lift head briefly when on the tummy (which baby should be on only when supervised)The wait is over. Your baby—the little person you’ve been eagerly expecting for nine months—is finally here. As you hold this tiny warm bundle for the first time, you’re bound to be flooded by a thousand and one emotions, running the confusing gamut from excitement and exhilaration to apprehension and self-doubt. And, especially if you’re a first-time parent, you’re also likely to be overwhelmed by (at least) a thousand and one questions. Why is her head such a funny shape? Why does he have acne already? Why can’t I get her to stay awake long enough to breastfeed? Why won’t he stop crying?
As you search around for the operating instructions (don’t babies come with them?), here’s something you need to know: Yes, you’ve got a lot to learn (after all, nobody’s born knowing how to care for an umbilical stump or massage a clogged tear duct), but give yourself half a chance, and you’ll be surprised to find how much of this parenting thing actually comes naturally (including the most important operating instruction of all: Love your baby). So find the answers to your questions in the chapters that follow, but as you do, don’t forget to tap into your most valuable resource of all—your own instincts.
Within a few days of birth your baby will probably be able to:
lift head briefly when on the tummy (which baby should be on only when supervised)
move arms and legs on both sides of the body equally well
focus on objects within 8 to 15 inches (especially your face!)
Your baby’s very first checkup will take place moments after his or her arrival, in the delivery or birthing room. Here, or later on in the nursery, you can expect that a doctor or nurse will do some or all of the following:
Clear baby’s airways by suctioning his or her nose (which may be done as soon as the head appears or after the rest of the baby is delivered).
Clamp the umbilical cord in two places and cut between the two clamps—although dad may do the cutting honors. (Antibiotic ointment or an antiseptic may be applied to the cord stump, and the clamp is usually left on for at least twenty-four hours).
Assign baby an Apgar score (rating of baby’s condition at one and five minutes after birth; see page 103).
Administer antibiotic ointment to the eyes (see page 117) to prevent gonococcal or chlamydial infection.
Weigh baby (average weight is 7½ pounds; 95 percent of full-term babies weigh in at between 5½ and 10 pounds).
Measure baby’s length (average length is 20 inches; 95 percent of newborns are between 18 and 22 inches).
Measure head circumference (average is 13.8 inches; normal range is from 12.9 to 14.7 inches).
Count fingers and toes, and note if baby’s observable body parts and features appear normal.
A few drops of blood can go a long way. Currently those drops, taken routinely from babies’ heels after birth, are used to test for PKU and hypothyroidism. But there is an effort under way to push states to test blood from heel sticks for more metabolic disorders, including congenital adrenal hyperplasia, biotinidase deficiency, maple syrup urine disease, galactosemia, homocystinuria, medium-chain acyl-CoA dehydrogenase deficiency, and sickle-cell anemia. Though most of these conditions are very rare, they can be life threatening if they go undetected and untreated. Testing for these and other metabolic disorders is inexpensive, and in the very unlikely event that your baby tests positive for any of them, your baby’s pediatrician can verify the results and begin treatment immediately—which can make a tremendous difference in the prognosis.
Different states test for different disorders. The federal government is looking into ways to standardize testing in all states. Until then, know which tests your state requires by contacting The National Newborn Screening & Genetics Resource Center at http://genes-r-us.uthscsa.edu. Or contact Baylor University Medical Center: 800-4Baylor (422-9567); www. baylorhealth.com/healthservices/metabolic/ (click on “Newborn Screening”); Mayo Medical Laboratories: www.mayoclinic.org/laboratorygeneticsrst/newbornscreening.html; or Pediatrix Screening: 954-384-0175; www.pediatrixscreening.com. For general information, go to www.savebabies.org.
Babies learn everything about their environment from their senses—from the sight of daddy’s smiling face, to the feel of warm skin as they’re cradled in loving arms, to the smell of a flower, to the sound of mommy’s voice as she matches coo for coo. But for approximately 1 out of every 700 to 2,500 babies born in the United States, the sense of hearing—so integral to the development of speech and language skills—is impaired.
Until recently, hearing loss usually went undetected in young children until delays in those important skills were noticed, often not until the preschool years, sometimes not until much later. Today, however, both the American Academy of Pediatrics and the Centers for Disease Control endorse universal screening of infants for hearing loss. And in fact, nearly two-thirds of all states require that newborns be tested in the hospital for hearing defects.
Today’s newborn hearing screening tests are highly effective. One test, called otoacoustic emissions (OAE), measures response to sound by using a small probe inserted in the baby’s ear canal. In babies with normal hearing, a microphone inside the probe records faint noises coming from the baby’s ear in response to the auditory stimulation. This test can be done while the baby is sleeping, is completed within a few minutes, and causes no pain or discomfort. A second screening method, called auditory brainstem response (ABR), uses electrodes placed on the baby’s scalp to detect activity in the brain stem’s auditory region in response to “clicks” sounded in the baby’s ear. ABR screening requires the baby to be awake and in a quiet state, but it is also quick and painless. If your baby doesn’t pass the initial screening, the test will be repeated to avoid false-positive results.
If your state is not among those that require newborn hearing screening, make sure you ask for it before your baby leaves the hospital. Though hearing loss can affect anyone, risk factors include NICU (Neonatal Intensive Care Unit) admission for two or more days; syndromes known to include hearing loss, such as Usher’s syndrome or Waardenburg’s syndrome; family history of childhood hearing loss; as well as congenital infections, such as toxoplasmosis, syphilis, rubella, cytomegalovirus, and herpes.
Assess gestational age (time spent in the uterus) in babies born before term.
Hand baby to you for breastfeeding and/or cuddling.
Before baby leaves the delivery or birthing room, place ID bands on baby, mom, and dad. Baby’s footprints and mom’s fingerprint may also be obtained for future identification purposes (the ink is washed off your baby’s feet, and any residual smudges you may note are only temporary).
The baby’s doctor, usually of your choosing, will perform a more complete examination of the new arrival sometime during the next 24 hours. If you can arrange to be present, this is a good time to start asking the thousands of questions you’re sure to have. The doctor will check the following:
Weight (it will probably have dropped since birth, and will drop a little more in the next couple of days), head circumference (may be larger than it was at first, as any molding of the head begins to round out), and length (which won’t actually have changed, but might seem to have because measuring a baby—who can’t stand or cooperate—is a highly inexact procedure)
Despite the oohs and aahs they elicit from excited friends and families, most freshly delivered babies aren’t exactly the dimpled, advertisement-ready bundles of cuteness most first-time parents expect to be handed. Loveable, yes. Ready for their close-up, usually not.
For starters, the average new arrival’s head looks too large for its body (it’s about one quarter of baby’s total length), and its legs are usually more chicken-scrawny than baby-round. If the trip through the birth canal was a particularly tight squeeze, the head may be somewhat molded—sometimes to the point of being “cone” shaped. A bruise might also have been raised on the scalp during delivery.
Newborn hair may be practically nonexistent, limited to a sprinkling of fuzz, or so full it looks like it’s already due for a trim; it may lie flat or stand up straight in spikes. When hair is thin, blood vessels may be seen as a blue road map across baby’s scalp, and the pulse may be visible at the soft spot, or fontanel, on the top of the head.
Many newborns (like their mothers) appear to have gone a few rounds in the ring after a vaginal delivery. (Babies who arrive by cesarean, especially if they didn’t go through the compression of labor first, often have a significant edge in the looks department.) Their eyes may appear squinty because of the folds at the inner corners, swelling from delivery and, possibly, because of the infection-protecting eye ointment gooping them up. Their eyes may also be bloodshot from the pressures of labor (which is often the case with mom, too). The nose may be flattened and the chin unsymmetrical or pushed in from being squeezed through the pelvis, adding to the boxer-like appearance.
Because a newborn’s skin is thin, it usually has a pale pinkish cast (even in non-Caucasian babies) from the blood vessels just beneath it. Right after delivery, it’s most often covered with the remains of the vernix caseosa, a cheesy coating that protects fetuses during the time spent soaking in the amniotic fluid (the earlier a baby arrives, the more vernix is left on the skin). Babies born late may have skin that’s wrinkled or peeling (because they had little or no vernix left to protect it). Babies born late are also less likely than early babies to be covered with lanugo, a downy prenatal fur that can appear on shoulders, back, forehead, and cheeks and that disappears within the first few weeks of life.
Finally, because of an infusion of female hormones from the placenta just before birth, many babies, both boys and girls, have swollen breasts and/or genitals. There may even be a milky discharge from the breasts and, in girls, a vaginal discharge (sometimes bloody).
Be sure to capture those newborn features on film quickly (as if you’ll need to be told to grab the camera!), because they’re all temporary. Most are gone within the first few days, the rest within a few weeks, leaving nothing but dimpled, picture-pretty cuteness in their place.
Internal organs, such as kidneys, liver, and spleen, by palpation (examining by touch, externally)
Newborn reflexes
Hips, for possible dislocation
Hands, feet, arms, legs, genitals
The umbilical stump
During your baby’s hospital stay, the nurses and/or doctors will:
Record passage or lack of passage of urine and/or stools (to rule out any problems in the elimination department).
Administer vitamin K injection, to enhance the clotting ability of baby’s blood.
Obtain blood from infant’s heel (with a quick stick), to be screened for phenylketonuria (PKU) and hypothyroidism. Blood is also tested for certain metabolic disorders; some states mandate tests for only a few disorders, but you can arrange for a private lab to screen for thirty metabolic disorders (see box, page 100).
Possibly, with your consent, administer the first dose of hepatitis B vaccine sometime before hospital discharge. This is routine in some hospitals, and necessary if an infant’s mother tests positive for hep-B. If you’re not a carrier, the first dose may be given anytime during the first two months, or the pediatrician may suggest giving the DTaP-polio-hep B combination vaccine starting at two months. Babies who’ve had the birth dose can also receive the combination vaccine; the extra dose of hep-B isn’t a problem. Follow the doctor’s recommendations.
Conduct a hearing screening (see box, page 101).
The first test most babies are given—and which most pass with good scores—is the Apgar, developed by anesthesiologist Virginia Apgar. The scores, recorded at one minute and again at five minutes after birth, reflect the newborn’s general condition and are based on observations made in five assessment categories. Babies who score between 7 and 10 are in good to excellent condition and usually require only routine postdelivery care; those scoring between 4 and 6, in fair condition, may require some resuscitative measures; and those who score under 4, in poor condition, will require immediate and maximal lifesaving efforts. Research shows that even babies whose scores remain low at five minutes usually turn out to be completely normal and healthy.
Mother Nature pulls out all the stops when it comes to newborn babies, providing them with a set of inborn reflexes designed to protect these especially vulnerable creatures and ensure their care (even if the new parents’ instincts haven’t fully kicked in yet).
Some of these primitive behaviors are spontaneous, while others are responses to certain actions. Some seem intended to shield a baby from harm (such as when a baby swipes at something covering his or her face, a reflex that is meant to prevent suffocation). Others seem to guarantee that a baby will get fed (as when a baby roots for a nipple). And while many of the reflexes have obvious value as survival mechanisms, nature’s intentions are more subtle in others. Take the fencing reflex. Though few newborns are challenged to a duel, some theorize that they take this challenging stance while on their backs in order to prevent them from rolling away from their mothers.
Startle, or Moro, reflex. When startled by a sudden or loud noise, or a feeling of falling, the Moro reflex will cause the baby to extend the legs, arms, and fingers, arch the back, draw the head back, then draw the arms back, fists clenched, into the chest.
Duration: Four to six months.
Babinski’s, or plantar, reflex. When the sole of a baby’s foot is gently stroked from the heel to toe, the baby’s toes flare upward and the foot turns in.
Duration: Between six months and two years, after which toes curl downward.
Rooting reflex. A newborn whose cheek is gently stroked will turn in the direction of the stimulus, mouth open and ready to suckle. This reflex helps the baby locate the breast or bottle and secure a meal.
Duration: About three to four months, though it may persist when baby is sleeping.
Walking, or stepping, reflex. Held upright on a table or other flat surface, supported under the arms, a newborn may lift one leg and then the other, taking what seem to be “steps.” This “practice walking” reflex works best after the fourth day of life.
Duration: Variable, but typically about two months. (This reflex does not forecast early walking.)
Sucking reflex. A newborn will reflexively suck when the roof of his or her mouth is touched, such as when a nipple is placed in the mouth.
Duration: Present at birth and lasts until two to four months, when voluntary sucking takes over.
Palmar grasping reflex. Touch the palm of your baby’s hand, and his or her fingers will curl around and cling to your finger (or any object). An interesting bit of baby trivia: A newborn’s grasp may be powerful enough to support full body weight—but don’t try this at home (or anywhere else, for that matter). Some more trivia: This reflex curls babies’ feet and toes, too, when they’re touched.
Having your baby at home means that you’ll have more control over the birth—plus no bags to pack—but it also means you’ll have more responsibilities afterward. Some procedures that are routine in hospitals and birthing centers may just be bureaucratic red tape that you and your baby can easily skip; others, however, are necessary for your baby’s health and future well-being; still others are required by law. Give birth in a hospital, and the following are automatically taken care of; give birth at home, and you’ll need to:
Give some thought to eye ointment. Some midwives allow the parents of a newborn to give informed consent not to administer antibiotic eye ointment (which protects babies from infection should their mother have a venereal disease) after birth. Though the ointment used is no longer irritating to baby’s eyes, it can blur vision, making that first eye-to-eye contact in mommy’s and daddy’s arms less clear. Discuss this option with your practitioner before delivery.
Plan for routine shots and tests. Many babies born in a hospital receive their first dose of hepatitis B vaccine, and all receive a shot of vitamin K (to improve blood clotting) shortly after delivery. They’re also given a heel stick to screen for PKU and hypothyroidism, and in some hospitals or at the parent’s request, for a variety of other conditions (see box, page 100). Speak to your baby’s doctor about when these procedures can be performed on your newborn. It’s also a good idea to ask the pediatrician to arrange a hearing test, typically administered to newborns before they leave the hospital (see page 101).
Take care of business. The filing of a birth certificate is usually taken care of by hospital staff. If you’re planning to give birth at home, you (or your birth attendant) will need to be responsible for the paperwork. Call your state’s Office of Vital Records and Statistics for information on how to file a birth certificate.
Be sure to contact your pediatrician immediately after the birth to arrange an appointment for your baby as soon as possible.
Duration: Three to six months.
Tonic neck, or fencing, reflex. Placed on the back, a young baby will assume a “fencing position,” head to one side, with arms and legs on that side extended and the opposite limbs flexed. En garde!
Duration: Varies a lot. It may be present at birth or may not appear for at least two months, and disappear at about four to six months—or sooner, or later.
For fun, or out of curiosity, you can try checking your baby for these reflexes—but keep in mind that your results may be less reliable than those of a doctor or other trained examiner. A baby’s reflexes may be less pronounced, too, if he or she is hungry or tired. So try again another day, and if you still can’t observe the reflexes, mention this to your baby’s doctor, who probably has already tested your baby successfully for all newborn reflexes and will be happy to repeat the demonstrations for you at the next office visit.
The actual process of feeding a baby a bottle, oddly enough, typically comes more naturally—or at least more easily—than breastfeeding. Babies have little trouble learning to suckle from an artificial nipple, and parents have little difficulty at the delivery end. (Which is why mothers who choose to do the “combo” should hold off on bottles until they and their babies are well established in their breastfeeding routine.) Getting to the feeding, however, may take a little more effort and a lot more know-how. After all, while breast milk is ready to serve, formula must be selected, purchased, sometimes prepared, and often stored. Whether you’re formula feeding exclusively or just supplementing, you’ll need to know how to get started. (See page 48 for tips on choosing nipples and bottles for your formula-fed baby.)
Formulas can’t precisely replicate nature’s recipe for breast milk (for instance, they can’t pass along antibodies), but they do come closer to that gold standard of baby feeding than they ever have before. In fact, all of today’s formulas are made with types and proportions of proteins, fats, carbohydrates, sodium, vitamins, minerals, water, and other nutrients similar to breast milk’s, and must meet standards set by the FDA (Food and Drug Administration). So just about any iron-containing formula you choose for your baby will be nutritionally sound. Still, the vast selection of formulas on your local supermarket or drugstore shelf can be dizzying—and more than a little confusing. Before you contemplate that selection, consider the following formula facts:
If you’re breastfeeding—either exclusively or in combination with the bottle—you’ll find everything you need to know in chapter 3, beginning on page 66.
Your baby’s doctor knows a thing or two about formula. In your search for the perfect formula for your baby, start with a call to the pediatrician. He or she can help steer you to a formula that is closest to human milk in composition, as well as the one that best fits your baby’s needs.
Cows make the best formula for most human babies. That’s why the majority of formulas are made with cow’s milk that has been modified to meet the nutritional needs of human babies. (Do not feed your baby regular cow’s milk until after his or her first birthday; it’s not as easily digested or absorbed as formula and doesn’t provide the proper nutritional elements a growing infant needs.) In infant formulas, cow’s milk proteins are made more digestible, more lactose is added (so that it’s closer to breast milk in composition), and butterfat is replaced with vegetable oils.
Soy-based formulas are best in some circumstances. In these formulas, soybeans are modified with vitamins, minerals, and nutrients to approximate breast milk. Since they stray further from human milk than cow’s milk formulas do, and because research shows that infants on soy are more likely to develop a peanut allergy later on, soy formulas are not usually recommended unless there are special health considerations for the baby, such as a cow’s milk allergy. Vegans may also choose to go soy from the start, without any medical indications.
Just when formula companies think they’ve come as close as they can to simulating the composition of breast milk, another discovery about what makes breast best sends them back to the formulating tables. The most recent is the importance of the omega-3 fatty acids found naturally in breast milk: DHA (docosahexaenoic acid) and ARA (arachidonic acid). These headline-making nutrients have been recognized by scientists as enhancing mental and visual development in infants, and as playing a pivotal role in brain function.
Scientists have found that infants accumulate DHA/ARA in their brains and retinas most rapidly between the third trimester of pregnancy (when they receive a supply of the fatty acid courtesy of the placenta) and age 18 months—not coincidentally, the period of greatest growth in young brains. Research so far has shown that infants benefit significantly from an adequate intake of DHA/ARA, though a direct link to boosted IQ and other developmental edges—while widely speculated—has yet to be clearly established.
Even without DHA and RHA supplementation, full-term infants already have some of these valuable fatty acids stored up from their stint in the womb. They also appear able to manufacture some DHA and ARA from other oils already in formula (though some studies suggest that the amount they can make themselves may not be enough to foster optimal brain and visual development). Premature babies, who missed out on all or part of the third trimester, are at a distinct disadvantage in the fatty acid department, since they have no reserves to tap into.
To ensure that all babies can receive all the DHA and ARA they need, the FDA opted to allow formula manufacturers to enrich their products with these fatty acids. This ruling came a little late in the game; the World Health Organization had been recommending supplementing formulas with DHA and ARA since 1994, and parents in more than sixty countries in Europe and around the world have been able to feed their babies formula enriched with fatty acids for years. Now American parents can have that choice, too—a choice that may just be a smart one for your baby.
Special formulas are best for some special babies. There are formulas available for premature babies, babies who turn out to be allergic to cow’s milk and soy, as well as those with metabolic disorders, such as PKU. There are also lactose-free formulas, as well as hypoallergenic formulas designed to trigger fewer allergies in those babies prone to them. For some babies, these formulas are easier to digest than standard formulations; not surprisingly, they are much more expensive. You don’t need to use them unless your baby’s doctor has recommended them. There are also some organic formulas that are produced from milk products untouched by growth hormones, antibiotics, or pesticides.
How much formula does your baby need? A lot depends on your baby’s weight, age, and once solids are being taken, how much he or she is eating. As a general rule, infants under six months (those not supplementing with solids) should be taking 2 to 2½ ounces of formula per pound of body weight over a twenty-four-hour period. So, if your baby weighs 10 pounds, that would translate to 20 to 25 ounces of formula a day; in a twenty-four-hour period, you’ll be feeding your baby around 3 to 4 ounces every four hours.
But because these are just rough guidelines, and because every baby is different (and even the same baby’s needs are different on two different days), you shouldn’t expect your infant to follow this formula (so to speak) with mathematical precision. How much your baby needs to take may vary somewhat—from day to day and feeding to feeding—and may stray significantly from what baby’s peers need.
Keep in mind, too, that your baby’s consumption will depend not just on weight but also on age. A large newborn, for example, probably won’t be able to drink as much as a small three-month-old—even if their weights are the same. So start your newborn out slow, with an ounce or two at each feeding for the first week every three to four hours (or on demand). Gradually up the ounces, adding more as the demand becomes greater, but never push baby to take more than he or she wants. After all, your baby’s tummy is the size of his or her fist (not yours). Put too much in the tummy, and it’s bound to overflow—in the form of excessive spit-up.
Most of all, remember that bottle-fed babies, just like breastfed babies, know when they’ve had enough—and enough, for a newborn, is like a feast. Take your cues from baby’s hunger, and you’re sure to find the perfect formula for feeding your baby. As long as your baby is gaining enough weight, is wetting and dirtying enough diapers, and is happy and healthy (see page 164), you can be sure you’re on target. For more reassurance, check with your baby’s pediatrician on formula intake.
Follow-ups are not always best. Follow-up formulas are designed for babies older than four months who are also eating solid foods. Check with your baby’s doctor before using follow-up formula; some doctors don’t recommend them.
Iron-fortified is best. While formulas come in low-iron formulations, they aren’t considered a healthy option. The AAP and most pediatricians recommend that babies be given iron-fortified formula from birth until one year.
For best results, look to your baby. Different formulas work well for different babies at different times. Coupled with the advice of the pediatrician, your baby’s reaction to the formula you’re feeding will help you assess what’s best.
Once you’ve narrowed your selection down to a general type, you’ll need to choose, too, between the different forms those formulations come in:
Ready-to-use. Premixed ready-to-go formula comes in 4- and 8-ounce single-serving bottles and is ready for baby with the simple addition of a bottle nipple. It doesn’t get easier than this, but it does get less expensive (see options below) and less environmentally unfriendly (with this choice you’ll be tossing or recycling a lot of bottles during the next year).
Ready-to-pour. Available in cans or plastic containers of various sizes, this liquid formula need only be poured into the bottle of your choice to be ready for use. It’s less expensive than single-serving feedings, but the formula left in the container needs to be stored properly. You’ll also pay more for the convenience of ready-to-pours than formulas that need to be mixed.
Concentrated liquid. Less expensive than ready-to-pour but a little more time-consuming to prepare, this concentrated liquid is diluted with equal parts of water to make the finished formula.
Powder. The least expensive option, yet the most time-consuming and potentially messy, powered formula is reconstituted with a specified amount of water. It’s available in cans or single-serving packets. Besides the low cost, another compelling reason to opt for powder (at least when you’re out and about with baby) is that it doesn’t need to be refrigerated until it’s mixed.
Formula feeding has never been safer—as long as you take just a few precautions:
Always check the expiration date on formula; do not purchase or use any formula that has expired. Don’t buy or use dented, leaky, or otherwise damaged cans or other containers.
Wash your hands thoroughly before preparing formula.
Before opening, wash the tops of formula cans with detergent and hot water; rinse well and dry. Shake, if the label specifies.
Use a clean punch-type opener to open cans of liquid formula, making two openings—one large, one small—on opposite sides of the can to make pouring easier. Wash the opener after each use. Most powdered formula cans come with special pull-open tops, making the use of a can opener unnecessary. If you’re using a single-serving bottle, make sure you hear the top “pop” when you open it.
It isn’t necessary to sterilize the water used to mix formula by boiling it. If you’re unsure about the safety of your tap water, or if you use well water that hasn’t been purified, have your supply tested and, if necessary, purified. Or just use bottled water (not distilled).
Here’s another step you can save: Bottles and nipples don’t need to be sterilized with special equipment. Dishwashers (or sink washing with detergent and hot water) get them clean enough. Some doctors recommend submerging bottles and nipples in a pot of boiling water for a few minutes before the first use.
But here’s a step you should never skip: Follow the manufacturer’s directions precisely when mixing formula. Always check cans to see if formula needs to be diluted: Diluting a formula that shouldn’t be diluted, or not diluting one that should be, could be dangerous. Formula that is too weak can stunt growth. Formula that is too strong can lead to dehydration.
Bottle warming is a matter of taste, namely baby’s. There is no health reason to warm formula before feedings, though some babies prefer it this way, especially if that’s what they’ve become accustomed to. In fact, you might consider starting your baby out on formula that’s been mixed with room temperature water or even a bottle right out of the fridge; if he or she gets used to it that way, you can save yourself the time and the hassle of warming bottles (something you’ll especially appreciate in the middle of the night or when your baby’s frantic for a feed). If you do plan to serve the bottle warm, place it in a pot or bowl of hot water or run hot water over it. Check the temperature of the formula frequently by shaking a few drops on your inner wrist; it’s ready for baby when it no longer feels cold to the touch—it doesn’t need to be very warm, just body temperature. Once it’s warmed, use formula immediately, since bacteria multiply rapidly at lukewarm temperatures. Never heat formula in a microwave oven—the liquid may warm unevenly, or the container may remain cool when the formula has gotten hot enough to burn baby’s mouth or throat.
Throw out formula remaining in the bottle after a feeding. It’s a potential breeding ground for bacteria, even if you refrigerate it, and should never be reused, tempting as that might be.
Rinse bottles and nipples right after use, for easier cleaning.
Cover opened cans or bottles of liquid formula tightly and store them in the refrigerator for no longer than the times specified on the labels, usually forty-eight hours. Opened cans of dry formula should be covered and stored in a cool, dry place for use within the month.
Store unopened cans or bottles of liquid formula at between 55°F and 75°F. Don’t use unopened liquid for long periods at temperatures at or below 32°F or in direct heat above 95°F. Also, don’t use formula that has been frozen (soy products freeze more quickly) or that shows white specks or streaks even after shaking.
Keep prepared bottles of formula refrigerated until ready to use. If you are traveling away from home, store previously prepared bottles in an insulated container or in a plastic bag with a small ice pack or a dozen ice cubes (the formula will stay fresh as long as most of the ice is frozen); or pack the bottles with a small box or can of juice that you’ve prefrozen (not only will the formula stay fresh, but you’ll have a cold drink handy, too). Do not use formula that is no longer cold to the touch (unless, of course, it’s ready-to-serve and hasn’t been opened or is powdered formula that has just been mixed with warm or room temperature water). You can also take along ready-to-use bottled formula, or bottles of water and single-serving formula packets to mix with them.
Whether you’ve chosen to feed your baby exclusively with formula or to mix it up with breast, the most important ingredient in any feeding session is love. Though you’ll always feel that love, it’s also essential that you communicate it to your baby. The kind of skin-to-skin, eye-to-eye contact that’s linked to optimum brain development and attachment in a newborn is a built-in feature of breastfeeding. With bottle feeding, that contact takes a conscious effort, and many well-meaning but harried bottle-feeding parents at least occasionally give in to feeding shortcuts that compromise closeness for convenience. To make sure you keep in touch with your baby while you’re bottle feeding:
Don’t prop the bottle. For a young baby, who is as hungry for emotional gratification in the form of cuddling as for oral gratification in the form of food, propping is very unsatisfying. And besides the emotional drawbacks, there are physical ones as well. For one thing, the risk of choking is always present when you prop, even if your baby is in a reclining high chair or infant seat. Prop with baby lying down, and he or she may also be more susceptible to ear infections. Once teeth come in, letting a baby fall asleep with a bottle in his or her mouth (which wouldn’t happen if you were administering the feeding) can lead to tooth decay, since the formula is left to pool in the mouth. So avoid the temptation to prop the bottle and leave your baby during a feeding, even if it means the million and one things you have to do won’t get done.
Go skin to skin, when possible. There are piles of research to show the developmental benefits of regular close contact with a newborn. But no research is as convincing as the satisfaction both you and your baby will get by sharing the warmth and intimacy of skin-to-skin contact. So whenever possible (it won’t work in public, but it will in private), open your shirt and nestle your baby close to you when you bottle feed. Breasts aren’t necessary to achieve the desired effect, either; dads can cuddle their babies cheek-to-chest just as effectively during an open-shirt feeding.
Switch arms. Breastfeeding also builds in this feature (alternating breasts means alternating arms); with bottle feeding, you’ll have to remember to switch. A switch midfeeding serves two purposes: First, it gives your baby a chance to see the world from different perspectives. Second, it gives you a chance to relieve the aches that can develop from staying in one position for so long.
Let baby call it quits. When it comes to feedings, your baby’s the boss. If you see only 3 ounces have been emptied when the usual meal is 4, don’t be tempted to push the rest. A healthy baby knows when to stop. And it’s this kind of pushing that often leads bottle-fed babies to become too plump—much more often than breastfed babies, who eat to appetite.
Take your time. A nursing baby can keep suckling on a breast long after it’s been drained, just for comfort and sucking satisfaction. Your bottle-fed baby can’t do the same with an empty bottle, but there are ways you can supply some of the same satisfactions. Extend the pleasure of the feeding session by socializing once the bottle is drained—assuming he or she hasn’t dropped off into a milk-induced sleep. If your baby doesn’t seem satisfied with the amount of sucking each feeding’s providing, try using nipples with smaller holes, which will ensure that your baby will get to suck longer for the same meal. Or finish off feedings by offering a pacifier briefly. If your baby seems to be fussing for more at meal’s end, consider whether you’re offering enough formula. Increase it an ounce or two to see if it’s really hunger that’s making your baby fretful.
Feel good about bottle feeding. If you were eager to breastfeed and for some reason couldn’t—or couldn’t keep it up—don’t feel guilty or frustrated. Such negative feelings can be unwittingly transmitted to your baby during feedings, and keep you both from enjoying what should be a treasured ritual. Remember: Filled with the right formula and given the right way, a bottle can be used to pass along good nutrition and lots of love.
Bottle feeding gives dad and other family members the chance to get close to baby. Use the time for cuddling and interaction; nourishment needn’t come from the breast to come with love.
If you’ve had some experience bottle feeding a young infant—either a sibling, a baby-sitting charge, or a friend’s baby—chances are the correct technique will come back to you (like riding a bike) virtually the moment you hold your baby in your arms. If you’re a first-timer—or if you just want to bone up on bottle-feeding basics—the following step-by-step tips should help:
Give notice. Let baby know that “formula’s on” by stroking his or her cheek with your finger or the tip of the nipple. That will encourage your baby to “root,” turning in the direction of the stroke. Then place the nipple gently between baby’s lips and, hopefully, sucking will begin. If baby still doesn’t get the picture, a drop of formula on the lips should clue him or her in.
Make air the enemy. Tilt the bottle up so that formula always fills the nipple completely. If you don’t, and air fills part of it, baby will be chasing formula down with air—a recipe for gassiness, which will make both of you miserable. Anti-air precautions aren’t necessary, however, if you’re using disposable bottle liners, which automatically deflate (eliminating air pockets), or if you’re using angled bottles that keep the formula pooled near the nipple.
Start slow. Don’t be concerned if your baby doesn’t seem to take much formula at first. The newborn’s need for nutrition is minimal for a few days after birth—a breastfed baby, on orders from Mother Nature, receives only a teaspoonful of colostrum at each feeding during this time. If you’re in the hospital, the nursery will probably provide you with full 4-ounce bottles, but don’t expect them to be drained. A baby who falls asleep after taking just half an ounce or so is probably saying, “I’ve had enough.” On the other hand, if baby doesn’t fall asleep but turns away from the bottle fussily after just a few minutes of nipping, it’s more likely a matter of gas than overfilling. In that case, don’t give up without a bubble. If after a good burping (see page 140) the nipple is still rejected, take that as your signal the meal is over. (See page 108 for more details on how much formula to feed.)
Check your speed. Be certain that formula isn’t coming through the nipple too quickly or too slowly. Nipples are available in different sizes for babies’ different sizes and age; a newborn nipple dispenses milk more slowly, which is usually perfect for a baby who’s just getting the hang of sucking (and whose appetite is still tender). You can check the speed of the nipples you’re using by giving the bottle, turned upside down, a few quick shakes. If milk pours or spurts out, it’s flowing too quickly; if just a drop or two escapes, too slowly. If you get a little spray, and then some drops, the flow is just about right. But the very best way to test the flow is by observing the little mouth it’s flowing into. If there’s a lot of gulping and sputtering going on, and milk is always dripping out of the corners of baby’s mouth, the flow is too fast. If baby seems to work very hard at sucking for a few moments, then seems frustrated (possibly letting go of the nipple to complain), the flow’s too slow. Sometimes, a flow problem has less to do with the size of the nipple than with the way the cap is fastened. A very tight cap inhibits flow by creating a partial vacuum; loosening it up a bit may make the formula flow more freely.
Minimize midnight hassles. Make night feedings less of an ordeal by investing in a bedside bottle holder, which keeps baby’s bottle safely chilled until ready to use and then warms it to room temperature in minutes. Or keep a bottle on ice, champagne-style, in the nursery (or by your bed), ready to serve cold or to warm under the bathroom tap when baby starts fussing for a feeding.
“My friends all seem to be having babies that weigh 8 and 9 pounds at birth. Mine weighed in at a little over 6½ pounds at full term. She’s healthy, but she seems so small.”
Just like healthy adults, healthy babies come in all kinds of packages—long and lanky, big and bulky, slight and slender. And more often than not, a baby can thank the adults in her life for her birth stats; the laws of genetics dictate that large parents generally have large children and small parents generally have small children (though when dad’s large and mom’s small, the progeny are more likely to follow in mom’s smaller footsteps, at least at birth). Mom’s own birth-weight can also influence her offspring’s. Still another factor is a baby’s sex: Girls tend to weigh in lighter and measure in shorter than boys do. And though there is a laundry list of other factors that can affect a baby’s size at birth—such as what mom ate during pregnancy and how much weight she gained—the only factor that matters now is that your baby is completely healthy. And, in fact, a petite 6½ pounder can be every bit as vigorous as a chubby 8 or 9 pounder.
Keep in mind, too, that some babies who start out small quickly outpace their peers on the growth charts as they start catching up to their genetic potential. (For more on this, see page 302.) In the meantime, enjoy your healthy baby while she’s still a relatively light load. It won’t be long before just hearing the words “Carry me!” from your strapping preschooler will make your back start aching.
“I had an emergency cesarean and they whisked my baby away to the ICU before I had a chance to bond with her. Could this affect our relationship?”
Bonding at birth is an idea whose time has come—and, by now, should be gone. That’s because the theory, first suggested in the 1970s, that a mother-baby relationship will be better when the two spend sixteen hours of the first twenty-four in close loving contact, just hasn’t held up in research or in practice.
Without a doubt, good things have come from the bonding theory. Because of it, hospitals now encourage new parents to hold their babies moments after birth, and to cuddle and nurse them for anywhere from ten minutes to an hour or more, instead of dispatching the newborn off to the nursery the instant the cord is cut. This encounter gives mother, father, and baby a chance to make early contact, skin to skin, eye to eye—definitely a change for the better. On the other hand, the concept leaves many parents who aren’t able to hold their babies immediately after birth (either because they had emergency surgical deliveries or traumatic vaginal births, or because the infants arrived in need of special care) feeling as though they’ve missed the chance of a lifetime to foster a close relationship with their offspring.
But not only do many experts believe that bonding doesn’t have to be firmly established at birth, most dispute that it can be. Freshly delivered infants come equipped with all their senses; they’re capable of making eye contact—and even of recognizing their mother’s voice (though they won’t recognize her face until somewhere around three months). They’re also alert in the hour right after birth, which makes this an especially good time for that first official get-together with their parents. But because they’re not capable of retaining these experiences—as wonderful as they are—those first few moments can’t make or break future relationships. A new mother will certainly remember that special first meeting, but she may not feel an immediate bond with her baby for a variety of reasons: exhaustion from a long labor and delivery, grogginess from medication, pain from cramping or an incision, a feeling of being overwhelmed by the enormous responsibility that’s just been handed her, or simply a lack of preparation for the experience of holding and caring for a newborn.
The first few moments a parent and baby spend together after birth are important—but no more important than the hours, and days, and weeks, and years that lie ahead. They mark only the beginning of the long and complex process of getting to know and love each other. And this beginning can just as well take place hours after birth in a hospital bed, or through the portholes of an incubator, or even weeks later at home. When your parents and grandparents were born, they probably saw little of their mothers and even less of their fathers until they went home (usually ten days after birth), and the vast majority of that generation grew up with strong, loving family ties. Mothers who have the chance to bond at birth with one child and not with another usually report no difference in their feelings toward the children. And adoptive parents, who often don’t meet their babies until hospital discharge (or even much later), can foster bonds as strong as those of birth parents who met their infants moments after delivery.
The kind of love that lasts a lifetime can’t magically evolve in a few hours, or even a few days. In fact, experts believe that it doesn’t completely take hold until somewhere in the second half of the baby’s first year. The first moments after birth may become a cherished memory for some, but for others they may be just a blur. Either way, these moments don’t indelibly color the character and quality of your future relationship.
The complicated process of parent-child bonding actually begins for parents during pregnancy, when attitudes and feelings toward the baby start developing. The relationship continues to evolve and change all through infancy, childhood, and adolescence, and even into adulthood. So relax. There’s lots of time to tie those bonds that bind.
“I’ve been told that bonding at birth brings mother and baby closer together. I held my new daughter for nearly an hour right after delivery, but she seemed like a stranger to me then, and still does now, three days later.”
Love at first sight is a concept that flourishes in novels and movies but rarely materializes in real life. The kind of love that lasts a lifetime usually requires time, nurturing, and plenty of patience to develop and deepen. And that’s just as true for parental love as it is for romantic love.
Physical closeness between parent and child immediately after birth does not guarantee instant emotional closeness. Those first postpartum moments aren’t automatically bathed in a glow of maternal (or paternal) love. In fact, the first sensation a woman experiences after birth is just as likely to be relief as it is love—relief that the baby is normal and, especially if her labor was difficult, that the ordeal is over. It’s not at all unusual to regard that squalling and unsociable infant as a stranger with very little connection to the cozy, idealized baby you carried for nine months—and to feel little more than neutral toward her. One study has found that it took an average of over two weeks (and often as long as nine weeks) for mothers to begin having strongly positive feelings toward their newborns.
While bonding is a process that involves both parents, fathers apparently have their own way of becoming close to their new infants—and researchers have even given it a name of its own: engrossment. Engrossment applies not only to what a father does for his baby (such as holding, comforting, rocking, massaging) and the unique way that he does it (fathers have a touch that’s different from mothers’, a difference babies respond to), but also what the baby does for his or her father (such as bringing out his sensitive, nurturing side). For more on fathering, see chapter 24.
Just how a woman reacts to her newborn at their first meeting may depend on a variety of factors: the length and intensity of her labor; whether she received medication during labor; her previous experience (or lack of it) with infants; her feelings about having a child; her relationship with her spouse; extraneous worries that may preoccupy her; her general health; and probably most important of all, her personality.
Your reaction is normal for you. And as long as you feel an increasing sense of comfort and attachment as the days go by, you can relax. Some of the best relationships get off to the slowest starts. Give yourself and your baby a chance to get to know and appreciate each other, and let the love grow unhurriedly.
If you don’t feel a growing closeness after a few weeks, however, or if you feel anger or antipathy toward your baby, talk to your practitioner. It’s possible that you’re suffering from postpartum depression, especially if you’re experiencing other symptoms of the condition. If that’s the case, treatment is important not just for your health but also for the well-being of your baby and your relationship with her. See page 672 for more.
“I expected my baby to lose some weight in the hospital, but she dropped from 7½ pounds to 6 pounds 14 ounces. Isn’t that excessive?”
New parents, eager to start issuing reports on their baby’s progress in the weight-gain department, are often disappointed when their babies check out of the hospital weighing considerably less than when they checked in. But nearly all newborns are destined to lose some of their birthweight (usually between 5 and 10 percent) in the first five days of life—not as a result of fad dieting in the nursery, but because of normal postdelivery fluid loss, which is not immediately recouped, since babies need and take in little food during this time. Breastfed babies, who consume only teaspoons at a time of the premilk colostrum, generally lose more than bottle-fed babies. Most newborns have stopped losing by the fifth day and have regained or surpassed their birthweight by ten to fourteen days of age—when you can start issuing those bulletins.
“People ask me whether the baby looks like me or my husband. Neither one of us has a pointy head, puffy eyes, an ear that bends forward, and a pushed-in nose. When will he start looking better?”
There’s a good reason why two- and three-month-old babies are used to portray newborns in movies and television commercials: Most newborns are not exactly photogenic. And though parental love is blinder than most, even parents who are head over heels can’t help but notice the many imperfections of their newborn’s appearance. Fortunately, most of the newborn characteristics that will keep your baby from costarring in films and selling diapers on TV are temporary.
The features you’re describing weren’t inherited from some distant pointy-headed, puffy-eyed, flap-eared relative. They were acquired during your baby’s stay in the cramped quarters of your uterus, during the stormy passage through your bony pelvis in preparation for birth, and during his final traumatic trip through the narrow confines of your birth canal during delivery.
If it weren’t for the miraculous design of the fetal head—with the skull bones not fully fused, allowing them to be pushed and molded as the baby makes its descent—there would be many more surgical deliveries. So be thankful for the pointy little head that came with your vaginal delivery, and rest assured that the skull will just as miraculously return to cherubic roundness within a few days or so.
The swelling around your baby’s eyes is also due, at least in part, to the beating he took on his fantastic voyage into the world. (Another contributing factor might be the antibiotic ointment placed in your baby’s eyes to prevent gonococcal or chlamydial infection.) Some have postulated that this swelling serves as natural protection for newborns, whose eyes are being exposed to light for the first time. The worry that the puffiness may interfere with a baby’s ability to see mommy and daddy, making that first eye-to-eye contact impossible, is unfounded. Though he can’t distinguish one from another, a newborn can make out blurry faces at birth—even through swollen lids.
The bent ear is probably another outcome of the crowding your baby experienced in the uterus. As a fetus grows and becomes more snugly lodged in his mother’s cozy amniotic sac, an ear that happens to get pushed forward may stay that way even after birth. But this is only temporary. Taping it back won’t help, say the experts, and the tape might cause irritation, but you can speed the return to normal ear positioning by being sure the ear is back against the head when putting baby (supervised) on his side to play. Some ears, of course, are genetically destined to stand out—but if that’s the case, both generally do, right from the start.
The pushed-in nose is very likely a result of a tight squeeze during labor and delivery, and should return to normal naturally. But because baby noses are so different from the adult variety (the bridge is broad, almost nonexistent, the shape often nondescript), it may still be a while before you can tell whose nose your baby has.
“I was hoping my baby would have green eyes like my husband, but her eyes seem to be a dark grayish color. Is there any chance that they’ll turn?”
The favorite guessing game of pregnancy—will it be a boy or a girl?—is replaced by another in the first few months of a baby’s life—what color will her eyes turn out to be?
It’s definitely too early to call now. Most Caucasian babies are born with dark blue or slate-colored eyes; most dark-skinned infants with dark, usually brown, eyes. While the dark eyes of the darker-skinned babies will stay dark, the eye color of Caucasian babies may go through a number of changes (making the betting more lively) before becoming set somewhere between three and six months, or even later. And since pigmentation of the iris may continue increasing during the entire first year, the depth of color may not be evident until around baby’s first birthday.
“The whites of my newborn’s eyes look bloodshot. Is this an infection?”
It’s not the late hours that newborns keep that often give their eyes that bloodshot look (no, that would be why your eyes will be looking so red for the next few months). Rather, it’s a harmless condition that occurs when there is trauma to the eyeball—often in the form of broken blood vessels—during a vaginal delivery. (Actually, many new mothers who put in a lot of pushing time during delivery sport matching broken blood vessels in their eyes.) Like a skin bruise, the discoloration disappears in a few days and does not indicate there has been any damage to your baby’s eyes.
“Why does my newborn have ointment in his eyes, and how long will it blur his vision?”
There are a lot of factors standing between a newborn baby and a clear view of his surroundings: the fact that his eyes are puffy from delivery; that they’re still adjusting to the bright lights of the outside world after spending nine months in a dark womb; that they’re naturally nearsighted; and, finally, as you’ve noticed, that they’re gooey with ointment. But the ointment serves an important purpose that makes a little increased blurriness well worthwhile: It is administered (as recommended by the AAP and mandated by most states) to prevent a gonococcal or chlamydial infection. Once a major cause of blindness, such infections have been virtually eliminated by this preventive treatment. The antibiotic ointment, usually erythromycin, is mild and not as potentially irritating to the eyes as the silver nitrate drops that were once the treatment of choice (and are still used in a few hospitals). Doctors found that the silver nitrate drops caused redness and inflammation, as well as a tendency for infants to develop a chemical conjunctivitis, characterized by swelling and a yellowish discharge.
The slight swelling and oozy blurriness of your newborn’s eye will last only a day or two. Tearing, swelling, or infection that begins after that may be caused by a blocked tear duct (see page 207).
“Having the baby room-in with me sounded like heaven before I gave birth. Now it seems more like hell. I can’t get the baby to stop crying, yet what kind of mother would I be if I asked the nurse to take her back to the nursery?”
You would be a very human mother (which, by the way, you might as well get used to being). Considering the challenge you’ve just been through (childbirth), and the one you’re about to undertake (parenting), it’s not surprising you’re more in the mood for sleep than you are for a crying baby. And it’s nothing to feel guilty about, either (remember, you’re only human).
Sure, some women handle round-the-clock rooming-in with ease, right from the first night. They may have had deliveries that left them feeling exhilarated instead of exhausted. Or they may have had some experience caring for newborns, their own or other people’s. For these women, an inconsolable infant at 3 A.M. may not be a joy, but it’s not a nightmare, either. For a woman who’s been without sleep for forty-eight hours, however, whose body has been left limp from an enervating labor, and who’s never been closer to a baby than a diaper ad, such predawn bouts can leave her wondering tearfully: Why did I ever decide to become a mother?
Playing the martyr can raise motherly resentments, feelings baby will be likely to sense. If, instead, the baby is taken back to the nursery between feedings at night, mother and child, both well rested, may find getting acquainted easier when morning comes. And morning is the best time to take advantage of one of the major advantages of daytime rooming-in: the chance to learn how to care for your new baby while there’s still experienced help just down the hallway if you need it. Remember, even if you’ve opted to have the baby with you during the day, you shouldn’t feel like you can’t call on the nursery staff to give you a hand. That’s what they’re there for.
When night falls again, and if you feel rested enough, try keeping the baby and see how things go. She may surprise you by doing more sleeping than crying, and you may surprise yourself by feeling more comfortable with her. Or if the second night turns out to be a repeat of the first, or if you’re still not up to working the evening shift, feel free to take advantage of the nursery again. Full-time rooming-in is a wonderful option in family-centered maternity care—but it’s not for everyone. You are not a failure as a mother if you don’t enjoy, or you’re too exhausted for, rooming-in. Don’t be pushed into it if you don’t think you want it; and once you’ve committed yourself, don’t feel you can’t change your mind and go part-time.
Be flexible. Focus on the quality of the time you spend with your baby in the hospital rather than the quantity. Round-the-clock rooming-in will begin soon enough at home. By then, if you don’t overdo now, you should be emotionally and physically ready to deal with it.
You haven’t been a parent for forty-eight hours yet, and already you’ve been on the receiving end of so much conflicting advice (on everything from umbilical stump care to feeding) that your head’s in a tailspin. The hospital staff tells you one thing, your sister (veteran of two newborns) has a completely different take, and both clash with what you seem to recall baby’s pediatrician telling you.
The fact is that the facts about infant care (at least, the most up-to-date facts) aren’t easy to sort out—especially when everyone (and their mother) is telling you something different. Your best bet when all that contradicting counsel leaves you in doubt about any infant care issue (or when you need a deciding vote you can count on): Stick with the doctor’s advice.
Of course, in listening to others, don’t forget that you’ve got another valuable resource you can trust—your own instincts. Often parents, even the really green ones, do know best—and usually, much more than they think they do.
“I’ve been having some pretty bad pain from my cesarean incision. My obstetrician has prescribed some pain medication, but I’m worried about the drug getting into my milk.”
You don’t need to suffer in order to keep your baby safe. In fact, not taking medication for your pain can actually do you both more harm than good. The tension and exhaustion that can result from unrelieved postcesarean (or vaginal birth) pain will only interfere with your ability to establish a good nursing relationship with your baby (you need to be relaxed) and a good milk supply (you need to be rested). Besides which, the medication will appear only in very minuscule amounts in your colostrum; by the time your milk supply comes in, you probably won’t need narcotic pain relief. And if your baby does receive a small dose of medication, he or she will sleep it off easily, with no ill effects.
If your pain is not extremely severe—or once it starts to ease up—you might consider asking the nurse for extra strength acetaminophen (Tylenol), the pain reliever of choice during lactation.
“My baby seemed very alert right after she was born, but ever since, she’s been sleeping so soundly I can hardly wake her to eat, much less to socialize.”
You’ve waited nine long months to meet your baby—and now that she’s here, all she does is sleep. Don’t worry, though, this chronic sleepiness is no reflection on your feeding or socializing skills—it’s just a sign that baby’s doing what comes naturally. Wakefulness for the first hour or so after birth followed by a long stretch, often twenty-four hours, of pronounced drowsiness is the normal newborn pattern (though she won’t sleep for twenty-four hours straight). It is a pattern probably designed to give babies a chance to recover from the exhausting work of being born, and their mothers a chance to recover from giving birth. (You will need to make sure that your baby fits feedings into her sleep schedule, however; see page 122 for some waking techniques.)
It may seem to the casual observer—or the brand-new parent—that infants have just three things on their minds: eating, sleeping, and crying (not necessarily in that order). In fact, however, researchers have shown that infant behavior is actually at least twice as complex as that and can be organized into six states of consciousness. Learn to observe and understand these states, and you’ll be able to decipher the messages your baby’s sending you, and even figure out what he or she wants.
Quiet Alert. This state is a baby’s secret agent mode. When babies are in quiet alert, their motor activity is suppressed, so they rarely move. Instead, they spend all their energy watching (with their eyes wide open, usually staring directly at someone) and listening intently. This behavior makes quiet alert the perfect time for one-on-one socializing. Newborns by the end of their first month typically spend two and a half hours a day in this state.
Active Alert. The motor’s running when babies are in active alert—with arms moving and legs kicking. They may even make some small sounds. Though they’ll be doing a lot of looking around in this state, they’re more likely to be focused on objects than on people—your cue that baby’s more interested in taking in the big picture than in doing any serious socializing. Babies are most often in this newborn state of mind before they eat or when they are borderline fussy. You may be able to preempt full-fledged fussiness at the end of an active alert period by feeding or doing some soothing rocking.
Crying. This is, of course, the state newborns are best known for. Crying occurs when babies are hungry, uncomfortable, bored (not getting enough attention), or just plain unhappy. While crying, babies will contort their faces, move their arms and legs vigorously, and shut their eyes tightly.
Drowsiness. Babies are in this state, not surprisingly, when they’re waking up or nodding off to sleep. Drowsy babies will make some moves (such as stretching upon waking) and make a variety of adorable but seemingly incongruous facial gestures (that can run the gamut from scowling to surprised to elated), but the eyelids are droopy and the eyes will appear dull, glazed, and unfocused.
Quiet Sleep. In this state, baby’s face is relaxed and the eyelids are closed and still. Body movement is rare, with just occasional startles or mouth movements, and breathing is very regular. Quiet sleep alternates every thirty minutes with active sleep.
Active Sleep. Half of the time babies sleep, they are in the active sleep state. In this restless sleep state (which is actually a lot more restful for baby than it looks), the eyes, though closed, can often be seen moving under the lids—thus the name REM, or rapid eye movement sleep. Breathing is not regular; babies may move their mouths in a sucking or chewing motion or even smile; arms and legs may also shift around a great deal.
Don’t expect your newborn to become much more stimulating company once those twenty-four hours of sleepiness are over, either. Here’s approximately how you can expect it to go: In the first few weeks of life, her two- to four-hour-long sleeping periods will end abruptly with crying. She’ll rouse to a semiawake state to eat, probably doing a fair amount of dozing while she’s feeding (shaking the nipple around in her mouth will get her sucking again when she drifts off midmeal). Once she’s satiated, she’ll finally fall more soundly asleep, ready for yet another nap.
At first, your little sleepyhead will be truly alert for only about three minutes of every hour during the day, and less (you hope) at night, a schedule that will allow a total of about an hour a day for active socializing. Though that may be frustrating for you (after all, how long have you waited to try out your peek-a-boo prowess?), it’s just what Mother Nature ordered for your baby. She’s not mature enough to benefit from longer periods of alertness, and these periods of sleep—particularly of REM (or dream state) sleep—apparently help her develop.
Gradually, your baby’s periods of wakefulness will grow longer. By the end of the first month, most babies are alert for about two to three hours every day, most of it in one relatively long stretch, usually in the late afternoon (at which point, you can start testing out your baby-entertaining material on her). And some of their evening “naps,” instead of being two or three hours long, may last as long as six or six and a half hours.
In the meantime, you may continue to be thwarted in your attempts to get to know your baby. But instead of standing over the crib waiting for her to wake up for a play session, try to use her sleeping time to store up a few zzz’s of your own. You’ll need them for the days (and nights) ahead, when she’ll probably be awake more than you’d like.
“It’s been two days since I gave birth to my little girl, and nothing comes out of my breasts when I squeeze them, not even colostrum. I’m worried that she’s starving.”
Not only is your baby not starving, she isn’t even hungry yet. Infants aren’t born with an appetite, or even with immediate nutritional needs. And by the time your baby begins to get hungry for a breast full of milk, usually around the third or fourth postpartum day, you will almost certainly be able to oblige.
Which isn’t to say that your breasts are empty now. Colostrum (which provides your baby with nourishment and with important antibodies her own body can’t yet produce, while helping to empty her digestive system of meconium and excess mucus) is almost certainly present, though in very tiny amounts (first feedings average less than a half-teaspoon; by the third day, less than three tablespoons per feeding over ten feedings). But colostrum isn’t that easy to express manually. Even a day-old baby, with no previous experience, is better equipped to extract this premilk than you are.
“When they brought my baby to me this morning, he seemed to gag and choke and then spit up some liquidy stuff. I hadn’t nursed him yet, so it couldn’t have been spit-up. What’s wrong?”
Your baby spent the last nine months, more or less, living in a liquid environment. He didn’t breathe air, but he did suck in a lot of fluid. Though a nurse or doctor probably suctioned his airways clear at birth, there may have been additional mucus and fluid in his lungs, and this gagging and choking is your baby’s way of clearing out what remains. It’s perfectly normal, and nothing to worry about.
“The doctor says I should feed my baby every two to three hours, but sometimes I don’t hear from him for five or six. Should I wake him up to eat?”
Some babies are perfectly happy to sleep through meals, particularly during the first few days of life. But letting a sleeping baby lie through his feedings means that he won’t be getting enough to eat, and if you’re nursing, that your milk supply won’t be getting the jump start it needs. If your baby is a sleepy baby, try these rousing techniques at mealtime:
Choose the right sleep to wake him from. Baby will be much more easily roused during active, or REM, sleep. You’ll know your baby is in this light sleep cycle (it takes up about about 50 percent of his sleeping time) when he starts moving his arms and legs, changing facial expressions, and fluttering his eyelids.
Unwrap him. Sometimes, just unswaddling your baby will wake him up. If it doesn’t, undress him right down to the diaper (room temperature permitting) and try some skin-to-skin contact.
Go for a change. Even if his diaper’s not that wet, a change may be just jarring enough to wake him for his meal.
Dim the lights. Though it may seem that turning on the high-voltage lamps might be the best way to jolt baby out of his slumber, it could have just the opposite effect. A newborn’s eyes are sensitive to light; if the room is too bright, your baby may be more comfortable keeping them tightly shut. But don’t turn the lights all the way off. A too-dark room will only lull baby back off to dreamland.
Try the “doll’s eyes” technique. Holding a baby upright will usually cause his or her eyes to open (much as a doll’s would). Gently raise your baby into an upright or sitting position and pat him on the back. Be careful not to jackknife him (fold him forward).
Be sociable. Sing a lively song. Talk to your baby and, once you get his eyes open, make eye contact with him. A little social stimulation may induce him to stay awake.
Rub him the right way. Stroke the palms of your baby’s hands and soles of his feet; massage his arms, back, and shoulders. Or do some baby aerobics: move his arms, and pump his legs in a bicycling motion.
If sleepyhead still won’t rise to the occasion, place a cool (not cold) washcloth on his forehead or rub his face gently with the washcloth.
Of course, getting baby up doesn’t mean you’ll be able to keep baby up—especially not after a few nips of sleep-inducing milk. A baby that’s still drowsy may take the nipple, suckle briefly, then promptly fall back asleep, long before he’s managed to make a meal of it. When this happens, try:
A burp—whether baby needs a bubble or not, the jostling may rouse him again.
A change—this time, of feeding position. Whether you’re nursing or bottle feeding, switch from the cradle hold to the football hold (which babies are less likely to sleep in).
A dribble—some breast milk or formula dribbled on baby’s lips may whet his appetite for his second course.
A jiggle—jiggling the breast or bottle in his mouth or stroking his cheek may get the sucking action going again.
And repeat—Some young babies alternate sucking and dozing from the start of the meal to the finish. If that’s the case with your baby, you may find you’ll have to burp, change, dribble, and jiggle at least several times to get a full feeding in.
Sure, crying is a baby’s only form of communication—but that doesn’t mean you’ll always know exactly what he or she is trying to say. Not to worry. This cheat sheet can help you figure out what those whimpers, wails, and shrieks really mean:
“I’m hungry.” A short and low-pitched cry that rises and falls rhythmically and has a pleading quality to it (as in “Please, please feed me!”) usually means that baby’s in the market for a meal. The hunger cry is often preceded by hunger cues, such as lip smacking, rooting, or finger sucking. Catch on to the clues, and you can often avoid the tears.
“I’m in pain.” This cry begins suddenly (usually in response to a stimulus—for instance, the jab of a needle at shot time) and is loud (as in ear-piercing), panicked, and long (with each wail lasting as long as a few seconds), leaving the baby breathless. It’s followed by a long pause (that’s baby catching his or her breath, saving up for another chorus) and then repeated, long, high-pitched shrieks.
“I’m bored.” This cry starts out as coos (as baby tries to get a good interaction going), then turns into fussing (when the attention he or she is craving isn’t forthcoming), then builds to bursts of indignant crying (“Why are you ignoring me?”) alternating with whimpers (“C’mon, what’s a baby got to do to get a cuddle around here?”). The boredom cry stops as soon as the baby is picked up.
“I’m overtired or uncomfortable.” A whiny, nasal, continuous cry that builds in intensity is usually baby’s signal that he or she has had enough (as in “Nap, please!” or “Diaper change, pronto!” or “Can’t you see I’ve had it with this infant seat?”).
“I’m sick.” This cry is often weak and nasal sounding, with a lower pitch than the “pain” or “overtired” cry—as though baby just doesn’t have the energy to pump up the volume. It’s often accompanied by other signs of illness and changes in the baby’s behavior (for example, listlessness, refusal to eat, fever, and/or diarrhea). There’s no sadder cry in baby’s repertoire than the “sick” cry, nor one that tugs harder at parental heartstrings.
It’s fine to occasionally let your baby sleep when he’s dropped off to dreamland after just a brief appetizer, and all efforts to tempt him into his entrée have failed. But for now, don’t let him go more than three hours without a full meal if he’s nursing or four hours if he’s formula fed. It’s also not a good idea to let your baby nip and nap at fifteen- to thirty-minute intervals all day long. If that seems to be the trend, be relentless in your attempts to waken him when he dozes off during a feed.
If chronic sleepiness interferes so much with eating that your baby isn’t thriving (see page 164 for signs), consult the doctor.
“I’m afraid my baby is going to turn into a little blimp. Almost immediately after I put her down, she’s up, crying to be nursed again.”
Your baby may indeed be destined for the Goodyear fleet if you feed her again immediately after she’s had a full meal. Babies cry for reasons other than hunger, and it may be that you are misreading the signals she’s sending (see box, above). Sometimes, crying is a baby’s way of unwinding for a few minutes before she falls asleep. Put her back to the breast, and you may not just be overfeeding her but also interrupting her efforts to settle down for a nap. Sometimes, crying after a meal may be a cry for companionship—a signal that baby’s in the mood for some socializing, not another meal. Sometimes, crying means that baby is having trouble calming herself down, in which case a little rocking and a few soft lullabies may be just what she’s fussing for. And sometimes, it’s just a simple matter of gas (which more feeding would only compound). Bringing up the bubble may bring her the contentment she’s craving.
Whether it’s a breast or a bottle that will be your newborn’s ticket to a full tummy, the guidelines that follow should help make the trip a smoother one:
Minimize the mayhem. While you’re both learning the ropes, you and your baby will have to focus on the feeding, and the fewer distractions from that job, the better. Turn off the television (soft music is fine), and let voice mail pick up the phone at baby’s mealtimes. Retire to the bedroom to feed baby when you have guests or when the general atmosphere in the living room rivals that of a three-ring circus (which in many homes, is around the clock). If you have other children, chances are you’ll already be pretty proficient at feeding—the challenge will be keeping your older ones and your baby happy at the same time. Try diverting their attentions to some quiet activity, like coloring, that they can settle down with at your side, or take this opportunity to read them a story.
Make a change. If your baby is relatively calm, you’ve got time for a change. A clean diaper will make for a more comfortable meal and reduce the need for a change right after—a definite plus if your baby has nodded off to dreamland and you’d rather he or she stay there for a while. But don’t change before middle-of-the-night feedings if baby’s only damp (sopping’s another story); such a disruption makes falling back to sleep more difficult, especially for infants who are mixing up their days and nights.
Wash up. Even though you won’t be doing the eating, it’s your hands that should be washed with soap and water before your baby’s meals.
Get comfy. Aches and pains are an occupational hazard for new parents who use unaccustomed muscles to carry growing babies around. Feeding baby in an awkward position will only compound the problem. So before putting baby to breast or bottle, be sure you’re comfortable, with adequate support both for your back and for the arm under baby.
Loosen up. If your baby is tightly swaddled, unwrap him or her so you can cuddle while you feed.
Cool down a fired-up baby. A baby who’s upset will have trouble settling down to the business of feeding, and even more trouble with the business of digesting. Try a soothing song or a little rocking first.
Sound reveille. Some babies are sleepy at mealtimes, especially in the early days, and a concerted effort is required to rouse them to the task of nursing at breast or bottle. If your little one is a dinner dozer, try the wake-up techniques on page 122.
Break for a burp. Midway through each feeding, make a routine of stopping for a burp. Burp, too, any time baby seems to want to quit feeding prematurely or starts fussing at the nipple—it may be gas, not food, that’s filling that little tummy. Bring up the bubble, and you’re back in business.
Make contact. Cuddle and caress your baby with your hands, your eyes, and your voice. Remember, meals should fill your baby’s daily requirements not just for nutrients but for parental love as well.
If you’ve ruled out all of the above scenarios—as well as done a quick check for a dirty or uncomfortably wet diaper—and your baby’s still crying, then consider that perhaps she really hasn’t gotten enough to eat. It’s possible that a growth spurt may be temporarily sending her appetite into overdrive. But keep in mind that offering your daughter food every time she cries after eating won’t just blimp her out but may also get her hooked on a snack-and-snooze habit that will be difficult to break her of later on.
Do be sure, however, that your baby is gaining weight at an adequate rate. If she isn’t, she may indeed be crying out of chronic hunger—which may be a sign that you’re not producing enough milk. (See pages 165–168 if your baby doesn’t seem to be thriving.)
“Sometimes, especially when he’s been crying, my baby’s chin quivers.”
Though your baby’s quivering chin may look like another one of his ingenious inborn ploys for playing at your heartstrings, it’s actually a sign that his nervous system, like those of his newborn peers, is not fully mature. Give him the sympathy he appears to be craving, and enjoy the quivering chin while it lasts—which won’t be for long.
“I’m worried that there’s something wrong with my baby’s nervous system. Even when she’s sleeping, she’ll suddenly seem to jump out of her skin.”
Assuming your baby hasn’t been over-doing the black coffee, the jumpiness you notice is due to her startle reflex, one of the many very normal (though seemingly peculiar) reflexes newborns are born with. Also known as the Moro reflex, it occurs more frequently in some babies than in others, sometimes for no apparent reason, but most often in response to a loud noise, jolting, or a feeling of falling—as when a young infant is picked up or placed down without adequate support. Like many other reflexes, the Moro is probably a built-in survival mechanism designed to protect the vulnerable newborn; in this case, it’s likely a primitive attempt to regain perceived loss of equilibrium. In a Moro, the baby typically stiffens her body, flings her arms up and out symmetrically, spreads her usually tightly clenched fists wide open, draws her knees up, then finally brings her arms, fists clenched once again, back to her body in an embracing gesture—all in a matter of seconds. She may also cry out.
While the sight of a startled baby often startles her parents, a doctor is more likely to be concerned if a baby doesn’t exhibit this reflex. Newborns are routinely tested for startling, the presence of which is actually one reassuring sign that the neurological system is functioning well. You’ll find that your baby will gradually startle less frequently and less dramatically, and that the reflex will disappear fully somewhere between four and six months. (Your baby may occasionally startle, of course, at any age—just as adults can—but not with the same pattern of reactions.)
“I’ve just noticed a raised bright red blotch on my daughter’s stomach. Is this a birthmark? Will it ever go away?”
Long before your daughter starts petitioning parental powers for her first bikini, that strawberry birthmark—like most birthmarks—will be a part of her childish past, leaving her belly ready (even if her parents aren’t) for beach baring. Of course, when you look at a newborn’s birthmark—which can be quite large and quite vibrant—this often seems hard to believe. Sometimes the mark (which often appears not at birth but rather in the first few weeks of life) grows a bit before fading. And when it does begin to shrink or fade, the changes from day to day are often difficult to see. For that reason, many doctors document birthmark changes by photographing and measuring the mark periodically. If your baby’s doctor doesn’t, you can do so just for your own reassurance.
Birthmarks come in a variety of shapes, colors, and textures and are usually categorized in the following ways:
Strawberry hemangioma. This soft, raised, strawberry red birthmark, as small as a freckle or as large as a coaster, is composed of immature veins and capillaries that broke away from the circulatory system during fetal development. It may rarely be visible at birth but typically appears suddenly during the first few weeks of life, and is so common that one out of ten babies will probably have one. Strawberry birthmarks grow for a while but eventually will start to fade to a pearly gray and almost always finally disappear completely, sometime between ages five and ten. Although parents may be tempted to demand treatment for a very obvious strawberry mark, particularly on the face, such birthmarks are often best left untreated unless they continue to grow, repeatedly bleed or become infected, or interfere with a function, such as vision. Treatment apparently can lead to more complications than a more conservative let-it-disappear-on-its-own approach.
If your child’s doctor determines treatment is advisable, there are several options. The simplest are compression and massage, both of which seem to hasten its retreat. More aggressive forms of therapy for strawberry hemangiomas include the administration of steroids, surgery, laser therapy, cryotherapy (freezing with dry ice), and injection of hardening agents (such as those used in treating varicose veins). Many experts believe few of these birthmarks require such therapies (though if it is decided that a strawberry mark needs to be removed, it will be easier to treat when it is small). When a strawberry, reduced by either treatment or time, leaves a scar or some residual tissue, plastic surgery can usually eliminate it.
Occasionally a strawberry mark may bleed, either spontaneously or because it was scratched or bumped. Applying pressure will stem the flow of blood.
Much less common are cavernous (or venous) hemangiomas—only one or two out of every hundred babies has one. Often combined with the strawberry type, these birthmarks tend to be deeper and larger, and are light to deep blue in color. They regress more slowly and less completely than strawberry hemangiomas, and are more likely to require treatment.
Salmon patch, or nevus simplex (“stork bites”). These salmon-colored patches can appear on the forehead, the upper eyelids, and around the nose and mouth, but are most often seen at the nape of the neck (where the fabled stork carries the baby, thus the nickname “stork bites”). They invariably become lighter during the first two years of life, becoming noticeable only when the child cries or exerts herself. Since more than 95 percent of the lesions on the face fade completely, these cause less concern cosmetically than other birthmarks.
Port-wine stain, or nevus flammeus. These purplish red birthmarks, which may appear anywhere on the body, are composed of dilated mature capillaries. They are normally present at birth as flat or barely elevated pink or reddish purple lesions. Though they may change color slightly, they don’t fade appreciably over time and can be considered permanent, though treatment with a pulse-dyed laser anytime from infancy through adulthood can improve appearance.
Café au lait spots. These flat patches on the skin, which can range in color from tan (coffee with a lot of milk) to light brown (coffee with a touch of milk), can turn up anywhere on the body. They are quite common, apparent either at birth or during the first few years of life, and don’t disappear. If your child has a large number of café au lait spots (six or more), point this out to her doctor.
Mongolian spots. Blue to slate gray, resembling bruises, Mongolian spots may turn up on the buttocks or back, and sometimes the legs and shoulders, of nine out of ten children of African, Asian, or Indian descent. These ill-defined patches are also fairly common in infants of Mediterranean ancestry but are rare in blond-haired, blue-eyed infants. Though most often present at birth and gone within the first year, occasionally they don’t appear until later and/or persist into adulthood.
Congenital pigmented nevi. These moles vary in color from light brown to blackish and may be hairy. Small ones are very common; larger ones, “giant pigmented nevi,” are rare but carry a greater potential for becoming malignant. It is usually recommended that large moles, and suspicious smaller ones, be removed if removal can be accomplished easily, and that those not removed be followed carefully by a dermatologist.
“My baby seems to have little white pimples all over his face. Will scrubbing help to clear them?”
No need to break out the Clearasil yet. Though parents may be dismayed to find a sprinkling of tiny whiteheads on their newborn’s face (particularly around the nose and chin, occasionally on the trunk or extremities, or even on the penis), these blemishes are temporary and not a signal of complexion troubles to come. The best treatment for these milia, which are caused by clogging of the newborn’s immature oil glands, is no treatment at all. As tempting as it may be to squeeze, scrub, or treat them, don’t. They’ll disappear spontaneously, usually within a few weeks, leaving your son’s skin clear and smooth—at least until middle school.
“There are red blotches with white centers on my baby’s face and body. Are these anything to worry about?”
Rare is the baby who escapes the newborn period with skin unscathed. The newborn complexion woe that caught your baby is also one of the most common: erythema toxicum. Despite its ominous-sounding name and alarming appearance—blotchy, irregularly shaped reddened areas with pale centers—erythema toxicum is completely harmless and short-lived. It looks like a collection of insect bites and will disappear without treatment.
“When my baby was screaming with her mouth wide open, I noticed a few little white bumps on her gums. Could she be getting teeth?”
Don’t alert the media (or the grandparents) yet. While a baby very occasionally will sprout a couple of bottom central incisors six months or so before schedule, little white bumps on the gums are much more likely to be tiny fluid-filled papules, or cysts. These harmless cysts are common in newborns and will soon disappear, leaving gums clear in plenty of time for that first toothless grin.
Some babies may also have yellowish white spots on the roof of their mouth at birth. Like the cysts, they are neither uncommon nor of any medical significance in newborns. Dubbed “Epstein’s pearls,” these spots will disappear without treatment.
“I was shocked to find my baby was born with two front teeth. The doctor says she’ll have to have them pulled—why?”
Every once in a while, a newborn arrives on the scene with a tooth or two. And though these tiny pearly whites may be cute as can be—and fun to show off—they may need to be removed if they’re not well anchored in the gums, to keep her from choking on or swallowing them. Such extra-early teeth may be preteeth, or extra teeth, which, after they’ve been removed, will be replaced by primary teeth at the usual time. But more often they are primary teeth, and if they must be extracted, temporary dentures may be needed to stand in for them until their secondary successors come in.
With health insurance, that is. One of the many calls you’ll need to make after the birth of your baby (though grandparents will probably want to hear the news first) will be to your health insurance company, so your new arrival can be added to your policy—something that doesn’t happen automatically. (Some insurance carriers require that they be notified within thirty days of the birth of a baby.) Having baby on the policy will ensure that those doctor’s visits will be covered right from the start.
So, add that to your list of 101 things to do.
“My baby seems to have a white curd in her mouth. I thought it was spit-up milk, but when I tried to brush it away, her mouth started to bleed.”
There’s a fungus among you—or, more accurately, between you. Though the fungus infection known as thrush is causing problems in your baby’s mouth, it probably started in your birth canal as a monilial infection—and that’s where your baby picked it up. The causative organism is Candida albicans, which is a normal inhabitant of the mouth and vagina. Kept in check by other microorganisms, it usually causes no problem. But should this arrangement be upset—by illness, the use of antibiotics, or hormonal changes (such as in pregnancy)—conditions become favorable for the fungus to grow and cause symptoms of infection.
Thrush appears in elevated white patches that look like cottage cheese or milk curds on the insides of a baby’s cheeks, and sometimes on the tongue, roof of the mouth, and gums. If the patches are wiped away, a raw red area is exposed, and there may be bleeding. Thrush is most common in newborns, but occasionally an older baby, particularly one taking antibiotics, will become infected. Call the doctor if you suspect thrush.
A breastfeeding mother can also develop thrush on her nipples, characterized by pink, itchy, flaky, crusty, or burning nipples, and if the thrush is not treated by antifungal agents, baby and mom can continue to reinfect each other. Breastfeeding need not be interrupted if one or both of you have been diagnosed with thrush (though the condition, because it’s painful, can interfere with baby’s feeding if it’s not treated). You’ll just both be treated at the same time for one to two weeks until the symptoms have cleared.
“The doctor says my baby is jaundiced and has to spend time under the bililights before she can go home. He says it isn’t serious, but anything that keeps a baby in the hospital sounds serious to me.”
Walk into any newborn nursery, and you’ll see that more than half the babies have begun to yellow by their second or third days—not with age, but with newborn jaundice. The yellowing, which starts at the head and works its way down toward the toes, tinting even the whites of the eyes, comes from an excess of bilirubin in the blood. (The process is the same in black- and brown-skinned babies, but the yellowing may be visible only in the palms of the hands, the soles of the feet, and the whites of the eyes.)
Bilirubin, a chemical formed during the normal breakdown of red blood cells, is usually removed from the blood by the liver. But newborns often produce more bilirubin than their immature livers can handle. As a result, the bilirubin builds up in the blood, causing the yellowish tinge and what is known as normal, or physiologic, newborn jaundice.
In physiologic jaundice, yellowing usually begins on the second or third day of life, peaks by the fifth day, and is substantially diminished by the time baby is a week or ten days old. It appears a bit later (about the third or fourth day) and lasts longer (often fourteen days or more) in premature babies because of their extremely immature livers. Jaundice is more likely to occur in babies who lose a lot of weight right after delivery, in babies who have diabetic mothers, and in babies who arrived via induced labor.
Mild to moderate physiologic jaundice usually requires no treatment. Usually a doctor will keep a baby with high physiologic jaundice in the hospital for a few extra days for observation and phototherapy treatment under fluorescent light, often called a bililight. Light alters bilirubin, making it easier for a baby’s liver to get rid of it. During the treatment, babies are naked except for diapers, and their eyes are covered to protect them from the light. They are also given extra fluid to compensate for the increased water loss through the skin, and may be restricted to the nursery except for feedings. Freestanding units or fiber-optic blankets wrapped around baby’s middle allow more flexibility, often permitting baby to go home with mom.
Health insurance for your new baby doesn’t come with your job? Think you can’t afford to pay for it yourself? Here’s some good news: Help is just a toll-free phone call away. Affordable (or free) coverage can provide access to regular medical care (including checkups and immunizations) for children from birth to age nineteen. Many kids are eligible, even those with two working parents. For more information, and to learn if your family qualifies for low-cost or free health care coverage, call 877-KIDS-NOW.
In almost all cases, the bilirubin levels (determined through blood tests) will gradually diminish in a baby who’s been treated, and the infant will go home with a clean bill of health.
Rarely, the bilirubin increases further or more rapidly than expected, suggesting that the jaundice may be nonphysiologic. This type of jaundice usually begins either earlier or later than physiologic jaundice, and levels of bilirubin are higher. Treatment to bring down abnormally high levels of bilirubin is important to prevent a buildup of the substance in the brain, a condition known as kernicterus. Signs of kernicterus are weak crying, sluggish reflexes, and poor sucking in a very jaundiced infant (a baby who’s being treated under lights may also seem sluggish, but that’s from being warm and understimulated—not from kernicterus). Untreated, kernicterus can lead to permanent brain damage or even death. Some hospitals are taking steps to monitor the level of bilirubin in babies’ blood through blood tests and follow-up visits to ensure that these extremely rare cases of kernicterus are not missed. New guidelines from a hospital accreditation organization are recommending that all hospitals institute similar screening procedures. The pediatrician will also check baby’s color at the first visit to screen for nonphysiologic jaundice.
To make sure that you go home from the hospital with your baby and not someone else’s, hospital personnel will check your hospital ID bracelet against your baby’s (the ones that were put on immediately after birth) any time you take the baby from the nursery and on your way out the hospital door. Some hospitals have color-coded badges given only to family members who have been authorized to visit the baby. And others place special detectors on the baby that will sound an alarm if the baby is removed from the maternity floor without permission.
The treatment of nonphysiologic jaundice will depend on the cause but may include phototherapy, blood transfusions, or surgery. New drug therapy with a substance that inhibits bilirubin production may also be used.
“I’ve heard that breastfeeding causes jaundice. My baby is a little jaundiced—should I stop nursing?”
Blood bilirubin levels are, on the average, higher in breastfed babies than in bottle-fed infants, and they may stay elevated longer (as long as six weeks). Not only is this exaggerated physiologic jaundice nothing to worry about, but it’s also not a reason to consider weaning. In fact, interrupting breastfeeding and/or giving glucose water feedings seem to increase rather than decrease bilirubin levels, and can also interfere with the establishment of lactation. It’s been suggested that Breastfeeding in the first hour after birth can reduce bilirubin levels in nursing infants.
True breast milk jaundice is suspected when levels of bilirubin rise rapidly late in the first week of life and nonphysiologic jaundice has been ruled out. It’s believed to be caused by a substance in the breast milk of some women that interferes with the breakdown of bilirubin, and is estimated to occur in about 2 percent of breastfed babies. In most cases, it clears up on its own within a few weeks without any treatment and without interrupting Breastfeeding. In very severe cases, when levels are extremely high, some doctors may advise supplementing with formula (or even stopping breastfeeding for a day, while mom pumps to keep her milk supply up), and/or using light therapy.
So you think if you’ve seen one dirty diaper, you’ve seen them all? Far from it. Though what goes into your baby at this point is definitely one of two things (breast milk or formula), what comes out can be one of many. In fact, the color and texture of your baby’s poop can change from day to day—and bowel movement to bowel movement—causing even the seasoned parent to worry. Here’s the scoop on what the contents of your baby’s diaper may mean:
Sticky, tar-like; black or dark green. Meconium—a newborn’s first few stools
Grainy; greenish yellow or brown. Transitional stools—which start turning up on the third or fourth day after birth
Seedy, curdy, creamy, or lumpy; light yellow to mustard or bright green. Normal breast milk stools
Slightly formed;light brownish to bright yellow to dark green. Normal formula stools
Frequent, watery; greener than usual. Diarrhea
Hard, pellet-like; mucous or blood streaked. Constipation
Black. Iron supplementation
Red streaked. Rectal fissures or milk allergy
Mucousy; green or light yellow. A virus such as a cold or stomach bug
“When I changed my baby’s diaper for the first time, I was shocked to see that his stools were greenish black.”
This is only the first of many shocking discoveries you will make in your baby’s diapers during the next year or so. And for the most part, what you will be discovering, though occasionally unsettling to the sensibilities, will be completely normal. What you’ve turned up this time is meconium, the tarry greenish black substance that gradually filled your baby’s intestines during his stay in your uterus. That the meconium is now in his diaper instead of his intestines is a good sign—now you know that his bowels are unobstructed.
Sometime after the first twenty-four hours, when all the meconium has been passed, you will see transitional stools, which are dark greenish yellow and loose, sometimes “seedy” in texture (particularly among breastfed infants), and may occasionally contain mucus. There may even be traces of blood in them, probably the result of a baby’s swallowing some of his mother’s blood during delivery (just to be sure, save any diaper containing blood to show to a nurse or doctor).
After three or four days of transitional stools, what your baby starts putting out will depend on what you’ve been putting into him. If it’s breast milk, the movements will often be mustard-like in color and consistency, sometimes loose, even watery, sometimes seedy, mushy, or curdy. If it’s formula, the stool will be soft but better formed than a breastfed baby’s, and anywhere from pale yellow to yellowish brown, light brown, or brown-green. Iron in baby’s diet (whether from formula or vitamin drops) can also lend a black or dark green hue to movements.
In the 1930s, new babies came home from the hospital after ten days, in the 1950s after four days, in the 1980s after two days. Then, in the 1990s, insurance companies, in a cost-cutting effort, began limiting hospital stays to just hours. To protect against such so-called drive-through deliveries, the federal government passed The Newborns’ and Mothers’ Health Protection Act in 1996. The law requires insurance companies to pay for a forty-eight-hour hospital stay following a vaginal birth and ninety-six hours following a cesarean section, though some practitioners and mothers may opt for a shorter stay if baby is healthy and mom is up to going home sooner. The decision is best made on a case-by-case basis with a physician’s input. Early discharge is safest when an infant is full-term; is an appropriate weight; has started feeding well; is going home with a parent (or parents) who knows the basics and is well enough to provide care; and will be seen by a practitioner (doctor, nurse practitioner, or visiting nurse) within two days of discharge. If for any reason you have concerns about early discharge, speak to your child’s doctor.
If you and your baby are discharged early, a practitioner’s visit should be scheduled within the next forty-eight hours. Also be on the lookout for newborn problems such as yellowing of the skin* and the whites of the eyes (a sign of jaundice); refusal to eat; dehydration (fewer than six wet diapers in twenty-four hours, or dark yellow urine); constant crying, or moaning instead of crying; fever; red or purple dots anywhere on the skin.
Whatever you do, don’t compare your baby’s diapers to those of the baby in the next bassinet. Like fingerprints, no two stools are exactly alike. And unlike fingerprints, they are different not only from baby to baby, but also from day to day (even movement to movement) in any one baby. The changes, as you will see when baby moves on to solids, will become more pronounced as his diet becomes more varied.
“I’ve always hated seeing older kids with pacifiers, and I’m afraid that will happen to my daughter if she gets a pacifier in the nursery.”
Being quieted with a pacifier during the few days your baby spends in the hospital nursery will not get her hooked—she’s too young to become a habitual sucker yet. There are, however, some sound reasons why you might prefer that the nurses find another way of comforting her, and that she pass on the pacifier for now:
If you’re nursing, pacifier use might cause nipple confusion (sucking on the artificial nipple requires a different motion than suckling at the breast) and interfere with the establishment of breastfeeding.
Whether you’re breast or bottle feeding, your baby may get sufficient sucking satisfaction from the pacifier and refuse to suckle at feeding times.
Your newborn is better off having her needs attended to—in the form of a meal, a cuddle, a little rocking, a clean diaper—when she cries than having a pacifier plugged in.
If you decide you’d rather the nursery staff not give your baby a pacifier, tell them so. If she’s not rooming-in, ask them to bring her to you for a feeding when she cries (or if she’s just finished a feeding, to try some other comfort measures). Or see if you can switch to rooming-in. If your baby seems to need more between-meal sucking once you’re at home, and you’re considering pacifier use, see page 194.
Put the diaper on backward? Took five minutes to get baby positioned for a productive burp? Forgot to wash under the arms at bath time? Don’t worry. Babies are not only forgiving—they also usually don’t even notice. Nevertheless, every new parent wants to do everything, or at least as much as possible, right. This Baby Care Primer will help guide you to that goal. But remember, these are only suggested ways to care for baby. You may come up with some of your own that are even better. As long as it’s safe and loving, do what works for you.
Until a baby starts getting down and dirty on all fours, a daily bath isn’t a necessity. As long as adequate spot cleaning is done during diaper changes and after feedings, a bath two or three times a week in the precrawling months will keep baby sweet smelling and presentable. Such a light bathing schedule can be particularly welcome in the early weeks when the ritual is often dreaded by both bather and bathee. Babies who don’t soon become fond of the bath (many eventually come to love it) can continue to be bathed two or three times a week, even when dirt begins to accumulate. Daily spongings, in such critical places as face, neck, hands, and bottom, can stand in between dunks (see page 356 for tips on reducing fear of the bath). For those babies, however, who find it a treat, a daily bath becomes a treasured ritual.
Just about any time of the day can be the right time for a newborn bath, though bathing just before bedtime will help induce the more relaxed state conducive to sleep. (Once baby’s spending the days getting dirty, nighttime baths will just make the most sense on all fronts—and backsides.) Avoid baths just after or just before a meal, since spitting up could be the result of so much handling on a full tummy, and baby may not be cooperative on an empty one. Allot plenty of undivided time for the bath, so it won’t be hurried and you won’t be tempted to leave baby unattended even for a second to take care of something else. Let voice mail pick up the phone during the bath.
While you are using a portable tub, any room in the house can accommodate the procedure, though with all the splashing and dripping, the kitchen or bathroom provides the most suitable setting. Your work surface should be at a level that’s easy for your maneuvering and roomy enough for all the paraphernalia it must hold. For baby’s comfort, especially in the early months, turn off fans and air conditioners until the bath is over, and be sure the room you choose is warm (75°F to 80°F, if possible) and draft free. If you have a hard time achieving such a temperature range, try warming the bathroom first with shower steam.
The sponge bath. Until the umbilical cord and circumcision, if any, are healed (a couple of weeks, more or less) tub baths will be taboo, and a washcloth will be your baby’s only route to getting clean. For a thorough sponge bath, follow these steps:
1. Select a bath site. The changing table, a kitchen counter, your bed, or the baby’s crib (if the mattress is high enough) are all suitable locations for a sponge bath; simply cover your bed or the crib with a waterproof pad or the counter with a thick towel or pad.
2. Have all of the following ready before undressing baby:
baby soap and shampoo, if you use it
two washcloths (one will do if you use your hand for soaping)
sterile cotton balls for cleaning the eyes
towel, preferably with a hood
clean diaper and clothing
ointment or cream for diaper rash, if needed
rubbing alcohol and cotton swabs or alcohol pads for the umbilical cord (if recommended, see page 151)
warm water, if you won’t be within reach of the sink
3. Get baby ready. If the room is warm, you can remove all of baby’s clothing before beginning, covering him or her loosely with a towel while you work (most babies dislike being totally bare); if it’s cool, undress each part of the body as you’re ready to wash it. No matter what the room temperature, don’t take off baby’s diaper until it’s time to wash the bottom; an undiapered baby (especially a boy) should always be considered armed and dangerous.
4. Begin washing, starting with the cleanest areas of the body and working toward the dirtiest, so that the washcloth and the water you’re using will stay clean. Soap with your hands or a washcloth, but use a clean cloth for rinsing. This order of business usually works well:
Head. Once or twice a week, use soap or baby shampoo, rinsing very thoroughly. On interim days, use just water. A careful hold (see illustration, page 137) at the sink’s edge can be the easiest and most comfortable way to rinse baby’s head. Gently towel-dry baby’s hair (for most babies this takes just a few seconds) before proceeding.
Face. First, using a sterile cotton ball moistened in warm water, clean baby’s eyes, wiping gently from the nose outward. Use a fresh ball for each eye. No soap is needed for the face. Wipe around the outer ears but not inside. Dry all parts of the face.
Covering baby’s bottom while you wash baby’s top keeps baby warm and comfortable while you work; and it protects you, particularly if baby is a boy, from a sudden spurt.
Neck and chest. Soap is not necessary, unless baby is very sweaty or dirty. Be sure to get into those abundant folds and creases, where dirt tends to accumulate. Dry.
Arms. Extend the arms to get into the elbow creases, and press the palms to open the fist. The hands will need a bit of soap, but be sure to rinse them well before they are back in baby’s mouth. Dry.
Back. Turn baby over on the tummy with head to one side, and wash back, being sure not to miss those neck folds. Since this isn’t a dirty area, soap probably won’t be necessary. Dry, and dress the upper body before continuing if the room is chilly.
Legs. Extend the legs to get the backs of the knees, though baby will probably resist being unfurled. Dry.
Diaper area. Follow directions for care of the circumcised penis (see page 150) or the uncircumcised penis (see page 148) and, if recommended, the umbilical stump (see page 151) until healing is complete. Wash girls front to back, spreading the labia and cleaning with soap and water. A white vaginal discharge is normal; don’t try to scrub it away. Use a fresh section of the cloth and clean water or fresh water poured from a cup to rinse the vagina. Wash boys carefully, getting into all the creases and crevices with soap and water, but don’t try to retract the foreskin on an uncircumcised baby. Dry the diaper area well, and apply ointment or cream if needed.
5. Diaper and dress baby.
The baby-tub bath. A baby is ready for a tub bath as soon as both umbilical cord stump and circumcision, if any, are healed. If baby doesn’t seem to like being in the water, go back to sponge baths for a few days before trying again. Be sure the water temperature is comfortable and that baby is held firmly to combat any reflexive fear of falling.
1. Select a site for the portable baby tub. The kitchen or bathroom sink or counter or the big tub (though the maneuvering involved when bathing a tiny baby while bending and stretching over a tub can be tricky) are all good candidates. Be sure you will be comfortable and have plenty of room for the tub and bath paraphernalia. The first couple of times you give a tub bath, you might want to omit the soap—wet babies are always slippery, but soapy, wet babies are extra slippery.
The diaper area will require the most concentrated cleaning effort, and should be saved for last so any germs from the region won’t be spread to other parts of the body.
Most babies are very tentative, even tearful, the first few times they’re in a tub. So go out of your way to offer support—with reassuring words and a strong, steady grip.
Until baby’s neck gains more control over the head, you’ll have to hold it steady with one hand while you use your other hand to wash the back.
If the tub doesn’t offer adequate support for your baby’s slippery body and floppy head, you’ll need to do so. Gently but firmly does it.
2. Have all of the following ready before undressing baby and filling the tub:
tub, basin, or sink scrubbed and ready to fill
baby soap and shampoo, if you use it
two washcloths (one will do if you use your hand for soaping)
sterile cotton balls for cleaning the eyes
towel, preferably with a hood
clean diaper and clothing
ointment or cream for diaper rash, if needed
3. Run water into the baby tub (enough so that part of baby’s body is in the water but not too much); test with your elbow to be sure it’s comfortably warm. Never run the water with baby in the tub because a sudden temperature change might occur. Don’t add baby soap or bubble bath to the water, as these can be drying to baby’s skin.
4. Undress baby completely.
5. Slip baby gradually into the bath, talking in soothing and reassuring tones to minimize fear, and holding on securely to prevent a startle reflex. Support the neck and head with one hand unless the tub has built-in support, or if your baby seems to prefer your arms to the tub’s support, until good head control develops. Hold baby securely in a semireclining position—slipping under suddenly could provide a bad scare.
6. With your free hand, wash baby, working from the cleanest to the dirtiest areas. First, using a sterile cotton ball moistened in warm water, clean baby’s eyes, wiping gently from the nose outward. Use a fresh ball for each eye. Then wash face, outer ears, and neck. Though soap won’t usually be necessary elsewhere every day (unless your baby tends to have allover “accidents”), do use it on hands and the diaper area daily. Use it every couple of days on arms, neck, legs, and abdomen as long as baby’s skin doesn’t seem dry—less often if it does. Apply soap with your hand or with a washcloth. When you’ve taken care of baby’s front parts, turn him or her over your arm to wash back and buttocks.
7. Rinse baby thoroughly with a fresh washcloth.
8. Once or twice a week, wash baby’s scalp, using mild baby soap or baby shampoo. Rinse very thoroughly and towel-dry gently.
9. Wrap baby in a towel, pat dry, and dress.
This is a fairly painless process with a young baby. But to help forestall future shampoo phobias, avoid getting even tearless soap or shampoo in your baby’s eyes from the first. Shampoo only once or twice a week, unless cradle cap or a particularly oily scalp requires more frequent head cleanings.
1. Wet baby’s hair with a gentle spray from the sink hose or by pouring a little water from a cup. Add just a drop of baby shampoo or baby soap (more will make rinsing difficult), and rub in lightly to produce a lather. A foam product may be easier to control.
2. Hold baby’s head (well supported) over the sink and rinse thoroughly with a gentle spray or two or three cupfuls of clean water.
Once baby has graduated to a big tub, you can try giving the shampoo at the end of the bath—right in the tub. Since most babies (and young children) don’t like to put their heads back for a shampoo—it makes them feel too vulnerable and often leads to tears, and later, tantrums—use a spray nozzle if your tub has one, and if your child doesn’t find it too frightening. A specially designed shampoo visor (available in juvenile-furnishing and toy stores and from mail-order or on-line catalogs) that guards the eyes from flowing water and soap, but leaves the hair exposed for washing, is ideal if your child will wear it—some won’t. If your baby resists both sprays and visors, you can continue shampooing (or at least rinsing, after doing the lathering in the tub) at the sink until he or she is more cooperative in the tub. Though the process isn’t perfect (and it can grow awkward as the child grows larger), it’s quick and consequently minimizes the period of suffering for both of you.
Sometimes rinsing off shampoo is best done with a few gentle wipes with a washcloth.
New parents taking their babies out for the first time are always careful to bundle them up (often overbundling them) against the elements, fearful of the consequences of a sudden gust of wind or sprinkle of rain. Yet many of these same parents fail to protect their offspring well enough where it counts—in the car. Though a little bad weather is unlikely to harm a newborn, riding without the protection of a safety seat or riding in a safety seat that is improperly secured can. Car crashes injure and kill more children yearly than all of the major childhood illnesses combined.
Safety seats, like seat belts, are the law. So for that first ride home from the hospital—and every ride after that—be sure an infant safety seat is properly installed in your car, and your baby properly secured in it. Even if your destination is literally just a few blocks away (most accidents occur within twenty-five miles of home and not, as is often believed, on highways). Even if you’re driving slowly (a crash at thirty miles per hour creates as much force as a fall from a third-story window). Even if you’re wearing a seat belt and holding your baby tight (in a crash, baby could be crushed by your body or whipped from your arms, possibly flying through the windshield). Even if you’re driving very carefully (you don’t actually have to crash for severe injuries to result—many occur when a car stops short or swerves to avoid an accident). Every time the car is in motion—whether it’s for a trip across the country or from one space to another in the same parking lot—your baby needs to be buckled up safely.
Getting your baby used to a safety seat from the very first ride will help make later acceptance of it almost automatic. And children who ride in safety restraints regularly are not only safer but also better behaved during drives—something you’ll appreciate when you’re riding with a toddler.
In addition to checking that a seat meets federal safety standards, be sure that it is appropriate for your baby’s age and weight and that you install and use it correctly:
Follow manufacturer’s directions for installation of the seat and securing of your baby. Check before each ride that the seat is property secured and the seat belts, or LATCH system (see page 60) holding it are snugly fastened. Use locking clips, available with most seats, to secure lap/shoulder belts that don’t stay tight (mostly needed in vehicles manufactured before 1996). The car seat should not wobble, pivot, slide side to side, tip over, or move more than an inch when you push it from front to back or side to side; instead, when properly installed it should stay tight. (You’ll know the rear-facing infant seat is installed tightly enough if, when you hold the top edge of the car seat and try to push it downward, the back of the seat stays firmly in place at the same angle.) To make sure you’ve installed the car seat correctly, check it out with the many available car-seat safety checks at local firehouses, police stations, hospitals, car dealerships, or baby stores.
Infants should ride in a rear-facing car seat (reclining at a 45-degree angle) until they reach 20 pounds and at least a year old. Even babies who pass the 20-pound mark before their first birthday (many do) or have outgrown the infant seat heightwise (they’re 27 inches tall and/or the top of their head is the same height as the back of the car seat) should stay in a rear-facing car seat until they’re a year old. Before that milestone, baby’s spine and neck are not strong enough to withstand a forceful back-and-forth motion (as in a car crash). If baby has outgrown the infant seat but isn’t ready to face forward, use a convertible seat, which can accommodate larger babies (as heavy as 30 to 35 pounds and taller than 27 inches) in the rear-facing position. After your baby has turned a year (and reached 20 pounds), you can switch the convertible seat to the front-facing position or invest in a toddler seat.
Place the infant safety seat, if at all possible, in the middle of the backseat—the safest spot in the car. Never put an ordinary rear-facing infant seat in the front seat of a car equipped with a passenger-side air bag; if the air bag is inflated (which could happen even at slow speeds in a fender bender), the force could seriously injure or kill a baby. In fact, the safest place for all children under thirteen is in the backseat—older children should ride up front only when absolutely necessary and when safely restrained and sitting as far from the passenger-side air bag as possible. (New air bag–compatible car seats are being marketed that can be safely used in the front seat when there is no backseat available—as in a pickup truck or two-seater sports car. Even those seats, however, provide greatest safety in the backseat.)
Adjust the shoulder harness to fit your baby. The harness slots on a rear-facing safety seat should be at or below your baby’s shoulders; the harness chest clip should be at armpit level. The straps should lie flat and untwisted, and should be tight enough so that you can’t get more than two fingers between the harness and your baby’s collarbone. Check the instructions to see how the carrying handle should be positioned during travel, if applicable.
Dress your baby in clothes that allow straps to go between his or her legs. In cold weather, place blankets on top of your strapped-in baby (after adjusting the harness straps snugly), rather than dressing baby in a snowsuit. A heavy snowsuit can come between your baby and an adequately tight harness.
Most infant seats come with special cushioned inserts to keep a very young baby’s head from flopping around. If not, pad the sides of the car seat and the area around the head and neck with a rolled blanket.
Be sure that large or heavy items, such as suitcases, are firmly secured so that they can’t become hazardous flying objects during a short stop or crash.
For older babies, attach soft toys to the seat with plastic links or very short cords. Loose toys tend to be flung around the car or dropped, upsetting baby and distracting the driver. Or use toys designed specifically for baby car seat use.
Many infant car seats can lock into shopping carts—something that’s sure to be convenient but is also potentially dangerous. The weight of the baby and car seat makes the shopping cart top-heavy and more likely to tip over. So be extra vigilant when placing your baby’s car seat on a shopping cart; or, as recommended by the AAP, for optimum safety use a sling, baby carrier, or stroller when shopping.
The Federal Aviation Administration (FAA) recommends that when flying, children be securely fastened in child safety seats (secured with the airplane seat belt) until they are four years old. Most infant, convertible, and forward-facing seats are certified for use on airplanes.
See chapter 2 for more on choosing an infant safety seat, types of harnesses available, and other safety information. For specific information about installing your car seat, to find out if your car seat has been recalled, and for other safety information, consult the National Highway Transportation Safety Administration, 888-DASH-2-DOT (888-327-4236) or www.nhtsa.dot.gov.
The most important rule of car seat safety is: Never make an exception. Whenever the car is moving, everyone in the car should be safely and appropriately buckled up.
The safest place in any vehicle is the middle of the backseat, which is why, when you have the choice, that’s where your baby should be sitting. But if that seat’s not always available (because you have more than one baby, for instance), or if your vehicle doesn’t have a middle seat in the back (because it has captain’s chairs instead), a seat on either side of the back (in a correctly installed and used child safety seat) is the next safest thing.
But what if your car comes equipped with side air bags, as more and more vehicles do? Though the data isn’t available yet to show that side air bags can injure young children when they inflate, crash tests show that they may. To play it safe—the only way to play it when there’s a baby onboard—ask your dealer about turning your side air bags off. (Side-curtain air bags, however, don’t appear to pose a risk to young children.)
Milk isn’t all baby swallows when sucking on a nipple. Along with that nutritive fluid comes nonnutritive air, which can make a baby feel uncomfortably full before he or she’s finished a meal. That’s why burping baby to bring up any excess air that’s accumulated—every couple of ounces when bottle feeding, and between breasts when Breastfeeding (or midbreast, if a young infant is managing only one breast at a time)—is such an important part of the feeding process. There are three ways this is commonly done—on your shoulder, facedown on your lap, or sitting up—and it’s a good idea to try them all to see which works most efficiently for both you and baby. Though a gentle pat or rub may get the burp up for most babies, some need a slightly firmer hand.
On your shoulder. Hold baby firmly against your shoulder, firmly supporting the buttocks with one hand and patting or rubbing the back with the other.
Facedown on your lap. Turn baby facedown on your lap, stomach over one leg, head resting on the other. Holding him or her securely with one hand, pat or rub with the other.
An over-the-shoulder burp yields best results for many babies, but don’t forget to protect your clothes.
The lap-burp position has the added benefit of being soothing to some colicky infants.
Sitting up. Sit baby on your lap, head leaning forward, chest supported by your arm as you hold him or her under the chin. Pat or rub, being sure not to let baby’s head flop backward.
Even a newborn can sit up for a burp—but be sure the head gets adequate support.
Especially in the early months, the time for a change can come all too often—sometimes hourly during baby’s waking hours. But as tedious a chore as it can be for both baby and you, frequent changes (taking place, at the very least, before or after every daytime feeding and whenever there’s a bowel movement) are the best way to avoid irritation and diaper rash on that sensitive bottom. Telling when it’s time for a change is easier if you’re using cloth diapers, since they feel wet when they are wet. If you’re using disposable diapers, however, you’ll probably have to take a closer look (and sniff) to gauge wetness; since they’re much more absorbent, they tend not to feel wet until they’re seriously saturated. Waking a sleeping baby to change a diaper is hardly ever necessary, and unless baby’s very wet and uncomfortable or has had a bowel movement, you don’t need to change diapers at nighttime feedings; the activity and light involved can interfere with baby’s getting back to sleep.
To ensure a change for the better whenever you change your baby’s diaper:
1. Before you begin to change a diaper, be sure everything you need is at hand, either on the changing table or, if you’re away from home, in your diaper bag. Otherwise, you could end up removing a messy diaper only to find out you have nothing to clean the mess with. You will need all or some of the following:
a clean diaper
cotton balls and warm water for babies under one month (or those with diaper rash) and a small towel or dry washcloth for drying; diaper wipes for other babies
Disposables make quick work of diapering. Once baby is in place, simply bring the front of the diaper through baby’s legs and fasten, making sure the tabs are pressed down securely.
a change of clothes if the diaper has leaked (it happens with the best of them); clean diaper wraps or waterproof pants if you’re using cloth diapers
ointment or cream, if needed, for diaper rash; lotions and powders are unnecessary. Be careful with diaper creams because if you get some on the tabs of the disposable diaper, it can interfere with their sticking power (this, of course, is not an issue if you’re using diapers with Velcro tabs).
2. Wash and dry your hands before you begin, if possible, or give them a once-over with a diaper wipe.
3. Have baby entertainment available—live or otherwise. Live shows (cooing, funny faces, songs) can be provided by the diaper changer or by siblings, parents, or friends on hand. Diversion can also come in the form of a mobile hanging over the changing table, a stuffed toy or two in baby’s range of vision (and later, within reach), a music box, a mechanical toy—whatever will hold your baby’s interest long enough for you to take off one diaper and put on another. But don’t use items such as powder or lotion containers for distraction, since an older baby may grab and mouth or upend them.
4. Spread a protective cloth diaper or a changing cloth if you are changing baby anywhere but on a changing table. Wherever you make the change, be careful not to leave baby unattended, not even for a moment. Even strapped to a changing table, your baby shouldn’t be out of arm’s reach.
5. Unfasten the diaper, but don’t remove it yet. First survey the scene. If there’s a bowel movement, use the diaper to wipe most of it away, keeping the diaper over the penis as you work if your baby is a boy. Now fold the diaper under baby with the unsoiled side up to act as a protective surface, and clean baby’s front thoroughly with warm water or a wipe, being sure to get into all the creases; then lift both legs, clean the buttocks, and slip the soiled diaper out and a fresh diaper under before releasing the legs. (Keep a fresh diaper over a penis for as much of this process as possible, in self-defense. Baby boys often get erections during diaper changes; this is perfectly normal, and not a sign that they’re being overstimulated.) Pat baby dry if you used water. Make sure baby’s bottom is completely dry before putting on his or her diaper or any ointments or creams. If you note any irritation or rash, see page 269 for treatment tips.
6. If you’re using cloth diapers, they’re probably prefolded and ready to use. But you may have to fold them further until your baby is a bit bigger. The extra fabric should be in the front for boys and the back for girls. To avoid sticking baby when using pins (there are pins made especially to minimize this possibility), hold your fingers under the layers of diaper as you insert the pin. Sticking the pins in a bar of soap while you’re making the change will make them slip more smoothly through the fabric. Once a pin becomes dull, discard it. Better still, look for diapers or diaper covers with Velcro fasteners. See page 23 for other options.
If you’re using paper diapers with sticky tabs be careful not to let the tape stick on baby’s skin. Or look for those that use Velcro fasteners instead, so you can open and close them with ease.
Diapers and protective pants should fit snugly to minimize leaks, but not so snugly that they rub or irritate baby’s delicate skin. Telltale marks will warn you that the diaper is too tight.
Putting clothes over baby’s head
Wetness will be less likely to creep up to drench undershirt and clothing on boys if the penis is aimed downward as the diaper is put on. If the umbilical stump is still attached, fold the diaper down to expose the raw area to air and keep it from getting wet.
7. Dispose of diapers in a sanitary way. Used disposable diapers can be folded over, tightly reclosed, and dropped into a diaper pail or the garbage can. Used cloth diapers should be kept in a tightly covered diaper pail (your own, or one supplied by the diaper service) until pickup or wash day. If you’re away from home, they can be held in a plastic bag until you get home.
8. Change baby’s clothing and/or bed linen as needed.
9. Wash your hands with soap and water, when possible, or clean them thoroughly with a diaper wipe.
With floppy arms, stubbornly curled-up legs, a head that invariably seems larger than the openings provided by most baby clothes, and an active dislike for being naked, an infant can be a challenge to dress and undress. But there are ways of making these daily tasks less of a chore for both of you:
Putting baby’s arms in sleeves
1. Select clothes with easy-on, easy-off features in mind. Wide neck openings or necks with snap closings are best. Snaps or a zipper at the crotch make dressing and diaper changes easier. Sleeves should be fairly loose, and a minimum of fastening (particularly up the back) should be necessary. Clothes made of stretch or knit fabrics are often easier to put on than stiff garments with less give.
2. Make changes only when necessary. If you find the odor from frequent spit-ups offensive, sponge the spots lightly with a diaper wipe rather than changing outfits every time baby has a productive burp. Or try guarding against such incidents by putting a large bib on baby during and after feedings.
3. Dress baby on a flat surface, such as a changing table, bed, or crib mattress. And have some entertainment available.
4. Consider dressing time a social time, too. Light, cheerful conversation (a running commentary on what you’re doing, for instance) can help distract baby from the discomforts and indignities of being dressed and make cooperation more likely. Making a learning game out of pulling on clothes will team distraction with stimulation. And punctuating your commentary with loud kisses (a smooch for each adorable hand and foot as it appears from the sleeve or pants leg) can add to the fun for both of you.
5. Stretch neck openings with your hands before attempting to get baby into a garment. Ease, rather than tug, them on and off, keeping the opening as wide as possible in the process and trying to avoid snagging the ears or nose. Turn the split second during which baby’s head is covered, which might otherwise be scary or uncomfortable, into a game of peekaboo (“Where is Mommy? Here she is!” and then, as baby gets old enough to realize that he or she is equally invisible to you, “Where is Daniella? Here she is!”).
6. Try to reach into sleeves and pull baby’s hands through, rather than trying to shove rubbery little arms into limp cylinders of cloth. A game here, too (“Where is Brandon’s hand? Here it is!”), will help distract and educate when baby’s hands temporarily disappear.
7. When pulling a zipper up or down, draw the garment away from baby’s body to avoid pinching tender skin.
The old adage “Never put anything smaller than your elbow in your ears” is advocated not only by grandmothers but also by modern medical authorities as well. They agree that putting anything in the ear that fits—whether it’s a dime inserted by a curious toddler or a cotton swab inserted by a well-meaning parent—is dangerous. Do wipe your baby’s outer ears with a washcloth or cotton ball, but don’t try to venture into the ear canal itself with swabs, fingers, or anything else. The ear is naturally self-cleaning, and trying to remove wax by probing may only force it farther into the ear. If wax seems to be accumulating, ask the doctor about it at the next visit.
For those who have never carried a tiny baby, the experience can, at first, prove very unnerving. But it can be equally unnerving for the baby. After months of being moved gently and securely in the snug uterine cocoon, being plucked up, wafted through the open air, and plunked down can come as quite a shock. Particularly when adequate support isn’t provided for the head and neck, this can result in baby having a frightening sensation of falling and, consequently, a startle reaction. So a good infant-carrying technique aims at carrying baby not only in a way that is safe, but also in a way that feels safe.
Be sure to carefully support the neck and back with your arm when lifting a baby who is lying faceup.
You’ll eventually develop techniques for carrying your baby that are comfortable for both of you, and carrying will become a completely natural experience. While you are sorting laundry, using the computer, or reading labels in the supermarket, baby will be casually slung over your shoulder or under your arm, feeling as secure as he or she did in utero. In the awkward interim, however, these tips will help:
Picking baby up. Before you even touch your baby, make your presence known through voice or eye contact. Being lifted unaware by unseen hands to an unknown destination can be unsettling.
Slip one hand under the chin and neck and the other under the bottom to pick up a baby lying facedown.
Let baby adjust to the switch in support from mattress (or other surface) to arms by slipping your hands under him or her (one under head and neck, the other under bottom) and keeping them there for a few moments before actually lifting.
Slide the hand under baby’s head down the back so that your arm acts as a back and neck support, and your hand cradles the buttocks. Use the other hand to support the legs, and lift baby gently toward your body, caressing as you go. By bending over to bring your body closer, you will limit the distance your baby will have to travel in midair—and the discomfort that comes with it.
Carrying baby comfortably. A small baby can be cradled very snugly in just one arm (with your hand on baby’s bottom, and your forearm supporting back, neck, and head) if you feel secure that way.
With a larger baby, you both may be more comfortable if you keep one hand under legs and buttocks and the other supporting back, neck, and head (your hand encircling baby’s arm, your wrist under the head).
Some babies prefer the shoulder carry, all the time or some of the time. It’s easy to get baby up there smoothly with one hand on the buttocks, the other under head and neck. Until baby’s head becomes self-supporting, you will have to provide the support. But this can be done even with one hand if you tuck baby’s bottom into the crook of your elbow and run your arm up the back with your hand supporting the head and neck.
The front carry is a favorite with babies, since it allows them a view of the world.
Even fairly young babies enjoy the front-face carry, in which they can watch the world go by, and many older babies prefer it. Face your baby out, keeping one hand across his or her chest, pressed back against your own, and the other supporting baby’s bottom.
When baby gets older and can carry his or her own weight well, the hip carry leaves the carrier with a free hand.
The hip carry gives you freedom to use one hand for chores while carrying an older baby resting on your hip. (Avoid this hold if you have lower-back problems.) Hold baby snugly against your body with one arm, resting his bottom on your hip.
Putting baby back down. Hold baby close to your body as you bend over the crib or carriage (again to limit the midair travel distance), one hand on baby’s bottom, one supporting back, neck, and head. Keep hands in place for a few moments until baby feels the comfort and security of the mattress, then slip them out. A few light pats or a bit of gentle hand pressure (depending on what seems to please your baby most), a few parting words if baby’s awake, and you’re ready to make the break. (For more tips on putting a sleeping baby down without waking him or her, see page 185.)
Although trimming a newborn’s tiny fingernails may make most new parents uneasy, it’s a job that must be done. Little hands with little control and long fingernails can do a lot of damage, usually in the form of scratches on his or her own face.
An infant’s nails are often overgrown at birth (it’s hard to get a trim in utero) and so soft that cutting through them is nearly as easy as cutting through a piece of paper. Getting your baby to hold still for the procedure, however, won’t be so easy. Cutting a baby’s nails while he or she is sleeping may work if you’ve got a sound sleeper or if you don’t mind waking him or her. When baby’s awake, it’s best to trim the nails with the help of an assistant who can hold each hand as you cut. Always use a special baby nail scissor or baby nail clipper which has rounded tips—if baby starts to bolt at the wrong moment, no one will be jabbed with a sharp point. To avoid nipping the skin as you clip the nail, press the finger pad down and out of the way as you cut. Even with this precaution you may, however, occasionally draw blood—most parents do at one time or another. If you do, apply pressure with a sterile gauze pad until bleeding stops; a Band-Aid probably won’t be needed.
As with the inside of the ears, the inside of the nose is self-cleaning and needs no special care. If there is a discharge, wipe the outside, but do not use cotton swabs, twisted tissues, or your fingernail to try to remove material from inside the nose—you may only push the matter back farther into the nose, or even scratch delicate membranes. If baby has a lot of mucus due to a cold, suction it out with an infant nasal aspirator (see page 548).
Never again will you be able to leave the house empty-handed—at least not when baby’s along. In general, you’ll need some or all of the following whenever you go out:
A diaper bag. Don’t leave home without it. Keep the bag packed and ready, restocking it regularly, so you can just pick up and go. (See page 62 for tips on choosing a diaper bag.)
A changing pad. If your diaper bag doesn’t have one, pack a waterproof pad. You can use a towel or a cloth diaper in a pinch, but they won’t adequately protect carpeting, beds, or furniture when you’re changing baby during a visit.
Diapers. How many depends on how long your outing will be. Always take at least one more than you think you’ll need—you’ll probably need it if you don’t.
Diaper wipes. A small convenience pack is easier to carry than a full-size container, but it must be refilled frequently. Or you can use a small zip-lock plastic sandwich bag to tote a minisupply. Wipes are handy, incidentally, for washing your own hands before feeding baby and before and after changes, as well as for removing spit-up and baby-food stains from clothing or furniture.
Zip-lock plastic bags. You’ll need these for disposing of dirty disposable diapers, particularly when no trash can is available, as well as for carrying wet and soiled baby clothes home.
Formula. If you are going to be out past the next feeding with a bottle-fed baby, or might be, you’ll have to bring a meal along. No refrigeration will be necessary if you take along an unopened bottle of ready-to-use formula or a bottle of water to which you will add powdered formula. If, however, you bring along formula you’ve prepared at home, you will have to store it in an insulated container along with a small ice pack or ice cubes.
Shoulder diapers. Your friends may enjoy holding your baby—but not being spit up on. A handy cloth diaper will prevent embarrassing moments and smelly shoulders.
A change of baby clothes. Baby’s outfit is picture-perfect and you’re off to a special family gathering. You arrive, lift your bundle of cuteness from the car seat, and find a pool of loose, mustardy stools has added the outfit’s “finishing touch.” Just one reason why you need to carry along an extra—and for extended outings, two extra—sets of clothing. And lots of diaper wipes.
An extra blanket or sweater. Particularly in transitional seasons, when temperatures can fluctuate unpredictably, the additional covering will come in handy.
A pacifier, if baby uses one. Carry it in a clean plastic bag.
Entertainment. Something to provide visual stimulation is appropriate for very young babies—particularly for the car seat or stroller. For older babies, lightweight toys they can swat at, poke at, and mouth will fill the bill.
Sunscreen. If adequate shade is not available, use a small amount of baby-safe sunscreen on baby’s face, hands, and body (now recommended even on babies under six months) year-round (in winter, snow and sun can combine to cause serious burns).
A snack for mom. If you’re breastfeeding or will be out for a long stretch and may not be able to find a nutritious snack easily, take one along: a piece of fruit; some cheese; whole-grain crackers or bread; a bag of dried fruit. A container or can of fruit juice or a thermos containing a hot or cold drink is a nice addition if your outing will be to a park where no liquid refreshment is available.
A snack (or two, or three) for baby. Once solids are introduced, bring along jars of baby food (no refrigeration is needed before they’re open, no heating up is needed before serving) if you’ll be out during mealtime; a spoon stashed in a plastic bag (save the bag to bring the dirty spoon home in); a bib; and plenty of paper towels. Later, a selection of finger foods (nonperishable if you’ll be out in hot weather) such as fresh fruit, crackers, or oat circles will ward off hunger between meals, while providing baby with a wholesome activity during your outing. Beware, however, of using snacks to ward off boredom or to keep baby from crying—the pattern of eating for the wrong reasons in childhood can continue as an undesirable habit later on.
Miscellaneous toiletries and first aid items. Depending on any particular health needs your child may have as well as on where you’re going, you may also want to carry: diaper rash ointment or cream; Band-Aids and antibiotic ointment (especially once baby has started crawling or walking); any medication your baby is taking (if you will be out when the next dose is due; if refrigeration is required, pack with an ice pack in an insulated container).
At birth, the foreskin (the continuous layer of skin that covers the penis) is firmly attached to the glans (the rounded end of the penis). Over time in an uncircumcised penis, foreskin and glans begin to separate, as cells are shed from the surface of each layer. The discarded cells, which are replaced throughout life, accumulate as whitish, cheesy “pearls” that gradually work their way out via the tip of the foreskin.
Usually by the end of the second year for nine out of ten uncircumcised boys, but sometimes not until they are five, ten, or more years old, foreskin and glans become fully separated. At this point the opening is sufficiently large that the foreskin can be pushed back, or retracted, uncovering the glans.
Care of the uncircumcised penis. Contrary to what was once believed, no special care is needed for the uncircumcised penis in infancy—soap and water, applied externally, just as the rest of the body is washed, will keep it clean. Not only is it unnecessary to try to forcibly retract the foreskin, or clean under it with cotton swabs, irrigation, or antiseptics—it can also actually be harmful. Once the foreskin has clearly separated, you can retract it occasionally and clean under it. By the age of puberty most foreskins will be retractable, and at that time a boy can learn to retract his and clean under it himself.
It’s hard to believe that a newborn baby will ever have any business to take care of (besides eating, sleeping, crying, and growing). But there are two very important documents that your baby will need periodically throughout life, and both should be registered for now.
One is a birth certificate, which will be needed as proof of birth and citizenship when (and all of these will come sooner than you think) registering for school and applying for a driver’s license, passport, marriage license, or Social Security benefits. Usually, the registering of your baby’s birth is handled by the hospital, and you receive official notification when the record of the birth is filed. If you don’t receive such notification and a copy of the birth certificate within a couple of months, check with the hospital, the local health department, or the state health department to see what’s holding it up. (If you gave birth at home, you or your birth attendant will have to register for the document.) When you do receive the birth certificate, examine it carefully to be sure it’s accurate—mistakes are sometimes made. If there are errors, or if you hadn’t quite settled on a name for your baby before leaving the hospital and want to add it now (you should), call the health department for instructions on how to make the necessary corrections or additions. Once you have a correct birth certificate, make a few copies and file them in a safe place.
The second document that your baby will need is a Social Security card. Though it isn’t likely you’re going to put your newborn to work immediately, you’ll need the number for other reasons, such as setting up a bank account, investing cash gifts, obtaining medical coverage, even purchasing U.S. savings bonds. The main reason to get a Social Security number, however, is to claim your baby as a dependent on your income tax return. And, if you bank baby’s savings in your own name and Social Security number rather than his or her own, you will have to pay taxes on the interest at your rate rather than the baby’s lower one.
Application for a Social Security number can be made during the birth certificate application process in the hospital. You can simply check a box on the birth certificate information form if you want a Social Security number assigned to your child. The hospital forwards this information to the Social Security Administration, which then assigns the social security number and issues the card directly to you. The parent’s signature on the birth registration form and the check in the box indicating the parent wants a Social Security number for the child constitute a valid application for one.
Or, you can apply for a Social Security number for your baby at your local Social Security office in person or by mail (you will have to send for an application first), submitting a copy of the birth certificate (see, you need it already), plus proof of your own identity, such as a driver’s license or passport, plus the Social Security numbers of both parents. It’s a good idea to call ahead to see if any other documents are needed. (If you decide your baby doesn’t need a Social Security number now, keep in mind the law requires one by age five.) Social Security numbers are available free of charge, so never pay anyone for getting a card or number.
Neither the uncircumcised penis (left) nor the circumcised penis, from which the foreskin has been removed, requires special care in infancy.
Care of the circumcised penis. The only care the circumcised penis will ever need, once the incision is healed, is ordinary washing with soap and water. For care during the recovery period, see page 198.
The safest way to place your baby down to sleep is on his or her back. Babies placed on their stomachs to sleep are at greater risk of Sudden Infant Death Syndrome (SIDS). The incidence of SIDS is highest in the first six months, although the recommendation of “back to sleep” applies for the whole first year. (Once baby starts rolling over, however, he or she may prefer to sleep on the stomach; still, continue to put your baby down on the back and let him or her decide about flipping.) You should also never place baby on soft bedding (firm mattresses only, with no “pillow-top”), or in a crib (or parents’ bed) with pillows, comforters or fluffy blankets, or stuffed animals because of the risk of suffocation. See page 259 for more on SIDS.
For some newborns, swaddling is soothing and may reduce crying, especially during colicky periods; others very much dislike the lack of freedom that comes with being wrapped up tightly. Swaddling does not increase the risk of SIDS, as long as baby is placed on the back to sleep and isn’t overheated. In fact, some research is even showing that swaddling may reduce the SIDS risk by keeping babies safely on their backs when they sleep. (And because many babies are more comfortable on their backs when they’re swaddled, another happy result may be less crying in that position.) Here’s how to swaddle:
1. Spread a receiving blanket on a crib, a bed, or a changing table, with one corner folded down about six inches. Place baby on the blanket diagonally, head above the folded corner.
2. Take the corner near baby’s left arm and pull it over the arm and across the baby’s body. Lift the right arm, and tuck the blanket corner under baby’s back on the right side. (If you have a swaddling blanket with Velcro tabs, no tucking is needed.)
3. Lift the bottom corner and bring it up over baby’s body, tucking it into the first swathe.
4. Lift the last corner, bring it over baby’s right arm, and tuck it in under the back on the left side.
If your baby seems to prefer more hand mobility, wrap below the arms, leaving hands free. Because being wrapped up can interfere with development as baby gets older, and because a blanket that a swaddled baby kicks off can pose a safety hazard in the crib, stop swaddling once baby becomes more active.
Tuck the blanket’s corner under baby’s back.
The last remnant of a baby’s close attachment to his or her mother in the uterus is the stump of the umbilical cord. It turns black a few days after birth and can be expected to drop off anywhere between one and four weeks later. You can hasten healing and prevent infection by keeping the area dry and exposed to air. The following will help accomplish this:
1. When putting on baby’s diaper, fold the front of it down below the navel to keep urine off and let air in. Fold the shirt up.
2. Skip tub baths and avoid wetting the navel when sponging, until the cord falls off.
3. Though it’s been traditional to keep swabbing the stump with alcohol once baby gets home, recent studies show that healing is faster without continued use of alcohol, and there is no increased risk of infection. Ask your doctor what he or she recommends. If you do apply alcohol, using a cotton swab will prevent irritation of tender surrounding skin.
Lift the blanket’s bottom corner over baby’s body.
Bring the last corner of the blanket over baby’s body.
4. If the area around the navel turns red, or the site oozes or has a foul smell, call the doctor.
* To check for jaundice in light-skinned babies, press your newborn’s arm or thigh with your thumb. If the area beneath the pressure turns yellowish rather than white, jaundice may be present.
