SAFETY GUIDELINES

SLEEPING AND CRIB SAFETY

Most people who care for babies suppose that a baby is always safe while sleeping. However, some sleep situations can lead to injury or death. Young babies have suffocated in soft bedding materials and others have died when they became caught between the mattress and the bed frame. Some babies have even been smothered by a parent who rolled over them while sleeping in the same bed. These situations can be prevented.

DON’T place your baby to sleep on any soft, loosely filled surface, such as comforters, pillows, sheepskins, or cushions filled with polystyrene beads. These surfaces can mold to your baby’s face and interfere with breathing.

■ DON’T allow hanging crib toys (mobiles, crib gyms) within your baby’s reach. Remove any hanging crib toy when your baby begins to push up on her hands and knees or when she is 5 months old, whichever comes first. These toys can strangle your baby.

■ DON’T let your baby sleep on a waterbed. Babies can become trapped and suffocate. ■ DON’T use thin plastic wrapping materials such as cleaning bags or trash bags as mattress covers. Do not allow these things near your baby. The baby may suffocate if these items are near the face.

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■ DON’T allow your baby’s head to become covered during sleep.

■ DON’T allow cords from drapes or window blinds near the crib. Do not place any items with strings or small parts near the crib. These things can strangle or choke the baby.

■ DON’T leave the baby alone on a couch or a bed.

FEEDING YOUR NEW BORN BABY

Breast-feeding is certainly best for your baby. You have probably heard or read about the advantages of breast-feeding. • Its constituents are best suited to meet the nutrition for the baby and is easily digested • Infections are less because milk comes directly from mother to the baby and therefore there is no chance of any germs entering it as it would from a bottle (even if you sterilize the bottles some germ contamination can still occur) • It contains many substances that help the baby’s body to resist the germs (viral and bacterial) • Besides these, there are many other advantages including stronger bonding between the mother and the baby Most of the mothers that I come across in my practice do want to breast feed their babies, but some mothers do not succeed. The main reason is wrong advice from relatives and friends. Some mothers do want to breast feed, but cannot breast-feed their babies because they have to go out to work. In this chapter, I will be discussing about breast-feeding as well as about formula feeding. 2.1 Breast-feeding A baby should be put on breast as soon as she is born and is crying vigorously. In case of caesarian section, the baby can suck from the breast as soon as the mother wakes up from the effect of anesthesia, i.e. about 4 to 6 hours after birth. She can keep on lying down, while someone else holds the baby and let the baby suck from the breast. You should tell the nurses 15 CHAPTER 2. FEEDING YOUR NEW BORN BABY 16 in the nursing home or hospital that you want this to be done. Ask them not to give the baby a bottle at all. Only exception is when the mother is too ill and not able to feed the baby. For the first 1 or 2 days, milk secretion is very little in quantity and yellowish in color. This is known as colostrum. If the baby sucks well on the breast, then this amount of milk is enough for her. Initially she will probably demand it frequently, but very soon, you will find that enough milk will be secreted and your baby will sleep well in between the feeds. Actually the more the baby sucks on the breast, more milk will be secreted, as when the baby sucks, mother’s body gets the signal that milk is needed and therefore more milk will be produced. At times, there is a problem initially in making the baby latch on the breast and thus she is not able to suck. This usually occurs if the baby has been given bottle feed before putting on the breast, but it may occur otherwise also. It may be because the way you are holding the baby, you and your baby are not comfortable or it may be due to flat nipple. You can try giving baby breastfeed while lying down. Flat or inverted nipple is one of the commonest reasons for difficulty in making the baby latch on to the breast. The treatment for this should start when the mother is pregnant. She should pull the nipple out a few times a day after applying some cream. When the mother, who has flat nipple, is having difficulty in trying to feed the baby in spite of all the attempt of pulling out the nipple, she can use nipple shield for a while. After a few days, she will find that the baby will be able to suck without the nipple shield. Once the baby latches and sucks well on the breast, there is no reason why she will not succeed in breast-feeding. If your baby is born prematurely then the baby may not be able to suck well on the breast. In such a case, you may have to express the breast milk and give it to the baby with a bottle or a spoon. However if the baby is very premature the baby will have to be given expressed breast milk with a feeding tube. This is always done in a hospital or nursing home and by the nurses, who are experts in feeding these babies. When the baby sucks over the breast, see that the areola (the dark portion around the nipple) is in the baby’s mouth. Sucking directly over the nipple alone causes cracked nipples. Also too much cleaning the skin over the nipple also causes dryness of the skin which causes cracked nipple. It is not advisable to clean the nipple before each feed. Cleaning once a day while taking bath is enough. Once cracked nipples occur, as this is very painful, it becomes very difficult to feed the baby. You can apply some lubricating cream over the nipple, after feeding, to ease the pain and help in healing. If the cracking is very severe, then you may have to stop feeding the baby for a day or two and give the baby expressed breast milk with a spoon or bottle. Do ask someone, who has experience in breastfeeding to help you. 2.2 How often to feed the baby and at what interval? Nowadays, we tell the mothers that the baby should be fed whenever the baby is hungry i.e. cries for feed and wants to suck. We call this demand feeding. You will find that after the first week of life your baby will usually set up her own routine. Some babies will finish their feed

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FEEDING YOUR NEW BORN BABY 17 within 10 to 20 minutes at one go, while others will take a longer time. Some babies will have a set pattern of feeding; that is they will feed for 10 minutes, rest for 10 minutes, again feed for another 10 minutes, and then rest for 30 minutes. During this 30 minutes they may sleep (light sleep) and then wake up and feed for a short interval and then sleep for 3 to 4 hours. I observed this pattern with my baby and many other mothers have told me that their baby have had a similar pattern of feeding. When babies keep on demanding feeds again and again at short intervals, some mothers think that the milk secreted by breast is not enough and therefore they supplement breastreast milk with bottle feeds. This is one of the reasons because of which many mothers do not succeed in fully b feeding. If your baby is passing urine frequently, and gaining weight after the first week of life, your baby is getting enough milk. Usually by 3 months of age, babies drink milk at interval of 3 to 4 hours. They will probably sleep for 3 hours, stay awake for 3 hours, and then again sleep for 3 hours. At night, many babies do sleep for 6 to 7 hours. During this time, they may wake up only once for feed and then sleep again after that. In 24 hours, a 3-month-old baby will sleep for about 15 hours. However not all babies follow the same pattern and if your baby follows a different pattern you do not need to worry about that.

NEW BORN BABY

It is certainly a great pleasure when a baby is born and there is an additional member in the family. This is the moment that you have been looking forward to all the previous nine months. If your baby is born by normal delivery or Caesarian section done under spinal anesthesia, then you will able to hear your baby’s’ first cry and will be able to hold, cuddle and breast feed your baby soon after birth. If your baby is born by Caesarian Section done under general anesthesia, your baby will be given to you after a few hours, after you wake up from affect of General anesthesia. However your husband will be able to cherish those first moments and, if allowed by your Obstetrician, may be able to take a video clip which you can see later on. Thereafter comes the task of looking after your precious baby and naturally you will be a bit anxious. However, all you need is lot of self confidence and a little bit of advice from health care providers, friends, relatives and baby books. It is easier if you can get some help to look after your baby for about one month after delivery until you can regain your strength. Probably the best help you can get is from your mother or mother in law. If that is not possible then you may need to hire a nanny. However it is essential that whoever helps you should be up-to-date with their knowledge about baby care. She should not be bossy and should not make you feel inadequate and undermine your confidence. Your husband’s help is the best help you can get, especially if he can take leave from his work. Neither of you may have any experience but if you try to get some knowledge about baby care from various sources you certainly will be able to cope. This will also help in building a strong bond between the baby and her father. In this chapter on New born baby I will guide you in meeting your baby’s needs and answer the concerns that you may have about her. 1.1 Bathing the baby There was a time when a baby was given bath soon after he was born. With this practice, babies at times became very cold and therefore this practice has been abandoned. Now as soon as the baby is born, he is kept warm under a heater or hot lamp and cleaning of baby is done after the 8 CHAPTER 1. NEW BORN BABY 9 baby has warmed up. Cleaning is done by wiping with moist cotton. Thereafter, cleaning of the baby should be done in a similar manner daily. Regular bath in a tub should be given only after the baby is 5 to 7 days, mainly after the umbilicus dries up, because dipping the baby in the tub will make the umbilicus moist and thus can cause infection. Baby soap and shampoo should be used 2 to 3 times a week. Baby cream should be used over the nappy area and other folds in the skin. It can also be used all over the body of the baby if the skin is dry. Do not rub the cream but leave a thin layer over the skin. This will protect the skin from stool and urine. It is better not to use powder, as it forms paste with moisture and this causes irritation of the skin. 1.2 Oil massage In our culture, almost all the babies are given oil massage daily. Some parents massage the baby 2 to 3 times a day. They believe that the baby’s skin will become better with the massage and the baby will become stronger. Little bit of oil that is massaged on the skin can get absorbed, however it is not necessary for the baby’s well being, as the baby will get its full nutrition from the breast milk or the formula milk that the mother gives to her baby. Usually oil massage is followed by passive exercise and then the baby is kept in the sunshine for 10 to 15 minutes, followed by a bath. This is certainly good for the baby as the exercise will make her muscles stronger, build up an appetite and sunshine will give her vitamin D. However if you cannot do this do not worry too much, as your baby will get enough vitamins from the milk and baby’s muscles will become stronger by the normal movements of her legs and arms. If you are doing passive exercises, be very careful that you do not use any force while doing the exercises, as this can produce fractures of the baby’s bones. Also, when you keep the baby in the sunshine, be careful that the sun is not too hot and there is no strong wind. Keep the baby in the sunshine for a very short time and cover the eyes as too much light can damage the eyes. 1.2.1 Which oil to use In different parts of India different types of oil is used, for example in East India and U.P., mustard oil is used, in South India coconut oil is used, and in Punjab Ghee is used. All these oils are fine, and it does not make any difference as to which oil is used. Olive oil can also be used. 1.2.2 When to start oil massage It is best to start oil massage after the baby is one month old. It is easier to handle the baby by this time and also there is less chance of rashes occurring due to oil massage. CHAPTER 1. NEW BORN BABY 10 1.3 Taking care of the umbilicus (navel) It takes 7 to 14 days before the umbilicus dries up and falls off. You have to take care that it remains clean and dry otherwise there is a chance that germs may collect over it and it may get infected. The best way to take care of the umbilicus is to dry it with soft cloth and then apply surgical spirit (with alcohol swabs) 3 to 4 times a day. However, some doctors may advice ointment or antiseptic powder to be applied over it. How do I know if it is infected or not? If the base is red, some pus is oozing out of it and has bad smell then it may be infected. Contact your doctor in such a case. He may take a swab from this for testing and prescribe antibiotic if necessary. 1.4 Jaundice About 50% of the babies become jaundiced when they are 2 to 3 days of age. This is called physiological jaundice in contrast to pathological jaundice that may occur before 2 days of age. Pathological jaundice may be due to the fact that you and your husband may have different blood groups and because of this, antibodies are produced in the baby’s blood. These antibodies destroy the baby’s red blood cells very rapidly and thus cause jaundice. Pathological jaundice can also be due to the fact that baby may have some deficiency in certain enzymes like G6PD. Physiological jaundice is mild jaundice and occurs after 2 to 3 days of birth. This jaundice is not due to any infection. The reason for this is that baby’s liver is not yet mature and cannot handle the extra bilirubin that is collected in the baby’s blood due to normal breakdown of red blood cells (breaking of old red blood cells is a normal phenomena that occurs in everyone’s body). After 7 to 10 days, the baby’s liver becomes mature and the jaundice disappears. In some babies, it may last up to one month of age, especially in breast fed babies. If jaundice is mild, there is nothing to worry. However, if it lasts more than 1 month or disappears and reappears again then you must contact your doctor. 1.4.1 How do I detect jaundice and how do I know if it is mild or severe? You may see the baby’s eyes are yellow and may come to know that baby has jaundice. However, the best way to know whether a baby has jaundice is to press over the baby’s forehead, and then you may find that the skin is yellow. There after you should press over the chest, the abdomen and then the legs. If the jaundice is detected only over the face, this is mild however, if it has spread over chest and abdomen, it is moderate and if it has spread over the legs it is severe. If it is mild and has occurred after the second day of age and baby is well, there is nothing to worry about. If it is moderate or severe then you should contact your doctor. CHAPTER 1. NEW BORN BABY 11 1.4.2 If the jaundice is physiological then why should I worry about moderate jaundice or severe jaundice? If the jaundice is moderate or severe, it is not physiological. It is due to some other reason although at times we cannot find out the reason even after doing all the investigations. Anyway, if jaundice is moderate or severe, then the baby needs investigation and treatment. In such a case, your doctor will ask for a blood test to detect the percentage of bilirubin in the blood. Usually if the bilirubin exceeds 15mg% in the blood, baby is given phototherapy in a hospital and if it exceeds 20mg% then exchange transfusion is done (i.e. baby’s blood is exchanged with compatible adult blood slowly, 10- 20ml at a time). Fortunately with proper preventive measures and early phototherapy (keeping the baby under many tube lights), it is very rare that we have to do exchange transfusion nowadays. So if you detect mild jaundice in your baby do not worry, however if you think it is more than mild or if you have any doubt, do contact your doctor, because very severe jaundice can cause brain damage. 1.4.3 Does keeping the baby in sunshine help? Yes it does, but only if you keep the baby naked. You cannot do that if the weather is cold or sun is too hot. If the baby’s blood bilirubin is more than 15mg %, you have to give phototherapy in a hospital. You cannot rely on the sunshine. 1.5 Head of the baby: swellings, lopsided head When the baby is born by normal delivery there is a soft swelling at the top of the head and is sort of dome shaped. This is because of the fact that the head had to come out through a narrow passage of the womb, so it got molded in that shape. This is nothing to worry about. In 2 to 3 days time the head shape becomes normal. At times there is a small swelling on one side of the head. Other times a similar swelling occurs on both sides. This is due to collection of small amount of blood under the skin of scalp. This may take 3 to 4 weeks to disappear. No treatment is required. No harm will come to the baby because of this. At times if the baby has the tendency to sleep only on one side, the head’s shape becomes lopsided. This happens mainly with preterm babies (babies born before expected date of delivery). In such cases, you should try to keep on changing the child’s position. Once the baby starts sitting up, the head will take its normal round shape. In certain regions in India, it is believed that the head of the baby should be kept on a sand pillow. This according to them gives a good shape to the head. Nothing like this is required. Sand pillows can be very uncomfortable. Babies normally do not require any pillows under their head, as their neck is very short. CHAPTER 1. NEW BORN BABY 12 1.6 Pink and salmon colored spots and bluish black spots You may find that your baby has some pink patches over the forehead, nape of the neck and over the eyelids. These are due to dilatations of blood vessels. These are quite normal and will disappear in time. Bluish black spots are found over the back and sometimes over legs and other parts of body. These are known as Mongolian Spots (nothing to do with the Mongolian race). Why these occur is not known. This is not a cause of worry; the spots will certainly disappear after 1 to 2 years. 1.7 Vomiting in new born babies Many babies spit out small amount of milk after feed. In some babies it is more and for other babies it is less. This is because the junction between the food pipe and stomach does not close properly. Hence after the baby has had milk, some of it comes out of the stomach into the food pipe and the baby throws out this milk. To prevent this spitting out, you should keep the baby in your lap with the head raised, for 5 to 10 minutes after feed. Thereafter, when you put the baby down on the cot check that the head end is kept raised for about half an hour. If you use a pillow, it keep under the head as well as the shoulders. You can also put the baby on her abdomen after feeds for some time, as this may reduce the spitting but never leave the baby in this position when not supervised. In spite of all these measures, the baby may still vomit small amounts. As long as the baby is well and gaining weight normally, you do not have to worry about this. 1.7.1 Conditions under which vomiting needs to be investigated Sometimes vomiting can be serious and needs investigations and treatment. Contact your doctor if: • The baby spits out large amount and is not gaining weight • The vomiting is projectile, i.e. the milk comes out in a jet and is thrown far away • If the vomit is yellowish green in color 1.8 Diaper and diaper dermatitis You can use either cloth diapers (nappies) or disposable nappies. Cloth diapers are cheaper and do not pollute the environment but they are inconvenient as compared to the disposable ones. If you use the cloth ones you will need at least 20 to 24 of these, so that you can collect the soiled ones in a bucket with a lid, and wash them once a day. If you use disposable ones, you will need to change 8 to 10 times a day in the 1st year and less often later on. CHAPTER 1. NEW BORN BABY 13 1.8.1 Diaper rash Babies get this commonly because of the use of the diaper. This is due to the irritation of the skin by the contact of stool and urine. Typically, there will be red colored rash at the diaper area and at times. in a severe case, there will be peeling of skin. 1.8.2 Prevention and treatment of the nappy rash Change the diapers as often as possible. Before putting on the diaper, clean the skin with cotton soaked in lukewarm water, tap dry it and then apply a thick layer of nappy rash cream. It is better to use a zinc based one (see the contents), but any other cream can be used. The idea is to create a barrier between the skin and the diaper. This should be done at every nappy change, even if the baby has no rash. Do not use powder as it forms a paste with the moisture and this irritates the skin. If the rash is very severe, you will have to contact your doctor. He may prescribe a rash cream, which may contain antifungal medicine with or without hydrocortisone. This should be used according to your doctor’s advice only. Hydrocortisone is corticosteroids. Too much use of all these medicines should be avoided as these can be absorbed by the skin and cause side effects. 1.9 Prevention of infection in a newborn baby Newborn babies can get infection very easily as they have very low immunity. Therefore, to prevent this, the caregivers should wash their hands or use hand sanitizers before touching the baby and, as far as possible, those who have cold and cough should not come near the baby. Difficulty arises when many visitors with their children come to visit your baby. Children usually suffer from cold and cough more often than adults and they can pass infection to your baby when they cough or sneeze while handling the baby. However, you will have to try to prevent this and, if you tell their parents tactfully, I am sure most people will understand. In spite of this, if you cannot avoid children handling the baby then ask them to wear a mask and clean the hands with hand sanitizers before touching your baby. 1.10 Hernia In some babies, a swelling occurs over the umbilicus after about 1 month of age. The swelling increases when baby cries and reduces in size when baby sleeps. This is umbilical hernia. It is more common in preterm babies. No treatment is required for this. It will subside once the baby is 8 to 9 months of age. Sometimes it may take longer but eventually it will disappear and there is no need to worry about this. In olden days, a bandage was tied around the abdomen after keeping a coin over the umbilicus. There is no need for such treatment. It does not help. Very rarely a small similar swelling occurs at inguinal (groin) region. This is inguinal hernia.