BABY'S CARE AFTER A CESAREAN DELIVERY

If your baby is born by a cesarean delivery, chances are good that you can be awake for the surgery. Only in rare situations will a mother require general anesthesia for delivery. This means she is not conscious for the birth. Most cesarean deliveries today are done with a regional anesthesia such as an epidural or spinal. With this type of anesthesia, only part of the body is numbed for surgery. The mother is awake and able to hear and see her baby as soon as he/she is born. Babies born by cesarean are usually checked by a nursery nurse or pediatrician right after delivery. This is often done right near you in the operating room. Because babies born by cesarean may have difficulty clearing some of the lung fluid and mucus, extra suctioning of the nose, mouth, and throat are often needed. Occasionally, deeper suctioning in the windpipe is required. Once a baby is checked over, a nurse will wrap the baby warmly and bring the baby to you to see and touch. In some cases, babies born by cesarean will first need to be watched in the nursery for a short time. All of the usual procedures such as weighing and medications are performed there. Usually, your baby can be brought to you while you are in the recovery area after surgery. Many mothers think that they will not be able to breastfeed after a cesarean delivery. This is not true. Breastfeeding can begin in the first hours right in the recovery room, just as with a vaginal delivery. Plan to have someone stay with you during your hospital stay after a cesarean delivery. You will have quite a bit of pain in the first few days and will need help with the baby.

BABY'S CARE AFTER A VAGINAL DELIVERY

Healthy babies born in a vaginal delivery are usually able to stay with the mother. In many cases, immediate newborn assessments including weight, length, and medications, and even the first bath are performed right in the mother's room. As quickly as possible, a new baby is placed in the mother's arms. In the first hour or two after birth, most babies are in an alert, wide awake phase. This offers a wonderful opportunity for parents to get to know their new baby. A baby will often turn to the familiar sound of the mother's voice. A baby's focus of vision is best at about eight to 12 inches - just the distance from baby cradled in a mother's arms to her face. This is also the best time to begin breastfeeding. Babies have an innate ability to begin nursing immediately after they are born. Although some medications and anesthesia given to the mother during labor and delivery may affect the baby's sucking ability, most healthy babies are able to breastfeed in these first few hours. This initial feeding helps stimulate breast milk production. It also causes contraction of the mother's uterus which can help prevent excessive bleeding.

BABY'S CARE IN THE DELIVERY ROOM

The birth of a baby is one of life's most wondrous moments. Few experiences can compare with this event. Newborn babies have amazing abilities, yet they are completely dependent on others for every aspect - feeding, warmth, and comfort.

Amazing physical changes occur with birth. When the baby is delivered, the umbilical cord is cut and clamped near the navel. This ends the baby's dependence on the placenta for oxygen and nutrition. As the baby takes the first breath, air moves into the lung airways. Before birth, the lungs are not used to exchange oxygen and carbon dioxide, and need less blood supply. The fetal circulation sends most of the blood supply away from the lungs through special connections in the heart and the large blood vessels. When a baby begins to breathe air at birth, the change in pressure in the lungs helps close the fetal connections and redirect the blood flow. Now, blood is pumped to the lungs to help with the exchange of oxygen and carbon dioxide. Some babies have excess amounts of fluid in their lungs. Stimulating the baby to cry by massage and stroking the skin can help bring the fluid up where it can be suctioned from the nose and mouth. Providing warmth for the newborn: A newborn baby is wet from the amniotic fluid and can easily become cold. Drying the baby and using warm blankets and heat lamps can help prevent heat loss. Often a knitted hat is placed on the baby's head. Placing a baby skin-to-skin on the mother's chest or abdomen also helps keep the baby warm. Immediate care for the newborn: Health assessments of the new baby begin immediately. One of the first checks is the Apgar test. The Apgar test is a scoring system designed by Dr. Virginia Apgar, an anesthesiologist, to evaluate the condition of the newborn at one minute and five minutes after birth. The physician and nurses will evaluate the following signs and assign a point value: Activity; muscle tone Pulse rate Grimace; reflex irritability Appearance; skin color Respiration A score of seven to 10 is considered normal. A score of four to six may indicate that the baby needs some resuscitation measures (oxygen) and careful monitoring. A score of 3 or below indicates that the baby requires immediate resuscitation and lifesaving techniques. Physical examination of the newborn: A brief physical examination is performed to check for obvious signs that the baby is healthy. Other necessary procedures will be done over the next few minutes and hours. These may be done in the delivery room or in the nursery, depending on several factors, including the condition of the baby. Some of these procedures include the following:

temperature, heart rate, and respiratory rate measurements of weight, length, head circumference These measurements help determine if a baby's weight and measurements are normal for the number of weeks of pregnancy. Small or underweight babies as well as very large babies may need special attention and care. cord care Cleansing of the umbilical cord stump may include treatment with a purple antiseptic dye which helps prevent infection.

bath Once a baby's temperature has stabilized, the first bath can be given. footprints Footprints are often taken and recorded in the medical record.

Before a baby leaves the delivery area, identification bracelets with identical numbers are placed on the baby and mother. Babies often have two, on the wrist and ankle. These should be checked each time the baby comes or goes from your room.

WHEN A BABY HAS DIFFICULTY AFTER BIRTH

All the baby's body systems must work together in a new way after birth. Sometimes, a baby has difficulty making the transition. Health assessments, including the Apgar test performed right after birth, can help determine if a baby is doing well or having problems. If there are signs the baby is not doing well, treatment can be given right in the delivery room. The physician and other members of the healthcare team work together to help the baby clear excess fluid and begin breathing. Babies who may have difficulty at birth include those born prematurely, those who experienced a difficult delivery, or those with birth defects. Fortunately for these babies, special care is available. Newborn babies who need intensive medical attention are often admitted into a special area of the hospital called the Neonatal Intensive Care Unit (NICU). The NICU combines advanced technology and trained healthcare professionals to provide specialized care for the tiniest patients. NICUs may also have intermediate or continuing care areas for babies who are not as sick but need specialized nursing care. Some hospitals do not have trained personnel or an NICU and babies may need to be transferred to another hospital. Having a sick baby can be distressing. Few parents expect complications with pregnancy or their baby to be sick or premature. It is quite natural for parents to have many different emotions as they try to cope with the difficulties of a sick baby. But, it is reassuring that today's advanced technology is helping sick babies get better and go home sooner than ever before. And it helps to know that although separation from a baby is painful, it does not harm the relationship between the mother and baby.

A [back to top] acne neonatorum (baby acne) - pimples on newborn skin common in the first month.

Apgar test - A scoring system to evaluate the condition of the newborn immediately after birth. areola - the pigmented (darkened) ring around each nipple. B [back to top] bilirubin - substance formed when red blood cells break down and are excreted by the liver. Too much bilirubin in the blood causes jaundice. biotinidase deficiency - an inherited disorder characterized by a deficiency of the biotinidase enzyme needed to metabolize a B vitamin. bonding - process of falling in love with a newborn baby. brachial palsy - birth injury to the nerves that supplies the arms and hands. C [back to top] candidiasis - a fungal (yeast) infection, often in the mouth, called thrush, or in the diaper area. caput - a severe swelling of the soft tissues of the baby's scalp that develops as the baby travels through the birth canal. cephalohematoma - an area of bleeding underneath one of the cranial bones that appears as raised lump on the baby's head. circumcision - a surgical procedure to remove the skin covering the end of the penis. cleft lip - an abnormality in which the lip does not completely form. The degree of the cleft lip can vary greatly, from mild (notching of the lip) to severe (large opening from the lip up through the nose). cleft palate - occurs when the roof of the mouth does not completely close, leaving an opening that can extend into the nasal cavity. The cleft may involve either side of the palate. It can extend from the front of the mouth (hard palate) to the throat (soft palate). The cleft may also include the lip. clubfoot - also known as talipes equinovarus, clubfoot is a foot deformity that is detected at birth. It affects the bones, muscles, tendons, and blood vessels and can affect one or both feet. The foot is usually short and broad in appearance and the heel points downward while the front half of the foot, or forefoot, turns inward. The heel cord (Achilles tendon) is tight. The heel can appear narrow and the muscles in the calf are smaller compared to a normal lower leg. colic - a condition in an otherwise healthy baby characterized by excessive crying. cyanosis - a blue coloring of the skin. D

[back to top] developmental dysplasia of the hip (DDH) - a condition of the hip joint that is congenital (present at birth). The hip joint is created as a ball-and-socket joint. In DDH, the hip socket may be shallow, letting the "ball" of the long leg bone, also known as the femoral head, slip in and out of the socket. The "ball" may move partially or completely out of the hip socket. diaper rash - an irritation of the skin in the diaper area. E [back to top] erythema toxicum - a common red rash on the skin of newborns. eye prophylaxis - eye drops or ointment containing an antibiotic medication that are placed in a newborn's eyes. F [back to top] facial paralysis - impairment of movement of the muscles of the face due to birth injury. G [back to top] galactosemia - an inherited disorder in which the baby is unable to metabolize galactose, a milk sugar. grunting - a sound made by a baby who is having difficulty breathing. H [back to top] harlequin color change - a normal change in a newborn baby's color due to immaturity of the circulation. homocystinuria - an inherited disorder caused by a deficiency of an enzyme necessary to digest an amino acid. hyperbilirubinemia - the build-up of bilirubin in the blood. hypoglycemia - a condition in which the amount of blood glucose (sugar) is lower than normal. hypospadias - a birth defect in which the male urethral (urine tube) opening is not located at the tip of the penis. hypothyroidism - a condition in which the baby is born with too little thyroid hormone. I

[back to top] immunization - vaccine to prevent diseases. J [back to top] jaundice - a yellow coloring of the skin and/or eyes that is caused by too much bilirubin in the blood. K [back to top] L [back to top] lactation consultant (IBCLC - International Board Certified Lactation Consultant) - a nurse or other healthcare provider specially trained to help women with breastfeeding. lanugo - soft, downy hair on a baby's body. M [back to top] maple syrup urine disease - an inherited disorder caused by an inability of the body to properly process certain parts of protein called amino acids. meconium - a sticky, greenish-black substance that forms in the intestines during fetal development and is the first bowel movement of a newborn. milia - tiny, white, hard spots that look like pimples on a newborn's nose. mongolian spots - blue or purple-colored splotches on the baby's lower back and buttocks common in dark-skinned babies. Moro reflex - Movement of arms and legs that occurs when a newborn is startled by a loud sound or movement. moulding - elongation of the shape of a baby's head due to delivery through the birth canal. N [back to top] neonatal intensive care unit (NICU) - a special care nursery that uses advanced technology and trained health professionals to care for sick and premature newborns. O

[back to top] P [back to top] phenylketonuria (PKU) - an inherited disease in which the body cannot metabolize a protein called phenylalanine. phototherapy - special lights used to treat jaundice. port wine stain - a flat, pink, red, or purple colored birthmark. Q [back to top] R [back to top] reflux - when stomach contents back up into the esophagus (the tube that connects the mouth to the stomach). REM (rapid eye movement) sleep - this is a light sleep when dreams occur and the eyes move rapidly back and forth. retracting - when the baby is pulling the chest in at the ribs with breathing. rooming-in - when mothers and newborns remain together in the same room through the hospital stay. rooting - when a newborn turns his/her head toward touch near the mouth. S [back to top] sickle cell disease - an inherited disorder that occurs primarily in African-Americans and causes a severe form of anemia. stork bite or salmon patch - small pink or red patches often found on a baby's eyelids, between the eyes, upper lip, and back of the neck. strawberry hemangioma - a bright or dark red, raised or swollen, bumpy area on the skin of a baby or child. subconjunctival hemorrhage - the breakage of small blood vessels in the eyes of a baby. sudden infant death syndrome (SIDS) - the sudden and unexplained death of an infant under 1 year of age. T

[back to top] thrush - a yeast infection in the mouth and throat of babies. transient tachypnea of the newborn (TTN) - a mild respiratory problem of babies, characterized by rapid breathing, that begins after birth and lasts about three days. tyrosinemia - an inherited disorder that causes severe liver disease in infancy. U [back to top] umbilical hernia - a weakness in the abdominal muscles. V [back to top] vernix - a white, greasy, cheese-like substance that covers the skin of many babies at birth. vitamin K - an essential component of blood clotting produced by intestinal bacteria. Babies normally have low levels of this vitamin. W [back to top] X [back to top] Y [back to top] Z [back to top]

NORMAL NEWBORN BEHAVIORS AND ACTIVITIES

It is exciting for new parents to watch their newborn's behaviors and activities. However, in some cases, the absence or presence of a behavior or activity may indicate a problem. Listed in the directory below you will find additional information regarding a normal newborn's behaviors and activities, for which we have provided a brief overview.

NEWBORN - REFLEXES

What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The following are some of the normal reflexes seen in newborn babies:

root reflex This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his/her head and open his/her mouth to follow and "root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding. suck reflex Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. Babies also have a handto-mouth reflex that goes with rooting and sucking and may suck on fingers or hands. Moro reflex The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his/her head, extends out the arms and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle him/her and begin this reflex. This reflex lasts about five to six months. tonic neck reflex When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the "fencing" position. The tonic neck reflex lasts about six to seven months. grasp reflex Stroking the palm of a baby's hand causes the baby to close his/her fingers in a grasp. The grasp reflex lasts only a couple of months and is stronger in premature babies. Babinski reflex When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age. step reflex This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his/her feet touching a solid surface.

NEWBORN - SENSES
The senses of a newborn: Babies are born fully equipped with all the necessary senses of sight, hearing, smell, taste, and touch. However, some of these senses are less precise than others. Below are some of the ways newborn babies express their senses:

vision A newborn's eyes are a little more than half the size of an adult's eyes. They grow the

most in the first year, then slowly grow until puberty. Most Caucasian babies have light gray or blue eye color, but this often changes by 6 months of age. Over the first few months, babies may have uncoordinated eye movements and may even appear crosseyed. Babies are born with the ability to focus only at close range - about 8 to 10 inches or the distance between a mother's face to the baby in her arms. Babies are able to follow or track an object in the first few weeks. Focus improves over the first two to three years of life to a normal 20/20 vision. Newborns can detect light and dark but cannot see all colors. This is why many baby books and infant stimulation toys have distinct black and white patterns.

hearing During pregnancy many mothers find that the baby may kick or jump in response to loud noises and quiet with soft, soothing music. Hearing is fully developed in newborns. Babies with normal hearing should startle in response to loud sounds, pay quiet attention to the mother's voice, and briefly stop moving when sound at a conversational level is begun. Newborns seem to prefer a higher-pitched voice (the mother's) to a low sounding voice (males). They also have an ability to tune out loud noises after hearing them several times. It is estimated that serious hearing loss occurs in about one to three of every 1,000 healthy newborns. Without screening or testing, hearing loss may not be noticed until the baby is more than 1 year old. If hearing loss is not detected until later years, there will not be stimulation of the brain's hearing centers. This can affect the maturation and development of hearing, and can delay speech and language. Social and emotional development and success in school may also be affected. It is now recommended that all newborns be screened for hearing loss before leaving the hospital.

taste Taste buds begin forming early in fetal development. It is known that babies prefer sweet tastes over sour or bitter tastes. Babies also show a strong preference for breast milk and breastfeeding, especially after the first few months. smell The brain's olfactory (smell) center forms very early in fetal development. Studies have found that newborns have a keen sense of smell. Within the first few days they will show a preference for the smell of their own mother, especially to her breast milk. touch Throughout the last months of pregnancy, a baby is snugly cocooned in the uterus, with arms and legs tucked. At birth, babies are suddenly thrust into a bright, cold world, where their arms and legs can suddenly move freely. This new freedom can make babies frantic and they may flail and thrash about. Placing a hand on the baby's abdomen, or cuddling close can help a baby feel more secure. Swaddling (wrapping snugly in a blanket) is another technique for babies who need to feel tucked and secure. Some mothers find their babies respond and calm when they are "worn" in a sling or carrier. This may be helpful for colicky or high-need babies. Holding a baby for feedings is also important. Breastfeeding ensures that a baby spends several hours in mother's arms

NEWBORN - SLEEP PATTERNS

What are the sleep patterns of a newborn?

The average newborn sleeps much of the day and night, waking only for feedings every few hours. It is often hard for new parents to know how long and how often a newborn should sleep. Unfortunately, there is no set schedule at first and many newborns have their days and nights confused - they think they are supposed to be awake at night and sleep in the daytime. Generally, newborns sleep about eight to nine hours in the daytime and about eight hours at night. Most babies do not begin sleeping through the night (six to eight hours) without waking until about three months of age, or until they weigh 12 to 13 pounds. Newborns and young infants have a small stomach and must wake every few hours to eat. In most cases, your baby will awaken and be ready to eat about every three to four hours. It is not necessary to wake a baby for feedings unless you have been advised to do so by your baby's physician. However, do not let a newborn sleep longer than five hours at a time in the first five to six weeks. Some premature babies need more frequent feedings and must be awakened to eat. Watch for changes in your baby's sleep pattern. If your baby has been sleeping consistently, and suddenly is waking, there may be a problem such as an ear infection. Some sleep disturbances are simply due to changes in development or because of overstimulation. Never put a baby to bed with a bottle propped for feeding. This is a dangerous practice that can lead to ear infections and choking. What are the sleep states of a newborn? Babies, like adults, have various stages and depths of sleep. Depending on the stage, the baby may actively move or lie very still. Infant sleep patterns begin forming during the last months of pregnancy - active sleep first, then quiet sleep by about the eighth month. There are two types of sleep:

REM (rapid eye movement sleep) This is a light sleep when dreams occur and the eyes move rapidly back and forth. Although babies spend about 16 hours each day sleeping, about half of this is in REM sleep. Older children and adults sleep fewer hours and spend much less time in REM sleep. Non-REM sleep: Non-REM has 4 stages:

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Stage 1 - drowsiness - eyes droop, may open and close, dozing Stage 2 - light sleep - the baby moves and may startle or jump with sounds Stage 3 - deep sleep - the baby is quiet and does not move Stage 4 - very deep sleep - the baby is quiet and does not move

A baby enters stage 1 at the beginning of the sleep cycle, then moves into stage 2, then 3, then 4, then back to 3, then 2, then to REM. These cycles may occur several times during sleep. Babies may awaken as they pass from deep sleep to light sleep and may have difficulty going back to sleep in the first few months. What are the different alert phases of a newborn? Babies also have differences in how alert they are during the time they are awake. When a newborn awakens at the end of the sleep cycles, there is typically a quiet alert phase. This is a time when the baby is very still, but awake and taking in the environment. During the quiet alert

time, babies may look or stare at objects, and respond to sounds and motion. This phase usually progresses to the active alert phase in which the baby is attentive to sounds and sights, but moves actively. After this phase is a crying phase. The baby's body moves erratically, and he/she may cry loudly. Babies can easily be overstimulated during the crying phase. It is usually best to find a way of calming the baby and the environment. Holding a baby close or swaddling (wrapping snugly in a blanket) may help calm a crying baby. It is usually best to feed babies before they reach the crying phase. During the crying phase, they can be so upset that they may refuse the breast or bottle. In newborns, crying is a late sign of hunger. Helping your baby sleep: Babies may not be able to establish their own sleeping and waking patterns, especially in going to sleep. You can help your baby sleep by recognizing signs of sleep readiness, teaching him/her to fall asleep on his/her own, and providing the right environment for comfortable and safe sleep. What are the signs of sleep readiness? Your baby may show signs of being ready for sleep when you see the following signs:

rubbing eyes yawning looking away fussing

How can you help your baby fall asleep? Although it is surprising, not all babies know how to put themselves to sleep. When it is time for bed, many parents want to rock or breastfeed a baby to help him/her fall asleep. Establishing a routine like this at bedtime is a good idea. However, be sure that the baby does not fall asleep in your arms. This may become a pattern and the baby may begin to expect to be in your arms in order to fall asleep. When the baby briefly awakens during a sleep cycle, he/she may not be able to go back to sleep on his own. Most experts recommend allowing a baby to become sleepy in your arms, then placing him/her in the bed while still awake. This way the baby learns how to go to sleep on his own. Playing soft music while your baby is getting sleepy is also a good way to help establish a bedtime routine. What sleeping positions are best for a newborn? For many years in the United States, babies have been put to bed on their stomachs. In most other countries, babies sleep on their backs. Research has found a link between sudden infant death syndrome (SIDS) and babies who sleep on their stomachs (in the prone position). Experts now agree that putting a baby to sleep on his/her back is the safest position. Sidesleeping may also be used, but this also has a higher risk than back sleeping. Other reports have found soft surfaces, loose bedding, and overheating with too many blankets also increase the risk for SIDS. When infants are put to sleep on their stomachs and they also sleep on soft bedding, the risk for SIDS is even higher. Smoking by the mother is also a major risk for SIDS, as are poor prenatal care and prematurity. Since the American Academy of Pediatrics (AAP) made the "back-to-sleep" recommendation in 1992, the SIDS rate has dropped more than 40 percent.

Back sleeping also appears to be safer for other reasons. There is no evidence that babies are more likely to vomit or spit up while sleeping on their back. In fact, choking may be more likely in the prone position. A task force of The US Consumer Product Safety Commission (CPSC), the American Academy of Pediatrics (AAP), and the National Institute of Child Health and Human Development (NICHD), offer the following recommendations for infant bedding:

Place your baby on his/her back on a firm, tight-fitting mattress in a crib that meets current safety standards. Remove pillows, quilts, comforters, sheepskins, stuffed toys, and other soft products from the crib. Consider using a sleeper as an alternative to blankets with no other covering. If using a blanket, put your baby with his/her feet at the foot of the crib. Tuck a thin blanket around the crib mattress, only as far as the baby's chest. Make sure your baby's head remains uncovered during sleep. Do not place your baby on a waterbed, sofa, soft mattress, pillow, or other soft surface to sleep.

According to the task force report, bed sharing or co-sleeping may be hazardous for babies in certain conditions. The report advises the following:

Parents should consider placing the infant's crib near their bed for more convenient breastfeeding and parent contact. If a mother chooses to have her infant sleep in her bed to breastfeed, care should be taken that the baby sleeps in a non-prone position, soft surfaces or loose covers are avoided, and the bed is moved away from the wall and other furniture to avoid the baby becoming entrapped between them. Adults other than the parents, children, or other siblings should not share a bed with an infant. Parents who choose to bed share with their infant should not smoke or use substances such as drugs or alcohol that may impair their ability to awaken.

To prevent overheating, the report recommends that the infant should be lightly clothed for sleep and the room temperature kept comfortable for a lightly clothed adult. Avoid over bundling and check the baby's skin to make sure it is not hot to the touch. Additional research has found that infants should not be put to sleep on a sofa, alone or with another person, as this practice increases the risk for SIDS. While babies should sleep on their backs, other positions can be used during the time babies are awake. Babies can be placed on their stomachs while awake to help develop muscles and eyes and to help prevent flattened areas on the back of the head.

NEWBORN - CRYING
What are the crying patterns of a newborn? The first cries of a newborn baby are often music to the ears of parents. However, over the next weeks and months this "music" can become grating and painful. This is especially true when all attempts fail to stop the crying. Surprisingly, crying does not produce tears until after the first month or two. Crying is the way babies communicate. They cry because of hunger, discomfort, frustration, fatigue, and even loneliness. Sometimes, cries can easily be answered with food, or a diaper change. Other times, it can be a mystery and crying stops as quickly as it begins. You will soon learn differences in cries, from a cry of "I'm hungry" to "I've been overstimulated." It is important to respond to your baby's cries. Contrary to old wives' tales, young babies cannot be spoiled by being picked up when crying. Being held is reassuring and comforting when a baby cannot express him/herself any other way. Some techniques to help console a crying baby include the following:

Take care of physical problems first - hunger, diaper change, need to burp. Walk with baby in a sling or in a stroller. Rock your baby in a rhythmic, gentle motion. Try a baby swing or rocking cradle. Gently pat or stroke on the back or chest. Try swaddling the baby. Go for a ride in the car. Turn on some white noise (such as a washing machine or vacuum cleaner).

No matter how frustrated you may become, NEVER SHAKE A BABY. This can cause severe injury to the baby's fragile brain. If you become angry or frustrated, allow someone else to take over for a while. If you are alone, put the baby down in a safe place, such as the crib, and go to another room for a few moments. This will give you time to collect yourself. Then you can return to your baby and try a different tactic to comfort your baby.

CHILDCARE
Deciding among childcare options is a particularly tough decision for many mothers, especially for a first child. In some instances, the child's parents arrange work schedules so that one or the other is available to stay home with the baby. Others are able to ask a grandparent or other

trusted family member to provide care. When neither is possible, you will want to select a childcare provider who is supportive of your efforts to breastfeed. Another consideration is the convenience of the location of the childcare provider to your workplace. Although in-home childcare has its advantages, some mothers find a care provider close enough to their work sites that they can drop in during work breaks or at lunchtime to breastfeed. Some mothers are able to have their care provider bring the infant to them at work. When the commute time between the place where childcare is provided and the workplace is minimized, you and your baby spend less time apart and you are able to make time for more direct breastfeeding (so fewer pumping sessions may be needed). The following are some questions you may want to ask candidates when choosing a care provider for your breastfed child:

Are they familiar with proper breast milk storage, thawing, and proper warming of breast milk? Do they have refrigerators or freezers where your breast milk can be stored for later use? What is the method for feeding young babies? Is a baby held closely for bottle feedings? Young babies cannot be expected to hold a bottle, and propping bottles is not safe or appropriate. Propping is associated with choking and increasing the risk of ear infections. Also, the social interaction during feedings/mealtime can be as important as obtaining food. If you plan for your baby to be fed by an alternative feeding method, such as cupfeeding, finger-feeding, or syringe-feeding, inquire about the care provider's ability and willingness to continue this practice when your child is in this type of care.

Taking care of yourself after birth:

The postpartum period begins after the delivery of the baby and ends when the mother's body has returned as closely as possible to its pre-pregnant state. This period usually lasts six to eight weeks. The postpartum period involves the mother progressing through many changes, both emotionally and physically, while learning how to deal with all the changes and adjustments required with becoming a new mother. The postpartum period also involves the parents learning how to care for their newborn and learning how to function as a changed family unit. A mother needs to take good care of herself to rebuild her strength. You will need plenty of rest, good nutrition, and help during the first few weeks.

rest: Every new parent soon learns that babies have different time clocks than adults. A typical newborn awakens about every three hours and needs to be fed, changed, and comforted. Especially if this is their first baby, parents - especially the mother - can become overwhelmed by exhaustion. While a solid eight hours of sleep for you may not happen again for several months, the following suggestions may be helpful in finding ways to get more rest now.

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In the first few weeks, a mother needs to be relieved of all responsibilities other than feeding the baby and taking care of herself. Sleep when the baby sleeps. This may be only a few minutes rest several times a day, but these minutes can add up. Save steps and time. Have your baby's bed near yours for feedings at night. Many new parents enjoy visits from friends and family, but new mothers should not feel obligated to entertain. Feel free to excuse yourself for a nap or to feed your baby. Get outside for a few minutes each day. You can begin walking and postpartum exercises, as advised by your physician. After the first two to three weeks, introduce a bottle to breastfed babies for an occasional night-time feeding. This way, someone else can feed the baby, and you can have a longer period of uninterrupted sleep.

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nutrition: A mother's body has undergone many changes during pregnancy, as well as with the birth of her baby. She needs to heal and recover from pregnancy and childbirth. In addition to rest, all mothers need to maintain a healthy diet to promote healing and recovery. The weight gained in pregnancy helps build stores for your recovery and for breastfeeding. After delivery, all mothers need continued nutrition so that they can be healthy and active and able to care for their baby. Whether they breastfeed or formula feed, all mothers need to eat a healthy and balanced diet. Most lactation experts recommend that breastfeeding mothers should eat when they are hungry. But many mothers may be so tired or busy that food gets forgotten. So, it is essential to plan simple and healthy meals that include choices from all of the recommended groups from the food pyramid. Although most mothers want to lose their pregnancy weight, extreme dieting and rapid

weight loss can be hazardous to your health and to your baby's if you are breastfeeding. It can take several months for a mother to lose the weight she gained during pregnancy. This can be accomplished by cutting out high-fat snacks and concentrating on a diet with plenty of fresh vegetables and fruits, balanced with proteins and carbohydrates. Exercise also helps burn calories and tone muscles and limbs. Along with balanced meals, breastfeeding mothers should increase fluids. Many mothers find they become very thirsty while the baby is nursing. Water, milk, and fruit juices are excellent choices. It is helpful to keep a pitcher of water and even some healthy snacks beside your bed or breastfeeding chair. Consult your physician or a registered dietitian if you want to learn more about postpartum nutrition. Certified lactation consultants can also help with advice about nutrition while breastfeeding.

help for new parents: New as well as experienced parents soon realize that babies require a lot of work. Meeting the constant needs of a newborn involves time and energy and often takes parents away from other responsibilities in the home. Although many parents do fine on their own, having someone else helping with the household responsibilities usually makes the adjustment to a new baby easier. Parents can concentrate on the needs of mother and baby, rather than the laundry or dirty dishes. Helpers can be family, friends, or a paid home care provider. A family member such as the new baby's grandmother or aunt may be able to come for a few days or longer. Home care providers offer a variety of services, from nursing care of the new mother and baby to housekeeping and care of other children.

Whoever you decide to have as helpers, be sure to make clear all the things you expect them to do. Communication is important in preventing hurt feelings or misunderstandings when emotions are fragile these first few weeks. It is generally best for the new mother to be relieved of all responsibilities except the feeding and care of herself and her baby. This is especially important if she is breastfeeding. Others should assume the chores in the home such as cooking, cleaning, laundry, and grocery shopping. This will prevent the new mother from limiting her time with her baby to take care of the house.

BREAST MILK IS THE BEST MILK

Nature designed human milk especially for human babies, and it has several advantages over any substitute ever developed. Your milk contains just the right balance of nutrients, and it contains them in a form most easily used by the human baby's immature body systems. Because it was developed for your human baby, your milk also is gentlest on your baby's systems. Why breast milk is the best milk: There are many reasons why breast milk is the best milk, including the following:

nutrients Human survival depends more on brain power than on strong muscles, rapid growth (rapid maturity), or body size, so your milk is rich in the nutrients that best promote brain growth and nervous system development. Research has found that breastfed babies perform better on different kinds of intelligence tests as they grow older. They also develop better eye function. This is due mostly to certain types of fat (fatty acid chains) in human milk, which are not available in artificial formulas. The sugar (carbohydrate) and protein in breast milk are also designed to be used easily and more completely by the human baby. Your milk is the perfect first food to help your baby achieve every aspect of ideal growth and development. The American Academy of Pediatrics recommends that babies who are exclusively breastfed receive additional vitamin D. Your baby's physician can recommend the proper type and amount of vitamin D supplement for your baby.

anti-infective properties Only human milk is alive with many different kinds of disease-fighting factors that help prevent mild to severe infections. Babies who are fully or almost-fully breastfed, or breast milk-fed babies, have significantly fewer gastrointestinal, respiratory, ear, and urinary infections. Antibodies in human milk directly protect against infection. Other anti-infective factors create an environment that is friendly to "good" bacteria, referred to as "normal flora," and unfriendly to "bad" bacteria, viruses, or parasites. Human milk also appears to have properties that help a baby's own immune system work best. If your baby does become ill when breastfeeding and receiving your milk, the infection is likely to be less severe. easily digested Since nature designed human milk for human babies, your milk is the most easily digested food your baby can receive. A nutritious, yet easily digested first food is

important for a baby's immature digestive tract. Your baby uses less energy, yet breaks your milk down more completely into its basic ingredients, so the nutrients, antiinfective factors, and all the other ingredients in your milk are more available to fuel your baby's body functions and to promote your baby's growth and development.

bio-availability Bio-availability is a fancy way of referring to how well the body can use the nutrients in a food. The high bio-availability of nutrients in human milk means your baby gets more benefits from the nutrients it contains - even for nutrients that appear in lower levels in breast milk when compared to artificial formulas (because your baby's body can absorb and use them most effectively). It also means your baby saves the energy that would be needed to eliminate any nutrients he/she had difficulty digesting or using. suitability Your milk is best suited to, and so it is more gentle on, your baby's body systems. The suitability of your milk plays a role in your milk's digestibility, and it allows your baby's body to function most efficiently while spending a lot less energy on body functions. Suitability is also thought to be one reason that breastfed babies are less likely to develop allergic-related skin conditions and asthma.

The digestibility, bio-availability, and suitability of your milk means that your baby's body is able to work less yet receive more nourishment.

GETTING STARTED
How to get started with breastfeeding: The process of breastfeeding and your milk change as your baby grows and develops. A newborn's feeding routine may be different than that of a breastfeeding 6-month-old. As the baby grows, the nutrients in your milk adapt to your growing baby's needs. The anti-infective properties also increase if you or your baby is exposed to some new bacteria or virus.

early breastfeeding The first weeks of breastfeeding should be considered a learning period for both you and your baby. Do not expect to work as a coordinated team immediately. Give yourselves plenty of time to recuperate from labor and birth, develop a daily routine, and overcome any initial breastfeeding difficulties. It may help to keep a simple checklist chart to mark daily feedings and diaper counts until your baby is gaining weight appropriately. To make a chart, take a piece of paper and number down 24 hours from midnight to 11 p.m. Then make several columns for breastfeeding, wet diaper, and stool, and put a check in the appropriate column as it occurs. (Some mothers add extra columns for pumping sessions and alternative feedings if a baby is having difficulty and they must express milk and offer it or a substitute at times.)

day 1 Most full-term, healthy babies are ready and eager to begin breastfeeding within the first half hour to two hours of birth. Then many sleep or act drowsy for the next two to 20 hours, so a baby may not be very interested in breastfeeding again on his/her birthday. However, a baby should breastfeed several times that first day. Expect to change only a couple of wet and dirty diapers during the first 24 hours. days 2 to 4 Although he/she may need practice with latching on and sucking, by the second day

your baby should begin to wake and cue (show readiness) for feedings every 1 1/2 to 3 hours for a total of 8 to 12 breastfeedings in 24 hours. These frequent feedings provide your baby with antibody-rich first milk called colostrum and tell your breasts to make more milk. Your baby should suckle for at least 10 minutes and may continue for about 30 minutes on the first breast before letting go, or "self-detaching," without help from you. When he/she finishes at one breast, you can burp and change his/her diaper before offering the second breast. As with Day 1, you probably will change only a few wet and dirty diapers on baby's second and third days, and do not be surprised if your baby loses weight during the first several days. The number of diaper changes and baby's weight will increase when your milk "comes in." You may feel uterine cramping when breastfeeding the first two or three days, especially if this is a second or subsequent baby. This is a positive sign that the baby's sucking has triggered a milk let-down, also called the milk-ejection reflex (MER). It also means your uterus is contracting, which helps minimize bleeding. A nurse can give you something to take before feeding if needed for the discomfort. Some mothers briefly feel a tingling, "pins and needles," or a flushing of warmth or coolness through the breasts with milk let-down; others notice nothing different, except the rhythm of baby's sucking. Because your baby still is learning, you may experience nipple tenderness when he/she latches on or during a breastfeeding. Other factors also may contribute to this tenderness, but usually it is mild and disappears by the end of the first week. If tenderness persists, develops into pain, or nipple cracking is noted, contact a certified lactation consultant (IBCLC).

days 3 to 5 The volume of breast milk produced increases dramatically at about 3 or 4 days after birth, and the milk is said to have "come in." Your baby probably will drift off after his/her 8 to 12, 10 to 30-minute feedings and act more satisfied after a meal. Within 12 to 24 hours, you should be changing a lot more wet diapers. The number of dirty diapers also increases, and the stools should be changing in color and consistency. From the dark, tarry meconium stool, they should progress to softer and brown color before becoming a mustard-yellow and loose and seedy. Weight gain should also pick up within 24 hours of this increase in milk production, so your baby begins to gain at least half an ounce (15 g) a day. You may notice that your breasts feel fuller, heavier, or warmer when your milk comes in. Some mothers find their breasts become uncomfortably engorged due to increased milk volume and tissue swelling. Then the breasts feel hard and tight; the areola and nipple may seem stretched and flat, making it difficult for a baby to latch-on. The most important thing to do when your milk first comes in is to move the milk out of your breasts by feeding your baby frequently. If your baby has difficulty latching on because of severe engorgement:

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Soften the nipple and areola by expressing some milk and then let baby latch on. Breastfeed or express milk by hand or breast pump frequently (every one to two hours) - your breasts should feel noticeably softer after breastfeeding or pumping. Apply cold packs or sandwich bags filled with ice or frozen vegetables to the breasts for 20 to 30 minutes after a feeding or pumping session. The application of cold packs has been shown to relieve the swelling that may interfere with milk flow. Some women do report improved milk flow if they also apply warm compresses to the breasts for a few minutes immediately before breastfeeding

or milk expression, but there are no studies that support this as effective. Using heat for more than a few minutes could increase the amount of swelling.

days 5 to 28 Your baby will become more proficient at breastfeeding as the first month progresses. Expect to feed your baby about 8 to 12 times in 24 hours and for approximately 10 to 30 minutes at the first breast before he/she lets go of the breast without your help. You can then burp the baby, change his/her diaper, and switch to the second breast. Usually, a baby will breastfeed for a shorter period at the second breast, and sometimes he/she may not want to feed on the second breast at all. Simply offer the second breast first at the next feeding. Babies that guzzle their food nonstop may self-detach in 10 to 15 minutes; babies preferring to savor their meals often take 20 to 35 minutes on the first breast, because they tend to take a few several-minute breaks between "courses." Whichever type your baby is, it is important to let him/her choose when to let go of the breast, as this selfdetachment will increase the amount of higher fat/higher calorie milk (hindmilk) your baby takes in.

Your baby should continue to:

Soak six or more wet diapers. Pass three or more loose, seedy, yellow stools. Gain more than one half ounce (15 g) a day, more than four to five ounces (120 to 150 g) a week, or one pound (454 g) a month (from lowest weight), regaining birthweight by 2 weeks.

Your baby probably will go through several two to four day "growth spurt" periods when he/she seems to want to eat almost around the clock. Babies commonly experience a growth spurt between 2 to 3 weeks, 4 to 6 weeks, and again at about 3 months. It is important to let a baby feed more often during these spurts. Within a few days, your baby will have returned to a more typical pattern. Let your baby set the pace for breastfeeding. Pay attention to his/her feeding cues. The number of feedings each baby needs and the length of time each feeding lasts will vary from baby to baby. Trying to force a breastfed baby to wait longer between feedings, or fit a particular feeding schedule, can result in poor weight gain.

HOW MILK IS MADE

How is breast milk made? Many mothers find they can appreciate their babies' breastfeeding patterns or the need for frequent feedings when they understand how breast milk is produced. Initially, hormones play a greater role. After the first one or two weeks postpartum (after the baby is born), milk removal has a greater effect on the amount of milk produced. With the expulsion of the placenta after a baby's birth, a drop in the hormones that maintained the pregnancy soon occurs and allows the hormone prolactin to begin to work. Prolactin "tells" the breasts it is time to begin producing large amounts of milk. A mother feels the result of prolactin when her milk "comes in" at around three to five days postpartum. Increased milk

production usually occurs at this time even if a baby has not been breastfeeding well or often. However, frequent breastfeeding sometimes speeds up the process of establishing increased milk production. Occasionally, a mother experiences a delay in the production of large amounts of milk. How much milk is needed? Ongoing, long-term milk production depends mostly on milk removal. The more often milk is removed and the more completely it is removed, the more milk the breasts make. The opposite is also true. When milk is removed less often or an insufficient amount is removed, the breasts get the signal to slow milk production and make less. Milk removal occurs when a baby effectively breastfeeds. Effective breastfeeding requires effective sucking by the baby so that enough milk is transferred from the breast into the baby's mouth where it is swallowed. To suck effectively, a baby must latch deeply onto the breast and use the structures in his/her mouth to create intermittent (periodic) suction and also compress the milk sinuses (enlarged area of milk ducts) lying beneath the areola - the area about 1 to 2 inches behind the nipple tip. Proper sucking signals the mother's body to release the hormone oxytocin, which results in a greater transfer of milk with the milk-ejection reflex (MER), or milk "let down." If a baby is not breastfeeding effectively, milk transfer also can be accomplished through milk expression techniques. When using manual expression, a mother compresses the milk sinuses by hand to remove milk. Breast pumps remove milk by creating suction, and a few also have features that compress milk sinuses to some degree. Generally, the milk-ejection reflex is triggered during milk expression sessions, especially if frequent and regular sessions occur.

CHILDCARE
Deciding among childcare options is a particularly tough decision for many mothers, especially for a first child. In some instances, the child's parents arrange work schedules so that one or the other is available to stay home with the baby. Others are able to ask a grandparent or other trusted family member to provide care. When neither is possible, you will want to select a childcare provider who is supportive of your efforts to breastfeed. Another consideration is the convenience of the location of the childcare provider to your workplace. Although in-home childcare has its advantages, some mothers find a care provider close enough to their work sites that they can drop in during work breaks or at lunchtime to breastfeed. Some mothers are able to have their care provider bring the infant to them at work. When the commute time between the place where childcare is provided and the workplace is minimized, you and your baby spend less time apart and you are able to make time for more direct breastfeeding (so fewer pumping sessions may be needed). The following are some questions you may want to ask candidates when choosing a care provider for your breastfed child:

Are they familiar with proper breast milk storage, thawing, and proper warming of breast milk? Do they have refrigerators or freezers where your breast milk can be stored for later use? What is the method for feeding young babies? Is a baby held closely for bottle feedings? Young babies cannot be expected to hold a bottle, and propping bottles is not safe or

appropriate. Propping is associated with choking and increasing the risk of ear infections. Also, the social interaction during feedings/mealtime can be as important as obtaining food.

If you plan for your baby to be fed by an alternative feeding method, such as cupfeeding, finger-feeding, or syringe-feeding, inquire about the care provider's ability and willingness to continue this practice when your child is in this type of care.

NEWBORN SCREENING TESTS

What are newborn screening tests? Nearly all babies will have a simple blood test to check for disorders that are not immediately apparent after delivery. Some of these disorders are genetic, metabolic, blood, or hormone related. Each state in the United States requires screening tests, but the specific tests performed vary among the states. Some disorders are more common in some states, making testing more important. A heel-prick is usually used to sample the baby's blood. The blood drops are collected in a small vial or on a special paper. The blood is then sent for testing. The baby's heel may have some redness at the pricked site, and some babies may have bruising, but this usually disappears in a few days. Newborn screening tests may include:

phenylketonuria (PKU) PKU is an inherited disease in which the body cannot metabolize a protein called phenylalanine. It is estimated that one baby in 10,000 to 25,000 is born with PKU in the United States. Without treatment, PKU can cause mental retardation. Newborn screening for PKU is required in all 50 states. congenital hypothyroidism This is a condition in which the baby is born with too little thyroid hormone. Hypothyroidism is also quite common, occurring in about one in every 6,000 to 7,000 births in the United States. Untreated low thyroid hormone levels can lead to mental developmental problems and poor growth. All 50 states screen for hypothyroidism. galactosemia This is an inherited disorder in which the baby is unable to metabolize galactose, a milk sugar. It occurs in about one baby in every 50,000. Without treatment (avoidance of milk), galactosemia can be life-threatening. Symptoms may begin in the first two weeks of life. Nearly all states screen for galactosemia. sickle cell disease This inherited disorder occurs primarily in African-Americans, but may also occur in Hispanics and Native Americans. The disease causes a severe form of anemia. There are different types of the disease. The incidence ranges from one in 400 to one in 1,400, depending on the type of disease. Early diagnosis of sickle cell disease can help lower some of the risks which include severe infections, blood clots, and stroke. maple syrup urine disease This is an inherited disorder that affects one in 250,000 births. The disease is very common in the Mennonite population - as many as one in 760. The disorder is caused

by an inability of the body to properly process certain parts of protein called amino acids. The name comes from the characteristic odor of maple syrup in the baby's urine caused by the abnormal protein metabolism. If untreated, it is life-threatening as early as the first 2 weeks of life. Even with treatment, severe disability and paralysis can occur.

homocystinuria This inherited disorder affects one in 250,000 babies and causes mental retardation, bone disease, and blood clots. It is caused by a deficiency of an enzyme necessary to digest an amino acid called methionine. biotinidase deficiency This inherited disorder is characterized by a deficiency of the biotinidase enzyme. This enzyme is important in metabolizing biotin, a B vitamin. It affects one in 70,000 babies in the United States and is most common in the Caucasian population. Lack of the enzyme can lead to severe acid buildup in the blood, organs, and body systems. congenital adrenal hyperplasia Most states screen for this inherited disease of the adrenal glands. Babies born with congenital adrenal hyperplasia (CAH) cannot make enough of the hormone cortisol, which helps control energy, sugar levels, blood pressure, and how the body responds to the stress of injury or illness. The Endocrine Society estimates the incidence of CAH at about one in 1,000 to one in 15,000, depending on the serverity of the disease. CAH may also affect the development of the genitals and the hormones of puberty.

Other tests screen for disorders including congenital toxoplasmosis, cystic fibrosis, and a disorder of fatty acid oxidation called MCAD. Some states are using a new testing technique called tandem mass spectrometry (MS/MS) which can detect more than 30 disorders using a simple blood sample, including those involving protein and fatty acid metabolism. Most screenings cannot be performed until babies have received at least 24 hours of breast milk or formula. Your baby may need follow-up testing if you are discharged before this time or the baby is unable to be tested before discharge.

NEWBORN APPEARANCE
What does a newborn look like? Parents often dream of what their new baby may look like, thinking about a pink, round, chubby-cheeked and gurgling wonder. It may be surprising for many parents to see their newborn the first time - wet and red, with a long head, and screaming - nothing at all like they had imagined. Newborns have many variations in normal appearance - from color to the shape of the head. Some of these differences are just temporary, part of the physical adjustments a baby goes through. Others, such as birthmarks, may be permanent. Understanding the normal appearance of newborns can help you know that your baby is healthy. Some of the normal variations in newborns include the following, and are explained below:

color moulding vernix lanugo milia

stork bites mongolian spots erythema toxicum acne neonatorum "baby acne" strawberry hemangioma port wine stains newborn breast swelling swollen genitals/discharge A baby's skin coloring can vary greatly, depending on the baby's age, race or ethnic group, temperature, and whether or not the baby is crying. Skin color in babies often changes with both the environment and health. When a baby is first born, the skin is a dark red to purple color. As the baby begins to breathe air, the color changes to red. This redness normally begins to fade in the first day. A baby's hands and feet may stay bluish in color for several days. This is a normal response to a baby's immature blood circulation. Blue coloring of other parts of the body, however, is not normal. Some newborns develop a yellow coloring called jaundice. This may be a normal response as the body rids excess red blood cells. However, it may indicate a more serious condition, especially if the yellow color appears in the first day and worsens. Jaundice can often be seen by gently pressing on the baby's forehead or chest and watching the color return. Laboratory tests may be needed to assess jaundice.

Color

Moulding

Moulding is the elongation of the shape of a baby's head. It occurs when the movable bones of the baby's head overlap to help the baby pass through the mother's birth canal. Normal shape usually returns by the end of the first

week.

Vernix

This is a white, greasy, cheeselike substance that covers the skin of many babies at birth. It is formed by secretions from the baby's oil glands and protects the baby's skin in the amniotic fluid during pregnancy. Vernix may not be present in babies who are born postterm (after 41 weeks of pregnancy). It does not need to be removed and usually absorbs into the skin. This is soft, downy hair on a baby's body, especially on the shoulders, back, forehead, and cheeks. It is more noticeable in premature babies, but is not usually seen in babies born very late in pregnancy. Milia are tiny, white, hard spots that look like pimples on a newborn's nose. They may also appear on the chin and forehead. Milia form from oil glands and disappear on their own. When these occur in a baby's mouth and gums, they are called Epstein pearls. These are small pink or red patches often found on a baby's eyelids, between the eyes, upper lip, and back of the neck. The name comes from the marks on the back of the neck where, as the myth goes, a stork may have picked up the baby. They are caused by a concentration of immature blood vessels and may be the most visible when the baby is crying. Most of these fade and disappear completely. Mongolian spots are blue or purple-colored splotches on the baby's lower back and buttocks. Over 80 percent of African-American, Asian, and Indian babies have Mongolian spots, but they occur in darkskinned babies of all races. The spots are caused by a

Lanugo

Milia

Stork bites or salmon patches

Mongolian spots

concentration of pigmented cells. They usually disappear in the first four years of life.

Erythema toxicum

Erythema toxicum is a red rash on newborns that is often described as "flea bites." The rash is common on the chest and back, but may be found all over. About half of all babies develop this condition in the first few days of life. It is less common in premature babies. The cause is unknown but it is not dangerous. Erythema toxicum does not require any treatment and disappears by itself in a few days. About one-fifth of newborns develop pimples in the first month. These usually appear on the cheeks and forehead. It is thought that maternal hormones cause these, and they usually disappear within a few months. Do not try to break open or squeeze the pimples, as this can lead to infection. This is a bright or dark red, raised or swollen, bumpy area that looks like a strawberry. Hemangiomas are formed by a concentration of tiny, immature blood vessels. Most of these occur on the head. They may not appear at birth, but often develop in the first two months. Strawberry hemangiomas are more common in premature babies and in girls. These birthmarks often grow in size for several months, and then gradually begin to fade. Nearly all strawberry hemangiomas completely disappear by nine years of age. A port wine stain is a flat, pink, red, or purple colored birthmark. These are caused by a concentration of dilated tiny blood vessels called capillaries. They usually occur on the head or neck. They may

Acne neonatorum (baby acne)

Strawberry hemangioma

Port wine stain

be small, or they may cover large areas of the body. Port wine stains do not change color when gently pressed and do not disappear over time. They may become darker and may bleed when the child is older or as an adult. Port wine stains on the face may be associated with more serious problems. Skin-colored cosmetics may be used to cover small port wine stains. The most effective way of treating port wine stains is with a special type of laser. This is done when the baby is older by a plastic surgery specialist.

Newborn breast swelling

Breast enlargement may occur in newborn boys and girls around the third day of life. In the first week, a milky substance, sometimes called "witch's milk," may leak from the nipples. This is related to the mother's hormones and goes away within a few days to weeks. Do not massage or squeeze the breasts or nipples, as this may cause an infection in the breast. A newborn's genitals may appear different depending on the gestational age (the number of weeks of pregnancy). Premature baby girls may have a very prominent clitoris and inner labia. A baby born closer to full-term has larger outer labia. Girls may have a small amount of whitish discharge or bloodtinged mucus from the vagina in the first few weeks. This is a normal occurrence related to the mother's hormones. Premature boys may have a smooth, flat scrotum with undescended testicles. Boys born later in pregnancy have ridges in the scrotum with descended testicles.

Swollen genitals/discharge

BATHING AND SKIN CARE

Proper bathing and skin care for your newborn: A newborn's skin is soft and delicate. Proper skin care and bathing can help maintain the health and texture of the baby's skin while providing a pleasant experience for both of you. Contrary to popular thought, most babies do not need a bath every single day. With all the diaper changes and wiping of mouth and nose after feedings, most babies may only need to be bathed two or three times a week or every other day. Baths can be given any time of day. Bathing before a feeding often works well. Many parents prefer to bathe their baby in the evening, as part of the bedtime ritual. This works well especially if bath time is relaxing and soothing for the baby. Sponge baths are required at first. Bathing in a tub of water should wait until the baby's umbilical cord falls off, and a baby boy's circumcision heals, to prevent infection. What equipment is needed for bathing newborns?

thick towels or a sponge-type bath cushion soft washcloths basin or clean sink cotton balls baby shampoo and baby soap (non-irritating) hooded baby towel

clean diaper and clothing

How to give a sponge bath:

Make sure the room is warm, without drafts, about (75 F). Gather all equipment and supplies in advance. Add warm water to a clean sink or basin (warm to the inside of your wrist or between 90 and 100 F.). Place baby on a bath cushion or thick towels on a surface that is waist high. Keep the baby covered with a towel or blanket. NEVER take your hands off the baby, even for a moment. If you have forgotten something, wrap up the baby in a towel and take him/her with you. Start with the baby's face - use one moistened, clean cotton ball to wipe each eye, starting at the bridge of the nose then wiping out to the corner of the eye. Wash the rest of the baby's face with a soft, moist washcloth without soap. Clean the outside folds of the ears with a soft washcloth. DO NOT insert a cotton swab into the baby's ear canal because of the risk of damage to the ear drum. Add a small amount of baby soap to the water or washcloth and gently bathe the rest of the baby from the neck down. Uncover only one area at a time. Rinse with a clean washcloth or a small cup of water. Be sure to avoid getting the umbilical cord wet. Wash the baby's head last with a shampoo on a washcloth. Rinse, being careful not to let water run over the baby's face. Holding the baby firmly with your arm under his/her back and your wrist and hand supporting his/her neck, you can use a high faucet to rinse the hair. Scrubbing is not necessary, but most babies enjoy their arms and legs being massaged with gentle strokes during a bath. Wrap the baby in a hooded bath towel and cuddle your clean baby close. Follow cord care instructions given by your baby's physician. Use a soft baby brush to comb out your baby's hair. DO NOT use a hair dryer on hot to dry a baby's hair because of the risk of burns. Expect your baby to cry the first few times you bathe him/her. Usually, this is just because a bath is a new experience. However, be sure to check that the water is not too warm or cold or that soap has not gotten in your baby's eyes if your baby suddenly starts crying during a bath.

How to give your newborn a tub bath: Once your baby's umbilical cord has fallen off and the stump is healed, and after a boy's circumcision has healed, you can give your baby a tub bath. This can be a pleasurable

experience for you and your baby. However, some babies may not like to be bathed, especially the first few times. Talk softly or sing and try some bath toys if your baby protests. What equipment is needed for a tub bath?

baby bathtub (preferably with a bottom drain plug) nonslip mat or pad bath thermometer (these often have "safe" bath temperature ranges marked on them)

When bathing your baby in a tub:

Clear the counter or table top of breakable objects and electrical appliances to prevent injury. Fill the tub with warm water, using a bath thermometer. Follow the same general bathing instructions for a sponge bath. NEVER take your hands off your baby, or walk away, even for a moment. Be sure to clean the bathtub after each use.

Providing proper skin care for your newborn: A baby's soft and delicate skin needs special care. Generally it is best to use products made especially for babies, but your baby's physician can advise you about other products. Products for adults may be too harsh for a baby and may contain irritants or allergens. Many parents like to use lotions for the sweet baby smell. However, unless the baby's skin is dry, lotions really are not needed. Powders should be avoided, unless they are recommended by your baby's physician. When using any powder, put the powder in your hand and then apply it to the baby's skin. Shaking powder into the air releases dust and talc which can make it hard for the baby to breathe. Many babies have rashes and bumps that are normal. Some rashes may be a sign of a problem or infection. Diaper rash can be irritating to the baby and needs to be treated. If you have concerns about a rash, or your baby is uncomfortable or has a fever, call your baby's physician. Laundry detergents may cause irritation to a baby's delicate skin. Even if you use a detergent marketed for baby laundry, it is a good idea to rinse the laundry an extra time to remove residues.

BOTTLE-FEEDING
Health considerations when bottle-feeding: If you decide not to breastfeed, or are unable to breastfeed, commercial iron fortified formulas can provide adequate nutrition for your infant. Infant formulas contain adequate amounts of protein, calories, fat, vitamins, and minerals for growth. However, formula does not contain the immune factors that are in breast milk. The immune factors that are found in breast milk can help prevent infections. Infants who take enough iron-fortified infant formula usually do not need vitamin and mineral supplements. Fluoride is sometimes needed after 6 months of age if the water supply does not have enough fluoride. Check with your baby's physician about fluoride supplements. Types of infant formula include:

cow's milk-based formula Most infants should be able to tolerate a standard cow's milk formula that is recommended by your child's physician. These formulas use cow's milk as a base, but have been modeled after breast milk. These formulas have lactose as the carbohydrate (sugar) source. They are available in ready-to-feed cans, liquid concentrate, and powder. soy-based formulas Soy-based infant formulas can provide adequate nutrition for your infant and can be used if an infant is not tolerating the sugar (lactose) found in cow's milk-based formulas. Soy formulas do not contain lactose as the sugar source. Sometimes, soy formulas are used if your infant is not tolerating cow's milk protein. However, infants

who are allergic to cow's milk formula can also be allergic to soy-based formulas. Consult your baby's physician before changing his/her formula.

protein hydrolysates These are special formulas usually used if your baby is unable to tolerate standard infant formula. These formulas are more expensive than standard formulas. Often these formulas are used if your baby has a cow's milk protein allergy or if he/she is unable to digest a standard infant formula. Consult your physician before using these formulas. low iron formulas Standard cow's milk-based formulas are also available in low iron forms. Iron is a very important mineral for growth and development. A lack of iron in the diet can cause iron deficiency anemia. Many people think that the iron in formula can cause constipation. This is not true. Low iron formulas should not be used unless recommended by your baby's physician.

Helpful hints for feeding your baby:

Breast milk is best for your baby and is beneficial even if you only nurse for a short amount of time or part-time. Working mothers can use a breast pump on break time and refrigerate or freeze the milk for later use as a bottle-feeding. Refrigerated breast milk should be used within 24 hours after pumping. Frozen breast milk is good for several months in the freezer. Fathers and other family members can be involved in feeding time if breast milk is offered from a bottle periodically. Offer cow's milk-based formula with iron as first choice of formula if not breastfeeding. Keep your baby on breast milk or baby formula until he/she is 1 year old. After this time, you may change over to whole milk. Children under 2 years should not drink skim or low fat milk.