and after feeding

c. Foods to avoid Excess vaginal bleeding Fainting • Avoid too much caeine i.e. strong tea • or coee, energy drinks, etc.

Blurry vision References:

1. The pregnancy book. London, UK: Department of Health, NHS;2009. [Internet] Available at: https://www.stgeorges.nhs.uk/wp-content/uploads/2013/11/ Pregnancy_Book_comp.pdf. CHANGES IN LIFESTYLE Accessed on: 25.09.20. 2. My safe motherhood- booklet for expecting mothers. National Health Mission. India; The introduction of a new baby demands a drastic change in a Ministry of Health and Family Welfare. [Internet] Available at: new mom's lifestyle especially in the initial weeks as the baby http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/my_safe_motherhood will need most of the mother's attention. _booklet_english.pdf. Accessed on: 25.09.20. 3. Dietary guidelines For Indians- A manual. National Institute of Nutrition; Hyderabad, India. 2nd Ed.2011.[Internet] Available at: http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf. Accessed on: 25.09.20.

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YOUR NEW BORN • Immediately after birth, the baby is transferred onto the mother's , to develop skin-to-skin contact & bond with the mother. Newborns rapidly learn to co-ordinate sucking Do you know about and breathing in the first few days of life. This also helps in Pneumococcal disease? early secretion. • The baby is dried and wrapped at birth and covered, especially the head and feet.2 Yes No • The baby must pass first stools within the first 24 hours and first urine within the first 48 hours itself. • Interact with the baby as every moment the baby is learning from the mother. Ask your pediatrician about Pneumococcal disease and • Never place the child on the side, which Pneumococcal vaccine is right for your child. always place it on the back so that it doesn't choke. • Nothing should be applied on the Choose Wisely umbilical cord stump.

Pfizer Limited. The Capital, 1802/1901, Plot No. C-70, G Block, Bandra-Kurla Complex, Bandra (East), Mumbai 400 051, India.

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CHANGES OCCURRING IN YOUR BABY'S d. Baby cry BODY AFTER BIRTH Check for these reasons - hunger, temperature not tolerable, tired and not able to sleep, lonely wanting company, bored and wants to , wet , gas, colic or fright. a. Urine 2-3 wet nappies are seen in the first 48 hours. After day 5, there will be at COMMON PROBLEMS IN A NEWBORN least 6 wet nappies every 24 hours. b. Weight COLIC JAUNDICE DIARRHEA/ BLEEDING Initially, most babies lose weight up to Excessive crying, Is common at VOMITING Look out for any day 3 to 5. Babies start gaining weight but otherwise three days age. Substantial part bleeding either thriving baby, from the stump after that, and the is Causes of feeds are may be having of the umbilical discoloration of thrown up or regained in the first 2 weeks naturally. a colic. cord or from skin and eyes to there is watery the nose. c. Stools The baby has no yellow color. diarrhea for over feeding issues 2 weeks, it It might take 10 or Initially, black tar-like stool (poop) is passed by the baby called and gains weight indicates that more days to meconium. Around day 3, stools change to lighter, greenish, normally. the baby is and runnier stools, which are easy to clean. The baby should resolve. losing too Upsetting for Severe cases much fluid. pass at least two yellow stools from the 4th day till the first few . weeks. (continues for Needs prompt It can last for over two weeks), treatment. some weeks. need light therapy.

Brown Green Yellow please consult your doctor if you notice any of these problems.

Black Grey or white Red or Blood stained 10 11 POST NATAL CARE

PROBLEMS REQUIRING IMMEDIATE MEDICAL ATTENTION

On seeing any of these signs in your baby, immediately contact a pediatrician. • Baby crying for hours continuously,1 or in an unusual manner Do you know about • Baby turning blue or very pale,1,2 or yellow Pneumococcal vaccines? • Breathing is quick, di cult or grunting or unusual periods of breathing • Baby is unusually drowsy or doesn't seem to recognize you Yes No • A rash which does not fade and1 blanch when pressed • Loose motions

Spend some time with your pediatrician discussing vaccines against References: Pneumococcal disease. 1. The pregnancy book. London, UK: Department of Health, NHS; 2009. [Internet] Available at: https://www.stgeorges.nhs.uk/wp-content/uploads/2013/11/Pregnancy_Book_comp.pdf. Accessed on: 25.09.20. Choose Wisely 2. My safe motherhood- booklet for expecting mothers. National health Mission. India; Ministry of Health and Family Welfare. [Internet] Available at: ttp://nhm.gov.in/images/pdf/ programmes/maternal-health/guidelines/my_safe_motherhood_booklet_english.pdf. Accessed on: 25.09.20.

Pfizer Limited. The Capital, 1802/1901, Plot No. C-70, G Block, Bandra-Kurla Complex, Bandra (East), Mumbai 400 051, India.

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HOW TO BREASTFEED COLOSTRUM One must feed immediately after birth, within the 1st hour, in the delivery room itself by the breast crawl method. Benefits to Benefits to Benefits to family and the baby ontains Mother society COLOSTRUM Before milk flows from a new mom's , the thick and yellowish breast 2 milk, which is secreted in the first 2-3 days is called colostrum. This 'first milk' protects the new born from • Complete food, • Saves money • Helps in involution species specific of uterus infections as it contains high concentration of protective • Promotes family immunoglobulins and white blood cells. Do not discard the • Easily digested planning • Delays pregnancy and well absorbed colostrum. • Decreases need • Lowers risk of breast • Protects against for hospitalization and ovarian cancer infection • Contributes to • Decreases mother's • Promotes emotional child survival work load boanding • Better brain growth

Helping a Mother to Breastfeed

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HOW LONG SHOULD ONE BREASTFEED, AND WHEN TO INTRODUCE OTHER FOODS? The World Health Organization (WHO) recommends exclusive breastfeeds for the first 6 months of life. a. should receive complementary foods with continued breastfeeding up to 2 years of age or beyond. b. During the 2nd year of life, one must breastfeed at least 4-6 times in 24 hours, including night feeds. LATCHING TECHNIQUES AND SIGNS OF c. One may start complementary feeding after 6 months age GOOD ATTACHMENT along with breastfeeding. a. Express a little milk on the and touch the baby's lips to it. b. Wait for the baby's mouth to open wide, with the tongue POSITIONS DURING BREASTFEEDING placed down and forward. a. Feed in a sitting or lying position. c. Quickly move the baby onto the breast, with the b. Clean the hands and breasts before each feed. towards the baby's palate and the lower lip well below the nipple. c. The baby's head should always be supported by the mother's forearm and hands; the baby's head and body d. The baby should take many slow deep sucks before should be straight. swallowing, and then pause. d. Using the first finger, support the breast with the thumb e. Feed the baby on one breast, then switch to the other, after above the (pigmented area around the nipple). Do he/she leaves the nipple on his own. not keep the fingers near the nipple as this may suocate the baby.

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CHECKING THAT THE BABY IS RECEIVING ADEQUATE MILK The baby is receiving adequate milk supply if it does the following: • Passes urine 6-8 times in 24 hours • Sleeps for 2-3 hours after a feed Good Attachment Poor Attachment • Gains adequate weight FREQUENCY OF FEEDING References: One must breastfeed only whenever the baby is hungry and 1. My safe motherhood- booklet for expecting mothers. National Health Mission. India; gives cues. This is called on-demand breast feeding. One may Ministry of Health and Family Welfare. [Internet] Available at: feed the baby at least 8-10 times in 24 hours. More http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/my_safe_motherhood _booklet_english.pdf. Accessed on: 25.09.20. is produced if the baby is frequently breastfed. 2. Resource document on newborn and neonatal care of children: A report. New Delhi, India; 2016. National Institute of Public Cooperation and Child Development. [Internet] Keep a time interval of 2 to 3 hours between each feed. Ensure Available at: http://nipccd.nic.in/reports/neo.pdf. Accessed on: 25.09.20. that night feeds are not vomited. 3. World Health Organization. Nutrition. Breastfeeding. Available at: https://www.who.int/ nutrition/topics/exclusive_breastfeeding/en/ Accessed on: 25.09.20.

BREAST FEEDING EARLY CUES: • Rapid eye movement LATE CUES: • Sucking movements and sounds • Cooing • Lip smacking • Sighing • Restlessness • Crying • Licking the hand

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BREASTFEEDING - ARE YOU FINDING IT DIFFICULT? The new born has an inborn sucking reflex that helps it suck. Is your child vaccinated Here are some common di culties a new mom might face and against Pneumococcal tips to overcome them. diseases? LATCHING DIFFICULTIES Common causes include feeding bottles, lack of experience and skilled support. This results in painful, damaged or sore nipple, swollen breast, insu cient breast milk production Yes No leaving the unsatisfied. Inverted or flat nipples, sore nipples, engorged breast and breast abscess are common conditions that a new mom might experience. An obstetrician can help you treat these and continue feeding the baby. Common causes of lack of milk production include too short, infrequent or hurried breastfeeding practice; poor position; breast engorgement or .Other common problems Ask your pediatrician include too much or too little milk, mastitis (breast inflammation), which Pneumococcal vaccine is right and blocked milk duct for which you must visit an obstetrician.2 for your child Choose Wisely References: 1. Resource document on newborn and neonatal care of children: A report. New Delhi, India; 2016. National Institute of Public Cooperation and Child Development. [Internet] Available at: http://nipccd.nic.in/reports/neo.pdf. Accessed on: 25.09.20. 2. Breastfeeding problems. Your pregnancy and baby guide. London, UK: Department of Pfizer Limited. The Capital, 1802/1901, Plot No. C-70, G Block, Bandra-Kurla Complex, Bandra (East), Mumbai 400 051, India. Health, NHS; 2016. [Internet] Available at: https://www.nhs.uk/conditions/ pregnancy-and-baby/problemsbreastfeeding/? Accessed on: 25.09.20.

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GROWTH CHART AND BABY Do you know which Pneumococcal DEVELOPMENT vaccine provides broad Growth monitoring of a child should be carried out once every month, up to the age of 3 years using a growth chart. coverage against Thereafter, it should be done at least once in 3 months. Pneumococcal disease? WHAT IS A GROWTH CHART? The growth chart records weight up to 5 years and is based on Yes No World Health Organization (WHO) Child Growth Standards. Pink and blue colored growth charts are used for girls and boys, respectively. The printed growth curves on each growth chart act as reference lines, to compare and understand the growth pattern. A point is marked on the chart at the appropriate age each time the child is weighed, indicating the weight at that time. Joining many points gives a growth curve. This signifies Spend some time with your the growth pattern of the child over a period of time. The table pediatrician discussing vaccines against below shows the types of growth patterns. pneumococcal disease. Choose Wisely

Pfizer Limited. The Capital, 1802/1901, Plot No. C-70, G Block, Bandra-Kurla Complex, Bandra (East), Mumbai 400 051, India.

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Table: 1 Types of growth curves and their significance Direction of Growth Growth Pattern Curves Downward Growth Very dangerous Curve Indicates loss of weight. The child requires immediate referral and health care.

NORMAL WEIGHT GAIN BETWEEN 0 TO 3 YEARS OF AGE

Average Age Weight Gain Per Month Birth to 2 months 800 gm 3 to 4 months 600 gm Table: 1 Types of growth curves and their significance 5 to 6 months 400 gm Direction of Growth Growth Pattern Curves 7 to 3 years 200 gm Upward Growth Curve Good Indicates adequate weight gain for the age of the child. The child is growing well Birth weight should double by 5 months and be triple by the 1st and is healthy. year. By the 2nd year, weight should be 4 times the birth weight Flat Growth Curve Dangerous with an increase in 1 height by 7-8 cm. Indicates that the child has not gained weight and is not growing adequately. This is called stagration. The child needs attention by the mother. This needs to be investigated Table contd... 24 25 POST NATAL CARE

DEVELOPMENTAL MILESTONES IN A CHILD Developmental milestones are classified based on age groups as illustrated in the table below.

Age Social/ Communication Cognitive Physical emotional development development (learning, Physical thinking, problem- solving) 0 month 1 2 3 4 5 6 2 Months Communication • Makes gurgling • Observes faces • Head holding people, looks at sounds/coos • Starts following • Movements parents • urns head things with eyes turn smoother with arms legs

4 Months • Likes playing • Babbles with • Responds to • Holds head with people expression aection and steady • Starts copying and copies starts watching unsupported movements & sounds faces closely 6 month 7 8 9 10 11 12 • Rolls over facial • Learns • Eye movements from tummy to expressions, dierent ways from side to back like smiling or of crying to side • Brings hands frowning show hunger, • Recognizes to mouth pain, or being familiar people tired and things at a distance 6 Months • Recognizes a • Makes sounds • Looks around at • Rolls over in stranger • Strings vowels things nearby both directions, • Responds to and begins to • Brings things to sits without emotions say consonants mouth support and crawls • Looks in a • Makes sounds • Shows curiosity backward mirror to express • Passes things emotions • Supports from one hand weight on legs to the other while standing • Rocks back and forth Table contd...

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Age Social/ Communication Cognitive Physical Age Social/ Communication Cognitive Physical emotional development development emotional development development (learning, (learning, Physical Physical thinking, thinking, problem- problem- solving) solving) 9 Months • Stranger • Understands • Plays • Pulls to stand 18 Months •Hands over • Says many • Understand • Walks alone, anxiety “no” peek-a-boo by things single words things like can words • Clingy with • Makes and • Puts things in • Sits without • Shows temper • Says and telephone, walk up steps familiar adults copies her mouth support tantrums shakes head brush, spoon, and run etc. • Has favorite dierent • Smoothly • Crawls • Afraid of “no” • Pulls toys toys sounds like passes things strangers • Points to show • Points to get the while “mama” and from one hand Shows someone what attention of walking baba to the other aection to he wants others • Can help • Starts finger • Thumb and familiar people • Scribbles on his undress pointing index finger • Plays simple own herself movements pretend, such • Can follow • Drinks from a as feeding a 1-step verbal cup doll commands 12 Months • Shows • Responds to • Exploring things • Gets to a • Eats with a dierent simple spoken by shaking, sitting spoon emotions banging, position • Simple 2 Years Copies others • Says sentences • Finds things • Stands on • Parent gestures used, throwing without help • Gets excited with 2 to 4 even when tiptoe attachment shaking head, • Finds hidden • Pulls up to words deeply hidden waving things easily, stand, walks with other • Walks up and • Helps with children • Follows simple • Shapes and down stairs dressing • Tone puts things in holding on to container furniture • Shows instructions colors holding onto it • Repeats modulation orientation • Pointing at right (“cruising”) increasing • Repeats • Kicks, throws a sounds or • Says “mama” independence overheard • Completes ball and runs actions to get and “dada” and things • May take a few steps without • Shows words sentences and • Climbs without attention “uh-oh!” • Copies gestures rhymes Learns proper holding on defiance • Points to things help on • Tries to say in a book • Follows furniture words you say use of things • May stand alone two-step • Makes or instructions copies straight Table contd... lines and circles Table contd...

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Age Social/ Communication Cognitive Physical emotional development development (learning, Physical thinking, problem- Did you know that the best way to solving) 3 Years • Makes friends • Follows • Can work toys • Climbs well prevent Pneumococcal disease is to • Takes instructions etc. • Runs easily ownership • Converses in 2 • Understands • Pedals a get the vaccine(s)? • Shows many to 3 sentences what “two” tricycle(3-whe emotions • Says first means el bike) • Can stay name, age, and • Turns book • Walks up and without mom sex pages one at a down stairs, and dad • Names a time one foot on • Self dressing friend, familiar • Can open and each step things close bottles Yes No • Talks well enough for strangers to understand

Ask your Pediatrician References: which Pneumococcal vaccine is right 1. Resource document on newborn and neonatal care of children: A report. New Delhi, India; 2016. National Institute of Public Cooperation and Child Development. [Internet] for your child Available at: http://nipccd.nic.in/reports/neo.pdf. Accessed on: 25.09.20. 2. Milestone checklists. USA; Division of Birth Defects, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention. 2018. [Internet]. Choose Wisely Available at: https://www.cdc.gov/ncbddd/actearly/pdf/checklists/all_checklists.pdf. Accessed on: 25.09.20.

Pfizer Limited. The Capital, 1802/1901, Plot No. C-70, G Block, Bandra-Kurla Complex, Bandra (East), Mumbai 400 051, India.

30 31 POST NATAL CARE SHIELD YOUR BABY VACCINATION SCHEDULE VACCINES – WHAT THEY ARE, HOW THEY WORK, HOW Here is the list of recommended vaccines by the Indian LONG THEY HELP Academy of for children up to 12 years. Indian Academy of Pediatrics schedule for children aged 0-12 years, 2018-2019

Age (completed Sr. No Vaccines weeks/months/years)

1. Birth BCG, OPV0, Hep-B1

2. 6 weeks DTwP1/DTaP1, IPV1 (or bOPV1 and ID-fIPV1) Hep-B2, Hib1, Rotavirus 1, PCV1

3. 10 weeks DTwP2, Hepatitis B3, IPV2 (or bOPV2), Hib2, Rotavirus 2, PCV2 4. 14 weeks DTwP3, Hepatitis B4, IPV3 (or bOPV3 Vaccines are made from the infection-producing microbe itself and ID-fIPV2), Hib3, Rotavirus 3, PCV3 by certain chemical processes. They make the body produce 5. 6 months Influenza vaccine antibodies against the germ. In the future, if the baby comes in contact with the disease, his immune system will quickly 6. 6 months onward TCV recognize it and produce antibodies to fight it o. 7. 9 months MMR1/MR 8. 12 months Hep A1 9. 15 months MMR2 Varicella 1 PCV booster DTwP B1/DTaP B1, IPVB1 9. 16-18 months (or bOPV B1) Hib B1 10. 18 months Hep A2 11. 2 years or more Typhoid polysaccharide vaccine

12. 4–6 years DTwP B2/DTaP B2, MMRV or MMR3 + Varicella 2 13. 9–12 years Tdap/Td, HPV

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BCG: Bacillus Calmette–Guérin. OPV: oral poliovirus vaccine. Hep B: Hepatitis B. DTwP: diphtheria, tetanus and whole-cell pertussis. DTaP: diphtheria, tetanus and acellular pertussis. DTP: diphtheria, tetanus toxoids and pertussis. IPV: inactivated polio vaccine. bOPV: bivalent oral poliovirus vaccine. ID-fIPV: intradermal fractional oral poliovirus vaccine. PCV: pneumococcal conjugate vaccine. SIA: supplemental immunization activity. IM: intramuscularly. RV: rotavirus vaccine. BRV-PV: bovine-human reassortant pentavalent rotavirus vaccine. IIV: inactivated influenza vaccine. TCV: typhoid conjugate vaccine. MMR: measles, mumps, and rubella. MR: Measles-rubella. MMRV: measles, mumps, rubella, and Choose to protect your varicella. Tdap: diphtheria toxoid and acellular pertussis. Td: tetanus and diphtheria. HPV: human papillomavirus. IAP: Indian Academy of Pediatrics. child with a broad coverage vaccine

Pneumococcal disease can infect the lungs, the middle ear and the bloodstream. However, this can be prevented with appropriate † vaccination. Speak to your paediatrician about vaccination that provides broad coverage.

Choose Wisely

Reference:

1. The Indian Academy of Pediatrics. IAP Guidebook on Immunization 2018-2019. Available at: https://iapindia.org/pdf/124587-IAP-GUIDE-BOOK-ON-IMMUNIZATION-18-19.pdf Pfizer Limited. The Capital, 1802/1901, Plot No. C-70, G Block, Bandra-Kurla Complex, Bandra (East), Accessed on: Oct. 1, 2020. Mumbai 400 051, India.

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