DR. RAJIV CHHABRA

New Born Care

Being first time mum especially in a nuclear family can be a bit challenging. I have tried to pen down few points which can be of some help.

Click on the alphabetical list of issues to learn more about them:

Bathing, Body hair (lanugo), Breast nodules, Breastfeeding, Bruising, Burping, Circumcision, Clothing, Colic, Crying, Dehydration Fever, Diapers, Ears, Eyes, Fontanel, Handedness, Head Control, Hiccups, Jaundice, Molding, Nails, Nasal Congestion, Nasolacrimal duct obstruction (dacryostenosis), Normal movements, Rashes, Rolling Over, Seborrhoeic dermatitis or Cradle Cap, Sleep, Socialising, Stools/Bowel opening, Umbilical Cord care, Vaginal Discharge, Walkers, Weight Loss/Gain

Breastfeeding

One of the most essential things for survival is feeding and newborn solely depends upon milk. Breastfeeding is ideal and best for the baby and this dictum can’t be challenged. Initially the amount of milk produced which is also known as colostrums is less in quantity but it is very essential for the baby. The quantity of milk increases as per demand but generally speaking, by day 3 evening-day 4 morning milk comes in sufficient quantity and it may also take few days for a child to learn the art of sucking and swallowing. Therefore, one must keep trying. The more the mother tries, the better it is. Even if milk is not coming what we call as non nutritive sucking is beneficial for the mother. It increases milk production, reduces pain and helps in secretion of hormones which helps in shrinking down the size of uterus.

Breast feed should be done whenever the baby cries what we call as demand feeding but if the child is sleepy, should be woken up every 3 hourly. Ideally I would feed from 1 side in 1 go which means one must feed alternately from each breast. Feed for at least 20-30 minutes from one side only in 1 go as the initial part of milk which is foremilk is rich in water to satisfy the thirst while the latter part of the milk which is hind milk is rich in fats. The hind milk starts coming after 13 minutes of continuous feeding, therefore, we stress on 20-30 minutes. If a child goes to sleep in between, try waking the child up. Once feeding is over you need to burp the child well and the movement should be below upwards.

Burping

Kids tend to swallow a lot of air while taking breast feed which should be expelled by burping. It should be done below upwards and it can be done during feeding or after feeds as well. If child doesn’t take a burp, lay the baby towards one side as if he/she spits out a part of milk doesn’t go into windpipe. The swallowed air brings alongwith a small amount of milk which is known as regurgitation/possetting.

As long as it’s not a significant amount, child is taking feeds and showing adequate weight gain, one should not be bothered. It tends to decrease with time.

Bathing

You could either sponge a baby till cord gets shed down or you could give bath as well. For initial 2 weeks luke warm water is the only thing which is recommended. To test the temperature of water use your elbow, if it’s soothing for the elbow, it’s soothing for the baby as well. After 2 weeks you can use any of the baby shampoo for the whole body while the baby’s face should be washed with plain water. You could give bath on a daily basis. Ideally I prefer you give bath keeping the baby on your lap but later on you can use bathing chairs.

Soap:It's best to use shampoo for the whole body or liquid soap till the age of one year.

Body hair (lanugo)

Many of my patients especially those having a girl child are worried about lanugo hair. Lanugo is the fine, downy hair that may be present on the face, front of head, shoulders and backs of newborn babies. It generally disappears by 6-8 weeks of age. The belief is to apply Atta/Besan to remove the hairs which should be discouraged as application of these substances is harmful for the baby’s skin (causes severe allergic reaction)

Stools/Bowel opening

Its very variable ranging from 15-16 times in a day to once in 7 days.

The color of stool changes from black to green to ultimately yellow. It may be watery consistency with few seeds in it. Preferably the cleaning should be done by cotton and water and in girl child from front to back to prevent from urinary tract infection.

Clothing

It is quite a frequently asked and confusing question for parents. The rough formula is the child is comfortable in as many layer of clothes as the mother requires. At the most you can add 1 extra layer for the baby. It does not correlate to anyone else in the room. Yet, if hand and feet are cold, I would recommend caps, mittens and booties but everything should be of cotton only.

Umbilical Cord care

You will see a blue clip attached to the newborn baby which is cord clamp which generally gets shed off between the age of 1 -2 weeks. Once it gets shed off, there can be ooze, pus or some discharge from the site which can be cleaned by cotton and water and then wiped by dry cotton. At times particularly in Asian kids, there can be a protrusion seen of umbilicus which on pressing will produce gurgling noises. This condition is known as umbilical hernia which settles down on its own uptill first birthday.

Nasal Congestion

Nasal congestion is quite a common occurrence in newborn. Although pediatrician tries to clear everything from nostrils yet a part may stay in which a child reflexes removes by sneezing. Therefore sneezing is not unusual for initial 1-2 days and it doesn’t signify that child is feeling cold. Normal saline nasal drops are recommended which can be instilled as many times as you want 1 drop each nostril preferably before feeds. There are nasal mucous extractors available which I generally don’t prefer as it results in a traumatic experience for the child.

Sleep

Initially the newborn baby sleeps approx 23 hours in a day which should not be the reason of panic. Baby will wake up only to take feeds. Gradually the duration of sleep will reduce to 15 hours at 3 weeks of age but one must understand that no 2 kids are same, therefore, should not compare. As children are much more sleepy during day time and much more awake at night time, I would request all mothers to take adequate rest during daytime and try not to entertain visitors. The recommended position for sleeping is on their back and child not be put to sleep on their tummy.

Crying

Crying is the only way of expression for a child. The most common reason being thirst or hunger, therefore , always try for breast feed first. Check the diapers and if it is moist you need to change it. You may want to cuddle the baby, provide emotional warmth may do the trick.

Diapers

Personally speaking I prefer cotton nappies during daytime and diapers during night time. One must remember that if using diapers, one has to change it frequently. There are many myths associated with diapers that it results in increased frequency of urinary infections or result in abnormal gait while walking but they are not true. Diaper Rash: rash developing over diaper area is quite a common thing. As soon as you notice a rash over diaper region, try to keep the area open. You can also apply any of the rash free creams available or you may consult your doctor. It can be because of irritation by urine which is generally acidic which will get better by these ointments. Or it may be superadded fungal infection which will require medicated ointments.

Eyes

One must remember that newborns sleep throughout day and night and gradually the amount of sleep diminishes as child grows. This should not be a reason to panic but one must remember to feed the child every 3 hourly. Child begins to open the eyes from day 3 onwards when he/she has lost approx 10% of body weight. There can be bit of eye discharge/redness of eyes which can be a symptom of eye infection. Therefore, you must consult your pediatrician at the earliest. You may also notice yellowness of sclera which is because of jaundice (Normally seen in all newborns). Child may be squinting till 6 months of age as their vision is not well developed which is also a normal variant.

Jaundice

Almost all kids born on this earth will get jaundice. The reason why a newborn gets jaundice is not because that liver is affected. Its because when they are inside womb, they have a different hemoglobin called as fetal hemoglobin. As soon as they come out it has to change to adult hemoglobin. The destruction of those old cells result in liberation of a chemical called as bilirubin which gives yellowish hue to a child. This phenomena is exaggerated in few patients eg if mother’s blood is O positive and baby’s blood group is A, B or AB or if mother’s blood group is Rhesus negative and baby’s blood group is positive.

It normally develops around day 3 and disappears on day 7. If it develops earlier than that or crosses a particular limit, the doctor may want to do bilirubin level and would like to compare the values with certain normograms available. If it is beyond a limit, child has to be admitted for phototherapy. If its mild only, one can expose the baby to sunlight which will take care.

Dehydration Fever

A temperature of 99 degrees may noticed by parents on day 2-3 which is usually caused by decreased intake of feeds also known as dehydration fever/inanition fever. You need to increase the intake of feeds for the baby and it settles down but any fever after that age group unless over wrapped requires a visit to a pediatrician.

Nails

Even if a baby is born with long nails my personal recommendation would be to use mittens and not try to trim the. You can use infant nail clippers after 2 weeks of age and don’t try to be particular of every finer point.

Rashes

there are many rashes over newborn skin which may be normal.

Few of them are:

Erythema toxicum:reddish/whitish rashes all over body which resembles mosquito bites. They appear, increase in size and number and disappears in 2-3 days, again come back and this phenomena may carry on for month and a half. You don’t need to do anything for such rashes.

You may also notice some red patches over back of neck or on eyelids. These are birth marks which disappears/fades with time.

There are some black/blue patches mostly over buttocks and back of trunk visible in Asians which is known as Mongolian blue spot which also fades with time.

There can be some peeling and wrinkling of skin noticeable especially in post term newborns. You can apply any of the baby moisturizer for that purpose.

Bruising

Bruising of the newborn is commonly seen especially at the areas of presentation. Bleeding in the scalp which is also known as cephalhematoma(swelling over skull) may take months to disappear.

Breast nodules

One may notice that breast nodules are enlarged in the baby and at times parents squeeze to bring out milk. The swelling of breast is because of hormones transmitted from the mother to the baby which settles down on its own in few weeks. Squeezing should be discouraged as it may result into infection.

Vaginal Discharge

At times parents may notice whitish mucoid discharge from vagina of newborn babies. This is also not a reason to panic as this is because of hormones transmitted from mother to the baby and it gets settles down in a month and half.

Colic

Tummy pain or colic is one of the most common complaint in neonatal age group. In my practice the incidence is very high. It usually starts after 1 week and especially much more during evening. The exact cause is not known to us but we attribute it to movement of intestines which is happening to digest the milk. All 9 months, the intestines were not being utilized as all the nutrients were going through umbilical vessels, now when intestines have to start work, it causes pain. The symptoms of colic are excessive wriggling, knees coming over abdomen, face getting red in between and moaning. There are medicines available to relieve colic which are prescribed by your doctor which are usually very safe. Also I must reiterate that it has no correlation to mother’s diet.

Seborrhoeic dermatitis or Cradle Cap

It is a scaly, oily crusting of the scalp which may extend to eyebrows, behind the ears or around the nose. I would recommend application of oil following which shampoo should be done. It generally gets better as child grows.

Hiccups

Hiccups are quite common phenomena in infants and one can burp at the time of hiccups

Ears

You don’t need to clean the ears from inside but if you wish to, then after giving bath you can clean superficially with a bud.

Fontanel

The soft tissue over forehead which pulsates is known as fontanelles. There are 2 fontanelles, 1 at front and the other one at back. The front one generally closes after 1st birthday. Most parents get frightened to see its pulsation but it is a normal finding and it does not stop you from shaving off the head.

Head Control

A child develops head control does by the age of 6 months. Therefore, till that time its not recommended to use a back pack carrier.

Circumcision

One must remember that foreskin is tightly attached to penis and that urethral opening is hardly visible. Do not try to retract the skin as it is normal finding. However, one must see that child passes wee-wee in a parabolic fashion. If one wants to get a child circumcised from religious perspective, it is generally done by a pediatric/plastic surgeon and it can be done at any age.

Handedness

A child may use left hand or right hand till the age of 2 years when usually dexterity gets established. Nearly 95% of Indians are right handed. If a child is particularly uses a arm predominantly before the age of 1 year, need to consult a doctor.

Molding

More and more parents are concerned about flattening of head on 1 side because of the baby lying on 1 side. You don’t need to do anything as the head will attain its normal shape by the age of first year.

Rolling Over

A child starts to rollover by the age of 6 months, therefore I would request not to leave the child unattended. Although I must confess that there may not be any child who has become an adult without falling during that age group. There are few things one must remember. As soon as you notice a bump or a bruise apply ice, give some pain relief in the form of paracetamol and watch for any of the sinister signs:
Bleeding from nostrils/ears
Unequal pupils
Loss of consciousness
Seizures
Altered behavior/sensorium
Vomiting more than 3 times

Weight Loss/Gain

All babies tend to lose weight and they regain birth weight somewhere around 10 days. Generally after discharge from hospital, pediatrician calls for revisit somewhere at the completion of 1 week to make sure that child is getting adequate feeds and showing an appropriate rise.

Nasolacrimal duct obstruction (dacryostenosis)

It is again a very common finding as the possibility of NLD getting obstructed is there till the age of 9 months. The symptoms are sticky eyes without redness, eye discharge, lacrimation after the age of 1 month. The doctor will teach you how to massage and open the nasolacrimal duct. If still not opened by the age of 1 year, eye specialist has to probe the duct to open it.

Socialising

According to Indian tradition in good old days, both mother and baby was kept in isolation for 40 days. I find this custom as still one of the relevant ones as visitors should be restricted so that possibility of the child being exposed to infections is less; mother gets adequate rest and can take due care of newborn baby. Baby can go out for stroll after the age of 1.5 month weather permitting. One should restrict going to crowded places like malls/cinema halls till the age of 6 months for the same reason. Rather I am very much pro holidays where a family can go out on holidays during initial 6 months where the requirement of child is only upto breast feeds.

Walkers

I generally advise all my patients not buy walkers as it has been proven that walkers tend to delay walking.

Normal movements

As soon as baby is born, there are few movements which can at times be frightening for parents but are normal for babies upto 3 months age. These are:
Chin trembling
Trembling of lower lips
Hiccups
Passing Gas
Noises caused by breathing or movement during sleep
Sneezing
Spitting up (small amounts) or burping
Startle reflex -- sudden flexion movement of the body in response to a loud noise
Straining while passing wee-wee or poo-poo
Throat clearing or gurgling sounds caused by secretions in the throat

These are not cause for concern unless the baby is having difficulty breathing.
Irregular Breathing – they may rapidly breathe for a while following a pause and then again they start breathing normally. Not a cause for concern as long as there is no respiratory distress and doesn’t turn blue.
Trembling or jitteriness of the arms and legs during crying