Newborn Instruction Booklet
Roger Knapp, M.D., 480 West Southlake Blvd., Southlake , TX 76092 Telephone: 817-347-1250
BOARD CERTIFIED IN PEDIATRICS
Web site: www.Rogerknapp.com App for smart phone.
Facebook: www.facebook.com/RogerKnappMDWelcome: Your baby is resting comfortably and warm in his or her own bassinet. I have given your baby a thorough physical examination. Any abnormalities will be explained to you as soon as they are apparent. If you notice any difficulties or have any questions, please notify the nurse or me. During the next few days, most of your time will be spent in resting and regaining your strength. You can put this time to good use by getting to know some of the simple things that will help to make your life with baby easy and fuss-free.
You must remember the baby is experiencing a new phase in his life. A short time ago, he was totally dependent on you as his mother. Now, even though he is actually quite helpless, he is to some extent independent in that he can breathe the open air, sleep peacefully, or object strenuously by crying loudly. He is truly an individual and with your help, care and love will grow physically and make rapid strides in his development. Adapt these instructions to your baby because every baby is different. Do not depend solely on friends and relatives. We will be happy to give you guidance and answer your questions, while you are in the hospital, later by phone and during your visits to the office. Bring in the list of questions. Do not let it frustrate you when every shift of nurses, every relative, and every book tells you something different. When someone tells you something different, just put that information into your mind's database for future reference that there is one more way you could feed, bathe, or diaper the baby.
Friends and Relatives: These people are interested in your baby and want to hold and hug him. So long as family and friends are not ill and they wash their hands, there is not a problem in their handling the baby. Stay out of crowds where you cannot be sure of the health of people present. You may take him out after 2 - 4 weeks but be careful not to expose him to anyone who is sick. Taking the baby out will not make them ill. Five things you can do to decrease illnesses, keep them away from people who are ill (duh... this is just common sense!), wash your hands, don't smoke in the house, try not to put them into daycare, and buckle them up in the car. Getting out does not make them ill. Put a TV tray stand by the front door with a hand sterilizer bottle and pleasant sign asking everyone that enters to do their hands. The family needs to do their hands after returning from the store, work, or school. Also visitors need to do their hands when entering. Then they do not have to their hands before picking up the baby. Also the family needs to do their hands after using the bathroom.
You can also drape the infant carrier when you go to the store. Put some cloth over the handle of the carrier to make a tent over the baby. Most studies show that germs usually only infect another person if the cough inside 3 feet. But worse is that people in the store reach in and touch the baby and they have not washed their hands. The most germs in town are on the grocery cart handle. So get the hand sterilizer and wash down the handle of the cart. The covers will get nasty and you will take the germs home with you. Just sterilize the plastic/metal handle.
In General:
Babies Are Babies: All babies sneeze, yawn, belch, have hiccoughs, pass gas, cough and cry. They may occasionally look cross-eyed. Sneezing is the only way in which a baby can clean his nose of mucus, lint or milk. Hiccoughs are little spasms of the diaphragm muscle. Coughing is baby's way of clearing their throat so coughing every few hours is normal. Crying is his way of saying I'm hungry, I'm wet, I'm thirsty, I want to turn over, I'm too hot, I'm too cold, I have a stomach-ache, or I'm bored, or constipated. You will gradually learn to know what the baby means. Even a well baby will probably cry for 3 hours a day.
FEEDING
The baby's first love for his parents arises primarily from the feeding situation. Both of you should be comfortable as possible.
Breast Feeding: If you choose to breast feed your baby, we want to help you in every way. Although the first several days may seem awkward and frustrating to you or the baby, most mothers are successful if they relax and have patience. Introduce as much of the nipple and areola (dark portion around your nipple) as possible into the baby's mouth to promote adequate sucking and milk flow. The most vigorous sucking occurs at the first breast, so alternate the breast on which you begin feedings.
Nurse the baby 5-10 minutes on each breast every 3-4 hours for the first 24 hours. Your breast milk usually "comes in" on the third day. Your breasts will then feel firm, hard, and tender. At that time you may nurse 10-15 minutes on each breast. Breast feeding a long time on an empty breast will cause cracked and sore nipples. Nursing a long time on an empty breast does not make more milk... it gets you sore. So I recommend less minutes than others recommend. Some will suggest nursing 20-30 minutes on each breast and wow will you get sore. Even when your breast milk comes in ... 10-15 minutes on each breast will empty most of the milk out. If the "hind" milk does not come out and left in the ducts, then the first thing to come out at the next feeding will be the hind milk from the last feeding. So I don't think it is important to worry about that. It is important not to get sore. After a feeding, always remove the baby from your nipple by inserting your finger between his/her gums to break suction on your nipple. If the baby wants to go longer, then give them a pacifier. To use your breast as a pacifier will make them sore and the pain will decrease the let down of the milk. Studies proved that use of a pacifier will not decrease the success of breast feeding and not give them "nipple confusion" but first breast and then pacifier. If they do not latch on to the breast then do not give them the pacifier yet.
There are two rules that need to be followed so that other nipples do not interfere with breast feeding.
First breast nipple and then other nipples. If the baby does not latch on to your breast, then no other nipple goes in their mouth. Once they have nursed 5-10 minutes, then you can use a pacifier (rather than using your breast)
If you have to supplement, then just one a day.. usually in the evenings. If you follow your breast up with formula after every nursing, then that satisfies them 4 hours and you will not be nursing every 2-3 hours to stimulate more milk.
Most babies are not hungry the first few days or so. Don't be alarmed if baby isn't interested at first. He or she will get hungry. If they are getting enough milk, he will be content after nursing and will go 3 to 4 hours between feedings. They are born with excessive fluids so they are not hungry for the first two or three days. They loose weight that week urinating off the fluid they don't need. Then they get hungry around the third day and that is when the mother's milk comes in. So this is the way it is designed to work. Don't be bothered by very poor nursing the first day or so. Call if the baby is not eating well by the fourth day.
Most infants go through a growth spurt at 1 to 3 weeks of age. He or she will be hungry every hour or two and appear to be unsatisfied. Stay calm and simply put baby to breast as often as needed. If your breasts get sore, cut back to 5 or 7 minutes. Frequent nursing will increase your milk supply in about a week or so, after which time feedings should be 3 to 4 hours apart and baby will seem more satisfied by the third to fourth week of life. If during this time you supplement with formula after most breast feedings thinking: "baby isn't getting enough to eat" or "you are drying up," then the baby will be satisfied with the formula for 4 hours and you will not be nursing frequently enough to stimulate the breast to increase your supply. So feed the baby "on demand" and ride with the fluctuations in his or her eating habits. Approximately 10-20% of mothers have less milk production by the evening time and have to supplement one bottle a day. That is not bad and will not turn off the baby to the breast if you only give one a day.
Your diet does not have to change, but we emphasize your eating well-balanced meals. Consuming too much of any one thing will determine whether baby gets a reaction. Any food item can affect the baby. For example, one cup of coffee may not bother the baby, but 5 cups could cause trouble. Some foods known to increase gas/colic in newborns are caffeine (chocolate, caffeine soft drinks, coffee, tea), milk products, dry beans, peas, cabbage, broccoli, and spicy foods. The number one cause of colic in the baby is cow's milk you drink. If you feel your diet is causing colic try eliminating some foods from your diet for two days and see if your baby calms down. The chemicals are out of your breast milk in 24 hours and they inter your breast milk and cause symptoms in the baby in approximately 4-6 hours.
Many medications for Mom are permissible while nursing, like acetaminophen (Tylenol), allergy pills and antacids. Ibuprofen (Advil, Motrin) is OK if no jaundice in the baby. We do not want the nursing mother to take it when the baby has high jaundiced. Mineral oil, Metamucil, and stool softeners are good for constipation. Most over-the-counter medications are OK but just watch the infant for any changes in behavior when you take any medication. Call us if you need to take any other medicines, or if you are in doubt. Ask your OB doctor or us on all prescription medications. What ever your OB doctor gives you and says it is safe, it probably is safe. There are very few drugs that you should stop breast-feeding. The PDR tells you that every medication should not be taken if breast-feeding your infant. Call us for more current advice.
Bottle Feeding: Sit comfortably with your baby in your arms. Relax and let baby feed at his own pace. Do not prop the bottle in his/her mouth. Hold your baby in your arms with his head raised and resting in the bend of your elbow.
Formula Preparation: Sterilization is not necessary if you prepare each bottle as you give it to the baby. If, however, you choose to make up 20 bottles ahead of time, then you will have to sterilize the bottle and water. You must use these bottles within 48 hours.
The easier way is to use the concentrated or powdered formula. Wash the bottles and nipples in hot water or dishwasher. They should be clean, but do not have to be sterile if you pour the formula into each bottle as you feed your baby. Wash the top of the concentrated formula can and open it. Either leave it in the can, covered, or pour formula into a covered container and refrigerate. When you are ready to feed a bottle, for example 4 oz., first pour 2 oz. of cold concentrate into the bottle and then add 2 oz. of bottle water. Discard any unused portion if there is very little remaining. If the baby takes a sip out of a full bottle, then you may put it immediately back into the refrigerator. Then you can warm it up, feed it to the baby one more time.
If you use powdered formula, mix it according to directions with bottle water. You can use the Nursery water to simply use Ozarka or other bottle water for 6 months. Then you can use straight tap water. Filters for water only filter out chemicals and do not filter out germs. There are germs in the tap water that the chlorine does not kill. Bottled water and powdered formula is easier to use on trips and going camping. You do not have to warm it to body temp 98. Room temp is just fine.
Burping: Burping the baby helps remove swallowed air. Hold him or her upright over your shoulder, pat or rub her back very gently until she lets go of the air. The baby can also be burped by holding him or her in a sitting position (baby leaning slightly forward) on your lap, with your hand supporting his or her chest and your thumb and finger supporting their cheek bones. Babies don't have to burp every time. The main reason to burp them is to slow down the feeding. If they "inhale" the bottle in one minute, then they will get a stomachache and spit up. The breast naturally does this. So burp the baby after each breast and every 1-2 oz of formula. The interval can be increased to 3-4 oz as they get older. But whether they burp or not is not important as to slow down the feeding.
A Schedule With Flexibility: Feeding schedules are usually more satisfactory if the baby is allowed to eat when he or she becomes hungry. It's better not to wake a baby for feeding. You will find out that if they are not hungry, then you cannot make them eat, and if they are crying hungry, you will end up feeding them. Let the baby set their pace..... baby rules the house. Feeding on demand allows the baby to tell your breast how much milk to produce. Babies do not generally over eat so when bottle feeding, let them have as much as they want when ever they want. Baby runs the house!
How Much Formula: Most babies are not hungry the first day and the amount of formula taken will vary with each baby. Some babies will only take 1/2 oz. at first and usually by the second to third day will take 1-2 oz. Others will take an entire 4 oz. When you put the nipple back into the baby's mouth and they spit it back out again, this usually indicates he or she is full. If your baby does not enough to grow then we need to run tests to see what is wrong with your baby and you should not force them to eat more than they want. It is not necessary for the baby to drink extra water since there is enough fluids in the formula and breast.
Testing bottle nipples regularly will save time when you are ready to feed your baby. Nipple holes should be the right size to help baby suck easily. When the nipple holes are the right size, warm milk should drip as rapidly as possible without forming a stream, about one drop per second. If nipple holes are too small, baby may tire of sucking before he gets all the formula he or she needs. If holes are too large, baby gets too much formula too fast, and may gag or spit up. To enlarge holes that are too small, push a hot needle gently through from the outside. If nipple holes are too large, the nipple is worn out and should be thrown away. Sometimes nipple holes become gummy. Place the nipples in a pan of water, add a pinch of salt, and boil for a few minutes.
BABY CARE
Bathing: Although you will bathe the infant most days, it is not necessary to bathe baby every day. Keep the room warm during the bath. Sponge bathe baby on a dry mat until the cord is healed. Or you can put them in the foam tub for babies and put them partly into warm water as long as the cord or circumcision is out of the water. It does not hurt them to get wet for a minute.
Face: Keep the face clean and dry. Wash with mild soapy water. "No Tears baby shampoo" is a good one to use on the face because it will not cause the eyes to sting. There are usually white bumps on the nose which is normal and will go away with time. The cheeks will occasionally get red bumps on them from the spitting up of milk and from baby rubbing his/her cheeks when sleeping. (Newborn acne) Wash and leave the face clean and dry. Do not apply lotion or anything else on the face or the pores will become more irritated and increase the rash. Watch out for your perfume or after-shave lotion when you place the baby against your cheek or neck.
Eyes: Clean with soft cloth and clean water. A little matter or mucus once or twice a day is normal. If the eyes tear a lot and matt up after sleeping, let me know at the next well check up. There may be a clogged tear duct. If there is pus coming out of the eye every hour, call the office.
Nose: The nose may be congested from time to time. If there is mucus, aspirate by carefully squeezing the bulb syringe, placing the tip at the entrance of the nostril to make an air seal, and releasing the bulb rapidly. This will extract mucus from the nose into the bulb, which can then be squirted out into a Kleenex. You also can help loosen mucous in nostrils by placing salt water nose drops or spray (Ocean or AYR nasal spray) in each nostril, then suction with bulb.
Head: Wash the scalp when needed. There may be dry white flakes at first. Wash with any standard brand of baby shampoo. Cradle cap is thick burnt orange scales after two months of age which requires different treatment.
Body: Wash with baby soap for the time being. Later you may switch to a bar soap after 2 months of age. You can use Oil of Olay or Dove unscented soap. Lotion on the body is permissible but not baby oil. Heat rash is nothing more than small red pinhead size bumps on the chest, neck, arms, etc. This is caused by the pores being clogged by sweat, lotion, milk, or chemicals in the clothes like Downy in the rinse or deodorant Bounce drier sheets. Rashes are almost never caused by the detergent so you do not have to use Dreft or Ivory or any special brand. Do the baby's clothes like yours. To help clear up the heat rash, wash area clean with soap and leave it clean and dry. Talcum baby powder can cause lung damage if inhaled. When using powder, do so sparingly and try to keep baby from inhaling any, or simply do not use it. Corn starch powder without talc is safer. They will have “dry skin” for a month but this really is the baby shedding a layer of cells. So it looks worse after the bath but that is helping get them off the skin so it will look good in a few weeks.
Diaper Area: Wash with water or mild soapy water. The commercial diaper wipes are very irritating and some infants may develop a rash due to their chemicals. Many of these chemicals have not been tested. Water and paper does a fine job of cleaning the area. Even dry paper like you and I use will clean up the diaper area very well. If you try to sterilize the diaper area and remove all the normal healthy germs, then the yeast or staph will get in there and cause more trouble. Most rashes are caused by the baby pooping and sitting in it for 15 minutes. You can protect the diaper area with Vaseline, A&D Ointment or other protective ointment. If rashes appear, discontinue wipe use and stay with washcloth/paper and water. Then try Desitin, Dr. Smith's, Budro's But Paste, or Diaperene diaper rash creams. If the rash continues to worsen, call the office for advice. Put A&D or Vaseline on the diaper area after every changing.
Navel: Keep clean and dry. The plastic clamp will be taken off before you go home. You do not have to clean the cord. If you ignore it then the cord will fall off just fine and not get infected. If you want to clean the cord, you can use a cotton ball with alcohol. Use the alcohol very sparingly. Rubbing alcohol is not good for you if you absorb it. Wipe the base of the cord when it is wet or draining mucus. You do not have to clean it after every diaper change. If it is dry and crisp and clean, then leave it alone. Getting the cord wet with water will not hurt the cord or cause it to get infected. The cord usually will fall off in 2 to 3 weeks. The area may smell bad and may also ooze mucous or blood for several days. This is normal. Continue wiping any drainage off until it stops draining. When the cord falls off you may wash with soap and water and give baby a tub bath. A sign of infection is when the skin of the abdomen surrounding the naval becomes a bright red. Binders or strapping the naval is not necessary to prevent/treat hernias and can cause irritation.
Circumcision: If you so desire, the pediatrician or obstetrician will perform the circumcision prior to discharge. There are two methods. One is the Plastic Bell and the other a metal clamp called a Gomco. If the "plastic bell" is used, the penis will have a plastic ring around the end. It will slowly come off in a week. Wash with clean water, leave it clean and dry, and wait until it is loose in the diaper. Some times a few spots of blood may appear on the diaper which is normal. If it bleeds excessively, apply pressure and let us know. If it gets infected, the whole shaft of the penis will get red and swell twice its normal size. A little redness at the edge of the ring is normal. After the bell comes off, rinse it with water and put Vaseline on it. It will be red and have a white or yellow-white mucous on it. Gently wash and put Vaseline on it. The other method of circumcision performed is with a Gomco clamp. The penis will have all the skin taken off with a raw red area present. A generous amount of Vaseline should be applied to the penis in order to prevent it from sticking to the diaper. Clean off any urine or stool with warm water or soap and water. Apply Vaseline with each diaper change. Continue applying the Vaseline until the area is completely healed (usually about 5-7 days). Do not pull back on the skin until months later as shown by your pediatrician.
Vaginal area: The girls will have a mucous discharge for weeks and some times bloody. Do not be alarmed. Clean with water and paper/washcloth and wipe front to back gently to clean out most of the stool and urine. You do not have to clean out all the mucous since that is nature's diaper-rash ointment and protection from irritation. Apply Vaseline between the labia so they do not get stuck together.
Stools: The initial stools are black tarry meconium. After a few days the stools may be yellow or green and are usually seedy. They normally have a stool after every feeding. Breast stools are usually yellow water with some seeds in it. Bottle fed babies have stools between apple sauce and loose mashed potatoes consistency. Not having a bowel movement for days is common and if they feel fine, eating well and acting normal, then ignore it. It has to come out some day and when it does, stand back. You do not have to make them have a BM every day. But if it has been several days since a BM and they are getting fussy, then stimulate a BM by taking their temperature with a lot of Vaseline. Watch for blood in the stools, crying continuously, vomiting green stuff, and not eating.
Diapers: Cloth or disposable diapers are fine and some mothers use both. If you wash the cloth diapers at home, you may use any average detergent but rinse them thoroughly. Any brand of diapers is fine but watch for rashes and change brands if you need to.
Comfort: Try to keep an even, comfortable temperature in the baby's room. The room temperature should be around 70-72 degrees. If you are comfortable in a short sleeve shirt, it is about right for your baby. Then the baby will be fine if a t-shirt, diaper, one outfit on, and one receiving blanket around them. If it is colder, put more layers on them and if hot, take some off. Common Sense.
Sleeping: You may expect your new baby to do a lot of sleeping. The Academy of Pediatrics has recommended that infants sleep on their back. This recommendation is based on research which found a 50% lower incidence of SIDS (Sudden Infant Death Syndrome) if slept on their back. Initially, most babies sleep 16 to 20 hours per day. Be sure to vary their head sleep position. One night on their right side, next on their left, and the next square on their back. Keep rotating them. If they keep their head turned to one side only, then let us know when you come in for a check up. If their skull gets deformed, then they have to wear a helmet to round it back to normal.
Bassinet or Bed: The baby's mattress should be firm and flat. No pillow should be used. It is OK to swaddle the baby and find out which the baby prefers. Swaddled or not.
Clothing: Your baby does not require any more clothing as an adult, so try not to over clothe him. Dress him according to the temperature. Some babies are allergic to certain materials, so watch for rashes in clothing contact areas. It is common to be allergic to the metal snaps on the garments and have small areas of rash where the snaps make contact. Most babies are comfortable in a diaper, shirt, one outfit, and one light receiving blanket.
Outdoors: A fairly good rule to follow is to take your baby out whenever the weather is pleasant. Babies may be taken out on a nice day after they are two weeks old. Babies need some indirect sunlight but they sunburn easily. Early morning or late afternoon reduces the risk of sun burning. Some type of cover overhead is also a good idea. Getting out does not cause babies to get sick. Wind in the ears does not cause ear infections. Keep baby away from people who are sick. Be sure to wrap baby up warmly when it is cold. Babies may fly in airplanes in 2 or 3 weeks. It generally does not hurt their ears to fly until nearly school age.
Fever. If your child has a fever during the first 2 months of life, your child will need to be seen emediately. If this occurs when the office is closed, bring him into Children's Medical Center Emergency room in Dallas or Cooks Children Emergency Room in Fort Worth. Many of these are admitted to the hospital and we don't put infants in the mid city hospitals. Fever is 100 degrees or more under the arm and 101 degrees in the rectum. I do not recommend the ear or forehead type at this time because they are not accurate.
Things That are Normal but Worry You:
1. Hiccups are normal and frequent. You can try to stop them by burping or giving a drink of water. Usually they do not upset the infant and you should ignore them.
2. Sneezing freuently is common. This is not a cold or allergy. This is the way they clear the nose.
3. Nasal congestion is frequent during the first week and frequently continues for up to 2 months. If there is a runny nose or a lot of coughing, it could be a cold and we should see the baby. The congestion does not need treatment as long as baby isn't fussy, and is eating and sleeping well. Expect a "snorty" baby for several months. They also do not know how to handle the post nasal secretions. So many babies have a gurgling in the back of their throat when they breath. This noise can echo down their airways into the chest where you feel and hear the "rattle in the chest". This in not in the lungs but is in the back of the throat and not an illness. Ignore it. Watch for labored breathing that looks like your brother who ran around the block and is out of breath.
4. The normal colic occurs in the evenings for 2 hours in the evenings and continues for around 2 months. Some babies it is after midnight. Yuck. Usually it is not severe crying and the infant can be rocked, given a pacifier or a drink of water or nursed more often. You can also put them in a vibrating chair or in a swing. It also does not hurt to put baby down and let him or her have a good cry as long as you have met all their possible needs. If the baby is crying all day or all night, we need to check the baby in the office. Mylicon and other preparations for gas usually do not help but is safe and if you want to waste your money, go ahead and give it to them. If needed, call the office for a prescription of Levsin that helps colic more. Burping more frequently does not help. Changing formulas can rarely help but you can try Lactofree, soy formula, or other "colic" formula. If breast feeding, try stopping certain things in your diet. Milk is the most common thing to cause colic in the breast fed baby.
5. Most babies spit up often. Once a week, a baby may vomit a large amount. Do not be alarmed. Clean up and watch for recurrence. If this happens 2-3 feedings in a row, bring the baby in for evaluation. If the baby is spitting a lot but gaining weight and is not colicy, then it is a messy problem and not a health problem. So most babies have "reflux" and do not need treatment. I like less drugs in the baby so put up with spit up.
6. Babies may have irregular breathing; have a startle reflex where their arms suddenly flip out; have chin, hands, and feet quiver (almost like a shiver but they are not cold), or they have crossing eyes. All of these are normal for newborns for weeks.
7. All babies turn yellow (jaundice). First their face and chest, then their arms and legs, and then their palms and soles of feet. If you go home and they are turning yellow, watch for the bottoms of the feet. Press on the bottom of the feet for a few seconds and if it is flesh pink, then they are OK. If it is yellow as the face, then call the doctor. Put them in some indirect sunlight, not directly into sunlight. Call the office if they start looking more yellow and especially is the feet are yellow. It usually hits the highest at 3-5 days of age. Breast babies may have higher jaundice and some small amounts of jaundice for a month or two.
Office Visits: Your baby should have his/her first routine office check-up when we recommend it. 2-3 days if there are issues with jaundice, eating, or excessive weight loss. If things are going well, the we can see them in 1-2 weeks. For your convenience, please call the office for an appointment right away. You also need to get your baby's newborn screening PKU blood test at the hospital lab. The nurses should instruct you about it at discharge.
Both well and sick child care visits to the office are an important part of comprehensive medical care. During a well-child visit we are mainly concerned with observing the growth and development, counseling and teaching of parents. There is also early detection of illness through screening examinations and laboratory tests, physical examination, immunizations, and getting to know one another. We limit our counseling to the disease at hand during a sick-child visit. Write down the questions you want answered before coming in for the well exam appointment. Make certain before leaving that your questions are answered fully and that you understand what we have discussed. Well-care and sick visits are scheduled separately. When making an appointment, tell the receptionist the reason for the visit plus any other pertinent information which will help her give the necessary amount of time. If cancellation of an appointment is necessary, please call us as soon as possible. Other patients are waiting for that time slot.
Immunizations are very important and will be started at the 2 month check-up. Your baby should have immunizations to prevent diseases which are still out there. These are safe vaccines and we follow the recommended schedule from the CDC and American Academy of Pediatrics. The immunizations do not cause Autism!!! See my web site for a complete discussion of vaccines.
Let us know if there is any way we can help you. This is exciting and scary. We want to be there for you.
Dr. Knapp