Newborn Normals

Congratulations! You have become proud parents! After months of preparation, pregnancy, and then labor and delivery, a moment’s relief in the hospital and now, on the verge of discharge, reality and panic have set in! What now?

As pediatricians and parents ourselves, we know what you are feeling and we have prepared this pamphlet to help you get started on the best possible footing with your newborn baby.

Fortunately for us parents, babies come with a limited number of needs. Although it will feel clumsy and can be incredibly tiring, parenting does not have to be difficult. For most of us, it is a labor of love. Babies need simply to be clothed, fed, changed and cuddled. They communicate in just one way – by crying – and it becomes our task to figure out what they mean – by trial and error. They give us feedback when we guess right. Dr. Spock’s advice to parents a generation ago still holds today – use your good common sense and you will do well. If you are worried about something the baby is doing, or about what you are doing, and this website does not address it, please call the office during daytime office hours. One of the providers is always available after hours for more urgent issues that cannot wait for the next business day (simply dial our office number and follow the prompts).

Hospital Routines

In the hospital, efforts to help ensure baby’s health and well-being should not interfere with your enjoyment of your baby. Routine procedures include applying nonirritating antibiotic eye ointment shortly after birth, to prevent eye infection. Vitamin K by injection is given to prevent bleeding. Occasionally, a blood test for blood sugar or blood count may be performed if the baby is very large or very small or “jittery.” At discharge from the hospital another blood test, the newborn metabolic screen, is routinely performed to evaluate the baby for a variety of rare diseases that require special treatment – diseases whose signs may not be recognizable at birth (i.e. sickle cell disease, PKU, hypothyroidism). This test is repeated at approximately 5-10 days of age. Blood for these tests is drawn from the baby’s heel. For more information about NB screening please visit: http://www.azdhs.gov/lab/aznewborn/parents.

Bottle Feeding

Commercial formulas come in several types. We usually recommend cow’s milk formula for most babies. If there is a strong family history of milk intolerance, we will usually recommend a protein hydrolysate or soy formula. Signs of formula intolerance include vomiting, diarrhea, bloody stools or severe irritability.

Commercial formulas are vitamin-fortified. Supplemental fluoride is not routinely recommended in this area, as too much fluoride can result in permanent staining of the teeth. Instead, fluoride varnish will be applied when your baby is 9 months or older.

Formulas come in three different formulations: Ready-To-Feed mixture (open the can and pour directly into bottle). Concentrated formula requires you to dilute half-and-half with water. Powdered formula requires mixing two scoops of powder per four ounces of water. Find the formula that works best for you and your family and be consistent with mixing. It is no longer necessary to sterilize water or bottles after each feeding. It is a good idea to boil bottles and nipples initially when purchased. Use the dishwasher or hot water and soap to clean them after each use. After a feeding, any remaining formula in the bottle should be discarded. Formula should be offered at room temperature. Microwaves are not recommended to warm formula because they heat unevenly and burns to the infant’s mouth could result.

Find the nipple that works best for your baby. If your baby sucks hard and chokes, he may need a slower-flow nipple. If your baby takes over 30 minutes to feed he may do better with a higher flow. If your baby is very gassy, try a collapsible plastic inner-type bottle (Playtex or Dr. Brown’s bottles). Periodically check to be sure the nipple hole is open, especially if the baby is fussy with feeding. On average infants should take 2 ounces per pound of body weight per day.

The average amount per feeding is approximately 1 ounce per each week of age (for example a 1 week old may take 1-2 oz. per feed and a 2 week old 2-3 oz. per feed.) Most babies feed approximately every 2-4 hours. As a general rule of thumb after 2 months of age, a baby should take 24-32 oz. per day. Maximum 40 oz. per day. Please remember, all babies are unique. Feel free to discuss your concerns with your doctor or nurse.

Infants usually set their own schedule by 1-2 months of age. If fussy and it has been more than 2 hours since last feeding, feed them. By 3-4 months of age most formula fed infants will give up middle of the night feeds. We generally don’t recommend solid food until 6 months of age. Adding rice cereal to the bottle does not make babies sleep through the night (sorry!) Most babies may begin to sleep through the night (which is 6-8 hours) by around 4 months of age on their own. Babies need 400 I.U. of vitamin D drops daily unless they are drinking 32 oz or more formula per day.

Burp your baby about halfway through a feeding, holding the baby up to the shoulder or sitting propped up on your knee. Pat the back gently for approximately one to two minutes. Hold your baby close during feedings and peer into his eyes – he will be able to see you. Some wet burps or spitting after feeding is common. Hiccups are common. Repetitive forceful vomiting, green or bloody vomitus or choking could be signs of serious problems – call the doctor. If your baby turns blue or seems not able to catch his breath call 911.

Breast Feeding

Nurse your baby on demand – usually every 1-3 hours. Wake your baby at three hours during the first week if he is not awake by then to feed. Nurse your baby 5-20 minutes per side on the first day and increase the amount of time gradually up to a maximum of 20 minutes per side by the fourth day. Some babies require only five minutes and others 20 to empty each breast. Try to empty each breast at each feeding. Milk “comes in” around the third to fourth day, with the breasts becoming hard, sore, and full. Burp the baby between feeding on each breast unless he is falling asleep, in which case move to the second breast and burp afterwards. If the baby is sucking well at the above intervals, acting satisfied after feeding, wetting the diaper over three times a day and having several daily stools, then rest assured that he/she is getting enough. Breast-fed babies normally can lose up to 10% of their body weight during the first week of life and then should be back to birth weight by two weeks old. Once we document good weight gain at an office visit, you can allow your infant to sleep undisturbed at night, if he/she will let you!

We do not recommend routine formula supplements for breast-fed infants unless the baby is sucking poorly or acts unsatisfied after nursing (crying). If the baby wants to suck more after nursing, you may try a pacifier. Babies have a need to suck to soothe themselves. Breast-fed babies need 400 I.U. of vitamin D drops daily. You can buy this over-the-counter at any pharmacy. Continue your prenatal vitamins and calcium supplements, eat sensibly, get plenty of rest and drink lots of fluids. If you have concerns, check with the office before taking any medicines while breast-feeding. For nursing babies it is often helpful to introduce a bottle at 2-3 weeks of age, and continue a bottle feeding 2-3 times a week so the baby knows how to take a bottle in the future. It also allows dads to be involved and not feel left out!

Some babies learn to nurse with ease. For others it is more difficult to master. We have lactation specialists available to coach you in the many “tricks” to help babies learn to nurse. If nursing doesn’t work out for you and your baby or you choose not to nurse, try not to take it personally. It is more important for the baby’s health and well-being for you to have a good mothering experience, and if that means bottle-feeding, so be it. Because your hormones are wreaking havoc with your emotions, such disappointments may seem devastating. If you are feeling very blue and need help – notify us.

Stools

Formula-fed babies have stools as often as several times per day or as infrequently as every three days. Breast-fed babies tend to have frequent and loose yellow or yellow-green stools almost after every feeding. Some babies grunt, push, turn red, or even cry when they pass a stool. Constipation refers to infrequent and very hard stools that are sometimes blood-streaked. One ounce of apple or prune juice mixed with one ounce of water is a safe natural stool softener for mild constipation. If your baby is still uncomfortable, please make an appointment.

The Umbilical Cord

Now that the umbilical cord has served its purpose it normally falls off at approximately two to three weeks of age. No care is needed unless you see yellow to brown discharge or the cord has a foul smell. You may then apply rubbing alcohol on a Q-Tip to the base of the cord approximately three times a day, folding the diaper down to let the cord dry out. Umbilical cord infections, while very rare, can be very serious. Early signs include extreme foul odor and redness of surrounding skin. Please contact us if you have concerns. A small amount of bleeding is normal when the cord is ready to fall off. When the cord is off and dry, the baby can have a tub bath – until then sponge baths only, please.

The Many Sounds and Faces of Babies

Babies make a lot more noise than you would think! Besides crying they also sneeze, cough, grunt, snort, squeak and have endless series of facial grimaces to match. Hiccups are very common for the first two months and bother us but not them. In your many hours of baby-gazing you will get to know your baby’s sounds and faces. Your baby will follow your face with his eyes and alert to the sound of your voice within the first few weeks. He or she may “startle” with a noise or jolt and may move his arms with jittery movements.

Clothing

It is a natural tendency for parents to dress the baby too warmly. As a rule of thumb, dress the baby as you would yourself – if you are comfortable in short sleeves, do the same with baby. At night or when sleeping use thicker clothing and be sure that the baby is not in direct line with cooling or heating vents. Do not put pillows or blankets or other objects in your infant’s crib or bassinet.

Bathing

Sponge bathe your baby in a warm area two to three times per week. Soap is not needed but may be used (Dove, Baby Magic, Neutrogena). Once your baby’s cord has fallen off, you can use a baby bathtub. A foam insert or a towel placed on the bottom will help steady your infant.

Sleeping Position

It is now recommended that you place your baby on his back to sleep. In recent studies this has shown to decrease the incidence of Sudden Infant Death Syndrome. You should also avoid pillows, sheepskins or heavy comforters. Put your baby down drowsy, but awake, rather than always feeding or rocking your child to sleep. Also, it is a good habit to alternate the side your baby’s head rests to avoid asymmetric flattening of one side of the head from consistent head position to one side. You may introduce tummy time as early as two weeks and try to do so at least 4 times a day.

Skin Rashes

During the first two weeks a splotchy red rash with tiny pimples comes and goes and then disappears. This is called “erythema toxicum” and is normal. Peeling of the skin in the first two weeks is also normal. Baby lotion is not necessary but may be used if desired. If cracking around the wrists or ankles occurs, apply Vaseline once or twice daily. At approximately one month of age most babies get small bumps on the face, scalp and neck which resemble acne – called “neonatal acne.” This rash is related to hormonal changes and excessive oiliness of the skin. Wash with a mild soap once or twice a day; this rash disappears by six to eight weeks of age. Almost all babies get diaper rash sooner or later. Desitin, Balmex, Triple Paste or other diaper creams applied to the rash with each diaper change usually cures it within several days; if not, see the doctor. For cradle cap (scaling of the scalp) use a dandruff shampoo approximately once every other day, using baby shampoo in between. Massage the baby’s scalp during shampoo. (Warning: dandruff shampoos are irritating to baby’s eyes – so be careful.)

Diapers

Cloth or disposable? From a health perspective there is little difference between cloth and disposable diapers. Cloth diapers are much more favorable to the environment, while disposable diapers are more convenient. Costs are similar. Baby wipes are okay (if you have a son, wait until the circumcision has healed); we prefer the unscented types. A wipe warmer will sometimes help not startle a tired baby at a middle of the night diaper change.

Urine

It is normal to see what appears to be crystals or tiny balls of gelatin in the diaper when using disposable diapers due to a reaction of the urine and chemicals in the diaper. You may also see on occasion a spot of red-orange discoloration on the diaper. This is not blood it is simply normal urate crystals from the urine. If, however, all of the urine itself is pink, then a physician should be called.

Care of the Genitals

Boys: If circumcised, gently sponge the circumcised area with a wet wash cloth. The plasti-bell will remain on your son’s penis for approximately 3-8 days and will fall off on its own. After that time, you may submerse your son for his baths. If your son was not circumcised using a plasti-bell, the circumcision site will look sore and red for one to two days, then a dry yellow scab forms. Bleeding should be minimal and the circumcision site should not hurt (even though it looks sore). Healing should be complete by the end of a week. If uncircumcised there is nothing special to do until age four to five years when boys should be taught to retract the foreskin with bathing.

Girls: Part the labia with each change and gently sponge off debris using a wet washcloth or baby wipe. Newborn girls normally have a white discharge for several days and then sometimes a small amount of blood for a day or two during the first week.

Normal Fussing and Colic

During the first week babies fuss very little except when they are hungry, soiled or need cuddling. Mysteriously, at about three weeks some babies begin to have fussy periods lasting one to three hours, usually in the early evening or night. For most babies, extra holding or sucking is all they need. However, in some babies the fussing period can be quite intense with the baby drawing up his legs as if in pain and passing large amounts of gas. This is “colic.” The fussy periods build until about two months of age and generally disappear by about three to four months. Typically, these infants are not fussy except in the evening. The cause of “colic” remains a mystery for most babies. In a few babies it may be related to the type of formula or may indicate an illness such as ear infection– so if fussing is severe, make an appointment with the doctor for examination. During fussy periods some babies like to be carried a lot more than usual; some respond to an infant swing or to a bath; some find the sounds of a radio, television or fan soothing; some are comforted by a car ride or by a vibrating infant seat. If fussing is intense, you may try Mylicon drops for gas (0.3 cc before feedings, up to four times a day). Alternately, many babies seemed relieved with the use of gripe water. For most babies with fussing you can quickly “diagnose” their fussy period and proceed through your checklist of remedies. If nothing seems to work and you have had the baby checked, the doctor may advise you to allow the baby to cry 5-10 minutes to release tension. Probably the most difficult thing for parents to see is their infant’s discomfort and not be able to do something. If fussing has posed a problem for you or your spouse, discuss this with the doctor.

Signs of Illness

Fever: If the baby feels hot to touch, take the baby’s temperature rectally with a digital thermometer. Over 100.4 degrees F should be considered a fever. Fever in newborns under two months old can be a sign of serious illness – call the doctor. Ear thermometers are not accurate in infancy. Temperatures may be artificially elevated if taken at feeding or if bundled. Unbundle your baby approximately 5-10 minutes and recheck temperature.

Lethargy (excessive sleepiness): Sleeping through two consecutive feedings (7-8 hours apart during the first week) could be a sign of a serious illness – call.

Fussing That Lasts Hours: Especially during the first week if feeding doesn’t work – call.

Jaundice: Jaundice occurs when yellow pigment (bilirubin) normally released from red blood cells is inadequately cleared from the circulation by an immature liver. About one third of infants develop mild jaundice on the third to fifth day of life involving the eyes and face, which is no cause for concern. As the bilirubin rises, the yellow color deepens and moves downward to involve the trunk and legs. At extremely high levels, bilirubin may cause damage to the brain. The hospital will check your baby’s bilirubin level before discharge and the doctor will advise you if any actions need to be taken.

At home if your baby’s face looks yellow but the color does not extend to the body, place your baby near a window but not in direct sunlight. Daylight aids the body in ridding itself of extra bilirubin. Stooling will eventually resolve the jaundice. If the yellow color is striking and particularly if it extends onto the abdomen and legs, be sure to call the office. We will usually do a blood test to measure the level of bilirubin. In babies with high levels of bilirubin, treatment may include phototherapy (special lights) which can sometimes require going back to the hospital.

Emergencies

We suggest that all parents take a CPR course through their local hospital, fire department or Red Cross. Know the location of the nearest emergency room, and keep these numbers ready by the phone: Pediatrician, Poison Control Center, Pharmacy. Also, instruct your babysitters about them. We recommend to also have your home address available by the phone in case your sitter needs to call 911 for help.

Immunizations

Immunizations have saved the lives of countless children and rendered previously feared diseases nearly extinct. Unfortunately, there is a lot of misinformation circulating around that immunizations are unnecessary or even harmful. Nothing could be further from the truth, they are safe and effective. While there may be “reactions” to certain vaccinations, these are usually minor. If you have any concerns about immunizing your child, please discuss these with us. Routine childhood immunizations may begin in the hospital with Hepatitis B vaccine. This vaccine is very safe and effectively prevents a viral disease that destroys the liver. Other vaccines will begin at the 2 month visit. You will have the opportunity to ask questions at the time. For more information regarding immunizations, see www.whyimmunize.org or www.cdc.gov/vaccine. To see the entire vaccine schedule, click here.

Safety

Begin practicing safe baby care. Always use a car seat properly; never leave a baby on a table or near water unattended. Avoid direct sun exposure. Never shake a baby. Avoid contact with cigarette smoke (even e-cigarettes).

Taking Care of Yourself: Avoid Burnout

It is surprising how much work it really is to take care of a newborn, and how stressful especially if your baby is colicky. Moms especially will always feel “on call” for the first month or so and will chronically feel sleep-deprived. Previously-working mothers sometimes find themselves socially isolated with a new baby. These feelings are probably at their worst at one to two months when the novelty of the experience has worn off, when the baby is still awakening at night and has not yet begun to smile and has not yet become socially responsive. What can you do? It is important for mothers to take care of themselves. Somethings to try are to enlist dad’s help in simple tasks or even, if possible, in spending some alone time with his baby while you get time away (not time to clean, time to take care of you!). If you have family locally, they likely want to help but may not know how to fill your needs. Ask for help and rely on people who love you. By one month, recruit a reliable babysitter and make a date with your spouse. Get some exercise; hook up with some friends, perhaps with other parents of newborns, for strolls, trips to the park, etc. After 6 weeks you can more safely visit relatives and friends and show off your baby.

Don’t Worry (or at least try!)

It is normal to feel anxious and clumsy and unsure at first. Be patient. You and the baby will get the hang of it before long. Relax and enjoy the slow pace of the early days. Don’t be surprised if it is hard to get things done. Moms, your main job is taking care of yourself and the baby. Allow your husband, visiting relatives and friends to help with household chores. Schedule your friends’ visits and calls so you can nap. If grandparents’ or relatives’ help or advice is interfering rather than helping, find a way to politely say “thanks,” but follow your instincts and our advice. If you still are sad, tearful or feel overwhelmed by 4 weeks, you may be suffering from postpartum depression. Please contact your doctor to discuss this.