Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 17 Caring for Your Baby

After months of waiting, meeting your newborn can be an overwhelmingly emotional experience. You rejoice at finally being able to hold your baby in your arms, but you may begin to worry how best to keep her happy and healthy. You realize there’s so much to learn about your baby and how to care for her.

This chapter describes general baby care (such as diapering, bathing, and calming your baby, and where and how to put her to sleep) as well as your baby’s abilities and communication skills. It also covers medical care, including newborn warning signs that indicate when you need to seek medical help, and discusses care for babies with special needs. With this information—along with time, practice, and guidance—your ability to care for your baby will soon become second nature.

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In this chapter, you’ll learn about:

• Your newborn’s appearance and abilities

• Your baby’s cues to communicate what he needs

• General baby care including bathing, diapering, comforting, and putting your baby to sleep

• Health care and concerns, including cord care, circumcision, newborn tests and procedures, vaccinations, and newborn warning signs

• Special care for premature and small babies

Meeting Your Baby

If you and your baby are doing well immediately after the birth, the best place for him is on your bare chest, with just a blanket covering you both. This skin-to-skin contact allows the two of you to bond and gives you a chance to discover all the things that make your baby unique. These first few moments together also provide you with some wonderful memories. The following sections describe what you can expect as you get to know your newborn.

Note: In some circumstances, additional time is necessary for mothers and babies to get acquainted. If you had a long and tiring labor, your recovery may delay the enjoyment of meeting your newborn. If your baby has trouble adjusting to life outside your womb, he may need to be separated from you so medical staff can care for him.

YOUR NEWBORN’S APPEARANCE

When you first meet your newborn, her appearance may surprise you, especially upon seeing the large size and unexpected shape of her head, her tiny hands and feet, her enlarged reddened genitals, her initial dusky blue coloring, and her little body streaked with blood and vernix caseosa (creamy white substance that protected her skin). These features can make a strong first impression, but they’re completely normal. You’ll probably find that you can’t take your eyes off your new baby.

Body

The average full-term baby weighs 7 to 71/2 pounds and measures about 20 inches in length. A newborn’s shoulders and hips are narrow, his belly is round, and his arms and legs are relatively short, thin, and flexed.

Head

Your baby’s head is large in proportion to her body. Her head may be molded (that is, appear cone-shaped or longer than expected) from pressures within your pelvis during birth. Her head will return to a normal round shape within a few days. Her scalp or face may appear bruised and swollen, but bruising and swelling will disappear with time.

Your baby’s skull has two soft spots called fontanels (areas where the bones haven’t completely fused). A large, diamond-shaped fontanel is on the top front portion of her skull, and a smaller, triangle-shaped one is at the back. The larger fontanel usually closes by eighteen months after the birth; the smaller one closes by two to six months. A thick, tough membrane covers the fontanels, so gently brushing or washing your baby’s hair and scalp won’t hurt her.

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Hair

At birth, your baby may have a full head of hair or be nearly bald. You may also notice lanugo (fine, downy body hair) on your baby’s back, shoulders, forehead, ears, and face—especially if he’s premature. Lanugo usually disappears during the first few weeks after the birth.

Eyes

Fair-skinned babies usually have gray-blue eyes at birth; dark-skinned babies have brown or dark gray eyes. If your baby’s eye color is going to change, it usually does so by the time she’s six months old. Her tear glands won’t produce many tears until she’s about a month old.

Sucking Callus (Blister)

Intense sucking often causes a painless white callus on the center of a baby’s upper lip. Sometimes the callus peels. It doesn’t need treatment and gradually disappears as the lip toughens.

Skin

At birth, your baby’s skin is dusky blue, wet, and streaked with blood and varying amounts of vernix caseosa, the white creamy substance that protected your baby’s skin before birth. Within a minute or two after your newborn begins breathing well, his skin color changes to normal tones, beginning with his face and trunk and soon reaching his fingers and toes. The vernix often remains in skin creases even after bathing. Gently rub it into your baby’s skin; there’s no need to remove it.

A fair-skinned newborn baby often looks blotchy. After a few weeks, his skin has a more even color, although it may appear blotchy when he’s cold.

Also common on a fair-skinned baby’s skin are stork bites and angel kisses, red areas formed by a collection of tiny blood vessels near the skin’s surface. They often appear on the baby’s eyelids, nose, forehead, or back of the neck. Most aren’t caused by injury and usually fade or disappear within six to nine months; however, some (especially those on the neck) may be permanent.

Mongolian spots (areas of dark pigmentation) commonly appear on the lower back and buttocks and occasionally on the thighs or arms of some babies, usually of Native American, Asian, African, or southern European descent. Although the spots are black and blue, they’re not bruises. They gradually fade and usually disappear by the time the child is four years old. If your baby has Mongolian spots, make sure those who care for him know that the marks aren’t bruises.

Many babies have peeling skin, particularly at the wrists, hands, ankles, and feet. Babies born after their due dates peel more than babies born at term. The peeling is normal and doesn’t usually require treatment. If cracks on the wrists or ankles bleed, apply skin ointment such as A&D ointment (available at pharmacies).

Breasts

During pregnancy, your hormones may have caused your baby’s breasts to swell. Some babies (male and female) leak milk from their nipples. Both swelling and leaking is normal and doesn’t require treatment. Don’t try to express milk from your baby’s nipples; doing so may cause infection. The condition typically disappears within a week or two after the birth.

Genitals

Your hormones during pregnancy also may have caused your baby’s genitals to swell. If your baby is a boy, he may have an unusually large, red scrotum. If your baby is a girl, she may have milky or bloody vaginal discharge called a “pseudo menstrual period.” This discharge indicates that her uterus has had a healthy response to your hormones and is now shedding its first lining. The conditions for both sexes are normal, temporary, and don’t require treatment.

Umbilical Cord

Immediately after your newborn’s umbilical cord is cut, it’s bluish-white and 1 to 2 inches long. To stop the bleeding, your caregiver applies a plastic cord clamp or tie umbilical tape around the cord. The cord clamp is removed when the cord is dry, usually before your discharge from the hospital or within twenty-four to forty-eight hours after the birth. The tape doesn’t have to be removed. Usually within one to two weeks after the birth, your baby’s umbilical cord will fall off.

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YOUR NEWBORN’S REFLEXES

When you observe your newborn, you may notice that loud noises, bright lights, or quick movements startle her or make her fling her arms and legs out and straighten her body, especially when she’s on her back. This physical response (called the “Moro reflex”) is one of the normal early reflexes that indicate good neurological health.

Another early reflex is when your newborn firmly grasps your finger when you place it on her palm. (Reflex or not, this action is simply wonderful!) The stepping (or automatic walking) reflex occurs when your baby alternately moves each foot when she’s held upright and her feet bear weight. Your baby’s sucking and swallowing reflexes let her eagerly suckle milk from your breast or a bottle nipple. She also may suckle your breast or suck on her fingers or yours to soothe herself. Your newborn responds to a touch on her cheek or lips by turning toward it and opening her mouth wide. This rooting reflex is especially pronounced when she’s hungry.

Your baby’s caregiver checks these reflexes in the newborn exam (see page 369). As your baby matures, many of these early reflexes will disappear.

Whether awake or asleep, your baby may yawn, quiver, hiccup, stretch, or cry without apparent reason. Many of these behaviors are reflexive and beyond your baby’s control. Hiccups are especially common soon after feeding and don’t require treatment.

Some reflexes are protective. Your baby coughs to help move mucus or fluid from her airway. She sneezes when she needs to clear her nose or when it’s irritated, or when a bright light shines in her eyes. She blinks if something touches her eyelashes, and she pulls away from a painful stimulus such as a blood draw from her heel. If lying on her stomach, she lifts her head and turns it to the side to avoid being smothered. If something is placed over her nose and mouth, she twists away from it, mouths it vigorously, or attempts to knock it away with her arms.

YOUR NEWBORN’S BREATHING PATTERN

You may notice that your baby breathes more rapidly than you do (between thirty and sixty times per minute). You also may notice that he has periods of irregular breathing, which can be worrisome but is normal. When your baby sleeps, he may snort, squeak, pant, groan, and even occasionally pause his breathing. These irregularities usually disappear a month or two after the birth, when you’ll notice that his breathing is more regular.

If you’re worried whether your baby’s breathing patterns are normal, observe him as he sleeps. If you see the irregularities described in the previous paragraph, don’t be concerned. However, if you observe signs of respiratory distress (such as blue lips, a struggle to breathe, flared nostrils, or a deep indentation of the chest with each breath), call your baby’s caregiver immediately.

YOUR NEWBORN’S BOWEL MOVEMENTS

Your baby’s first bowel movements (meconium) will be a sticky, green-black substance that was in her intestines before birth. By two to three days after the birth, she’ll produce brown, brown-green, or brown-yellow stools that are the consistency of cake batter. After your milk has come in (by three to four days after the birth), your baby will produce yellow, green, or brown stools that are mostly watery but may be curd-like.

The frequency and consistency of bowel movements depend on the baby and on the food she eats. Breastfed newborns typically poop after each feeding, or produce at least two large runny stools each day after their mothers’ milk has come in. Formula-fed babies poop frequently in the first several days after the birth. When they’re a week old, they may produce one to two putty-like stools each day.

What Happens after the Birth

If you give birth at a hospital, your baby will typically stay in your room (“room-in”), and you and your family will provide basic baby care, including diaper changes. This arrangement allows you to get acquainted with your baby and discover questions you may have about his care. Your nurses, caregiver, and other hospital staff can help you find answers.

If you give birth at a birth center, you’ll probably go home three to six hours after the birth. If you give birth at home, your caregiver will likely leave three to six hours after the birth. At either birthplace, your caregiver can answer any questions you may have about newborn care. You may also consult with a doula, lactation consultant, or your childbirth educator.

Regardless of where you give birth, your caregiver will likely evaluate your newborn soon after the birth. The following sections describe common tests and procedures including circumcision, a procedure to consider if you have a baby boy (see page 372).

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NEWBORN TESTS AND PROCEDURES

The table on pages 370–371 describes common tests and procedures that evaluate your baby’s health and ensure she remains healthy. They’re part of routine newborn care, and many are required by state or province government. Find out which tests and procedures your state or province mandates by contacting its public health department. You also may ask whether you can request further tests or procedures, or can decline some routine ones.

If you give birth at a birth center or at home, talk with your midwife about when and where she’ll offer these tests and procedures.

Newborn Tests and Procedures

Protocols for tests and procedures vary somewhat among caregivers. Ask your caregiver which tests are routinely performed at your birthplace and which are used only if medically indicated. You can find further information about these procedures on our web site, http://www.PCNGuide.com.

Test or Procedure

• Apgar score

• Infant vital signs

• Vitamin K

• Newborn eye care or prophylaxis

• Septic workup (only when medically indicated)

• Test for jaundice (used only when there are concerns)

• Test for hypoglycemia (low blood sugar)

• Infant security

• Newborn hearing screening

• Newborn screening7

What It Is

• Immediately after the birth, your caregiver will evaluate your baby’s well-being by a quick assessment of key factors.

• Your caregiver or nurse assesses your baby’s temperature, heart rate, and respiration to ensure she’s adjusting well, to detect any problems with her heart or lungs, or to determine whether she needs to be warmed.

• Vitamin K is injected into your baby’s thigh soon after the birth to enhance blood clotting and possibly prevent a bleeding disorder.12

• Erythromycin or tetracycline ointment (or, rarely, silver nitrate drops) is placed in your baby’s eyes within an hour after the birth to prevent infection and possible blindness if she was exposed to gonorrhea or chlamydia in the birth canal.6

• Your baby’s blood is drawn and cerebrospinal fluid may be obtained by spinal tap; samples are sent to a laboratory to be tested for bacteria. Results are available in 48 hours.

• Your baby’s blood is drawn from her heel and is sent to a laboratory, where the bilirubin level is determined. Sometimes, a jaundice meter is used to estimate bilirubin levels by flashing a light onto your baby’s forehead.

• Your baby’s blood is drawn from her heel to test for hypoglycemia.

• All hospitals should have policies to prevent kidnapping and to ensure all babies are properly identified, which can safeguard against accidentally switching infants.

• Your baby’s caregiver will assess her hearing in the first days after the birth using a device for about 10 minutes while she’s sleeping.

• Your baby’s blood is drawn from her heel before she’s a week old. (If the first sample was collected within the first 24 hours of birth, a second specimen is collected before she’s 2 weeks old.)9 The blood is then screened for various rare conditions.

Comments

• See page 266 for a full discussion on this routine assessment.

• A normal heart rate for infants is 90 to 160 beats per minute; normal respiration is 30 to 60 breaths per minute. Your baby should appear pink and breathe easily (that is, without grunting, flared nostrils, or a deep indentation of her chest with each breath). If there’s a concern, your baby’s caregiver will assess her or admit her to the hospital nursery. Normal axillary (underarm) temperature of newborns is between 97.4°F (36.3°C) and 99.5°F (37.5°C). If your baby has a fever, she’ll be admitted to the nursery and may have a septic workup and antibiotics. If she’s too cool, she’ll be placed on your bare chest and covered with warmed blankets, or placed under a special warming light in your room or in the nursery.

• Breastfed babies are slower to produce adequate amounts of vitamin K than formula-fed babies. Formula contains small amounts of vitamin K.3–5

• All treatments can cause temporary blurring of vision. In the first hour after the birth, your baby is very alert and wants to gaze at you. Wait until after that hour before giving treatment. Eye prophylaxis can’t prevent all possible eye infections caused by viruses or bacteria other than chlamydia and gonorrhea.

• If infection is suspected, your baby will be admitted to the nursery for intravenous (IV) antibiotics. If tests results are normal, antibiotics will be discontinued. If tests show the presence of bacteria, your baby will stay in the nursery for a full course of antibiotics.

• If your baby’s skin and the whites of her eyes are yellowish, an elevated bilirubin level is suspected. Most jaundice is mild and disappears with little or no treatment. (See page 389 for more information on jaundice.)

• Hypoglycemia is most common in babies that weigh more than 8 pounds 13 ounces or less than 5 pounds at birth, or in babies who had preterm or postterm births. It also can occur in babies who are cold or whose mothers are diabetic or received large amounts of IV fluids with dextrose during labor. Hypoglycemia can lead to respiratory distress, lethargy, slow heart rate, seizures, and (rarely) death. Treatment includes frequent breastfeeding or formula feeding. In more serious cases, the baby may be given IV dextrose.

• All babies should be given wrist and ankle bands at birth that match their mothers’. All staff caring for babies should wear easy-to-read identification badges, and the hospital should have a written plan that details how it’ll respond if an infant is missing (a very rare situation). Having your baby in your room and never leaving her unattended are the best ways to keep your baby safe.

• Caregivers typically test the hearing of newborns who are born prematurely, who have a family history of hearing deficits or deafness, or who have been exposed to pathogens or medications that put them at risk for hearing loss. However, health care professionals are considering universal screening because 50 percent of babies with hearing deficits have no known risk factors.

• Although screening detects rare conditions that most babies don’t have, affected babies greatly benefit from early diagnosis and treatment. These conditions include sickle cell anemia, beta thalassemia, phenylketonuria (PKU), hypothyroidism,8 and galactosemia. The American College of Medical Genetics recommends that caregivers screen newborns for twenty-nine conditions; however, states and provinces vary widely in the number of conditions that they screen. Visit http://www.marchofdimes.com for more information about these conditions and tests.

CIRCUMCISION

Circumcision is the surgical removal of the foreskin covering the glans (tip) of the penis. It may be the oldest-known surgery (dating back around six thousand years) and is done worldwide for social, cultural, religious, and medical reasons. It’s performed in hospitals and clinics, and at ceremonial sites.

Some communities practice circumcision more often than others. For example, the Jewish and Islamic communities use circumcision as a religious ritual. It’s a common procedure in North America, Africa, and the Middle East; however, it’s uncommon in Latin America, South America, Europe, Australia, and the Far East.

The benefits and risks of circumcision are debatable among health care professionals. Parents of baby boys will need to gather information on the subject (preferably during pregnancy) so they can make an informed decision about whether to give their written consent to have their sons circumcised.

The following sections provide facts about circumcision, as well as information about the procedure and aftercare.

Facts about Circumcision

Think about the following facts carefully as you consider circumcision. Consult with your baby’s caregiver to learn more about the benefits and risks of the procedure.

• There are few medical reasons for circumcision. Social or religious factors may guide your choice.

• The American Academy of Pediatrics (AAP) has remained neutral about circumcision, but recommends that parents become well informed before making the decision.10

• The procedure usually takes less than thirty minutes. Healing takes seven to ten days.

• A newborn will feel the pain caused by the procedure.

• Health care providers recommend an injection of local anesthesia to reduce the pain of circumcision.11 Complications from anesthesia are rare and include bruising at the injection site. Applying local anesthetic creams to the penis an hour or so before the procedure may decrease pain, although less effectively than an injection of anesthesia.12 Sucking on a special pacifier that delivers a small amount of sugar water during the procedure also may reduce pain.

• Out of 1,000 newborn circumcisions, 2 to 6 will develop minor to serious complications, including irritation of the glans from rubbing against wet diapers, painful urination, bleeding, infection, and scarring of the urinary outlet (where urine exits the penis).

• Health insurance might not cover the caregiver’s fee for doing the procedure or the hospital’s or clinic’s fee for using its equipment.

• Some studies find a connection between an intact (uncircumcised) penis and urinary tract infection (UTI) in the first year of life; however, the risk of infection is low (about 1 percent).13 Exclusive breastfeeding can significantly reduce the risk of UTIs (by 300 percent).14

• Contrary to previous reports, no evidence suggests that circumcision prevents cancer of the prostate gland or certain sexually transmitted infections (STIs). Although international studies link circumcision with a reduced risk of human immunodeficiency virus (HIV) infection, the U.S. Centers for Disease Control and Prevention (CDC) doesn’t recommend circumcision to prevent HIV infection, citing that circumcision itself carries risks and provides only partial protection that necessitates using other proven prevention measures such as correct condom use.15

• Opinions differ about whether newborn circumcision affects adult sexual performance. Some experts say it does, while others argue it doesn’t.

• In 2003, 56 percent of boys in the United States were circumcised. circumcised. (In some regions, rates were as low as 31 percent.) By 2009, the rate dropped to 32.5 percent nationwide.16

The Circumcision Procedure

If you decide to have your baby boy circumcised, talk with his caregiver about the potential risks and benefits of the procedure, including the use of anesthesia.

Before the procedure, you need to sign a consent form. Then your baby is placed on his back in a special plastic bed, with Velcro straps holding his body and limbs firmly in place. He then receives anesthesia. After it has taken effect, his penis is washed with an antiseptic. A sterile sheet with a hole in the center (to reveal the penis) is placed over his trunk. The foreskin is separated from the glans and removed by one of three instruments: Gomco clamp, Plastibell device, or Mogen clamp. Circumcision takes about five minutes, and you may be allowed to stay with your son during the procedure.

Care of the Circumcised Penis

After the circumcision, ask your baby’s caregiver or the medical staff how to care for your son’s penis. If a Mogen clamp or Gomco clamp was used to remove your baby’s foreskin, he’ll usually have Vaseline-covered gauze applied to the circumcision site for twenty-four hours, at which time the gauze typically falls off. Watch for bleeding, inability to urinate, or swelling; if you observe any of these signs, call your baby’s caregiver. If the gauze doesn’t fall off after twenty-four hours, wrap the area in a warm, moist washcloth or give your baby a bath. Once the gauze is soaked, gently remove it. (If you can’t, call your baby’s caregiver.) Once the gauze is removed, apply an ointment, such as A&D ointment, or diaper cream on your baby’s diaper where it touches his penis to prevent irritation at the circumcision site.

If a Plastibell device was used to remove your baby’s foreskin, a small plastic ring will remain on his penis, with a suture thread tying the foreskin tightly to the device. The device and foreskin usually fall off seven to ten days after the circumcision. Do not pull the ring off; let it fall off on its own. At the circumcision site, you may see small yellow or white patches of normal, healing tissue. Report any swelling, bleeding, inability to urinate, or pus-like discharge to your baby’s caregiver.

Care of the Intact (Uncircumcised) Penis

If you decide against circumcision, know that a newborn’s intact foreskin doesn’t usually retract (pull back) but instead adheres to the glans. Don’t force back your baby’s foreskin to clean the glans. Regular bathing will keep the area sufficiently clean. The foreskin will gradually loosen as your son matures. Most boys’ foreskins are fully retractable when they’re between four and eight years old. Once your son’s foreskin can be easily retracted, the glans can be cleaned with just soap and water.

Caring for Your Baby at Home

If you give birth in a hospital or birth center, you may feel both excitement and anxiety when heading home with your newborn. If you give birth at home, your caregiver’s departure after the birth may cause the same feelings. Once the anticipation of the birth is over, many new parents suddenly realize that they’re responsible for this tiny person, and they wonder whether they’re up to the challenge.

Caring for a baby becomes easier with practice. During the first days and weeks after the birth, you’ll begin to master diapering, bathing, dressing, and comforting your baby. To learn about these tasks, try to take a newborn care class before the birth. If that’s not possible, ask whether the hospital or birth center offers a “crash course” that you can take before you’re discharged. If you give birth at home, ask your caregiver about baby care during your last prenatal appointments or before she leaves after the birth. You may also consider hiring a postpartum doula to help you with baby care (see page 27).

The following sections are an introduction to the basics of baby care.

Two Views about Leaving the Hospital

The hospital stay was very pleasant. I didn’t want to leave! I enjoyed getting spoiled with attention, and I was nervous to be on my own with a newborn.

—Michelle

Leaving the hospital felt like such a big, momentous event. Then we arrived home, and that was really exciting for the first few minutes. Then we sat down, looked at each other, and said, “Okay, now what?” We realized that we had to figure out what this parenting thing was all about.

—Alice

CAR SAFETY

It’s the law in the United States and Canada that every baby traveling in a vehicle must be restrained in a car seat that meets current federal safety standards. If you give birth in a hospital or birth center, before you’re discharged you’ll need to have a car seat that’s the right size for your newborn correctly installed in your vehicle, according to the manufacturer’s instructions. For the latest information on car seats, visit the American Academy of Pediatrics’ web site, http://www.aap.org/family/carseatguide.htm, or visit http://www.saferchild.org/carseat.htm.

If your baby is premature or weighs 51/2 pounds or less before discharge, the hospital or birth center staff will place your baby in the car seat for an hour to assess her ability to breathe adequately. If your baby can’t breathe well at any point during the hour, the staff will remove her from the car seat and provide a special car bed to ensure safe transport.

DIAPERING YOUR BABY

Today’s parents have several options to manage their babies’ waste, from cloth diapers to disposable diapers to no diapers at all.

Cloth diapers have come a long way since diaper pins were used to fasten them. The design of most cloth diapers is similar to that of disposable brands, with Velcro tabs and elastic around the leg holes. Cloth diapers are usually used with a diaper wrap or plastic pants to prevent leaks. You can use a baby diaper service (if available in your area) to provide clean diapers and take away used ones. Or you can buy cloth diapers and launder them at home.

Pocket diapers have a diaper wrap on the outside and a fleece liner on the inside, which can keep your baby dry and reduce diaper rash. You can fill the pocket between the inner and outer layers with a cloth diaper, hemp, or other material that can be more absorbent than a cloth diaper. Launder pocket diapers at home according to the manufacturer’s directions.

Disposable diapers come in various sizes and styles. Although they may be more convenient than other diapering options, they also may be more expensive. You’ll need to properly dispose used diapers according to the directions on the package.

Ecologically friendly disposable diapers and biodegradable diapers can be composted if wet with only urine. With some brands, a portion of the diaper can be flushed if it’s poopy (check manufacturer’s instructions).

To learn how to diaper your baby and figure out the size and quantity of diapers you’ll need, ask your childbirth educator, nurse, or parent educator. You can also ask the staff at a speciality baby store or diaper service, or any experienced parent. You may also find helpful information online by using the search terms diaper choices to find web sites that review cloth diapers and disposable diapers.

Some parents use a diaper-free method called elimination communication (EC) and avoid using diapers entirely or part of the time. EC is a common practice worldwide, where access to diapers and the ability to launder them is limited or unavailable. This method requires paying close attention to a baby’s cues to urinate or have a bowel movement, but it eliminates or reduces the cost of diapers and is ecologically friendly. Parents practicing EC dress their babies with the diaper area open and unrestricted. When they observe their babies’ cues to urinate or have a bowel movement, they hold their babies over a sink or special potty. Some parents begin practicing EC soon after birth; others wait until their babies are older. Some use this method around the clock; others only during the day or while at home.

Common Q&A

Q: My son’s diapers are always leaking. Is the kind of diaper I’m using to blame? Or is there another reason?

A: The cause for the leaking may well be a matter of positioning. Try pointing your baby’s penis down as you diaper him. That way, the urine will be directed toward the most absorbent part of the diaper.

Diaper Rash

If the skin on your baby’s diaper area becomes irritated, he may have diaper rash. Many substances can cause diaper rash, including urine and stool, some laundry detergents, or chemicals used in some disposable diapers. Diaper rash also can appear if you inadequately launder your baby’s cloth diapers.

To prevent or treat diaper rash, change your baby’s diapers frequently and rinse his skin with water at each change. Before putting on a new diaper, wait a few minutes to allow your baby’s clean bare skin to air-dry (or blow-dry the diaper area with a hair dryer set on low or no heat).

If using cloth diapers, run them through an extra rinse cycle to reduce irritation from detergents, or use a milder detergent. To reduce the amount of ammonia (from urine) that stays in cloth diapers even after laundering, add a 1/2cup of vinegar to the diaper pail or to the rinse cycle. Because plastic pants can trap moisture and cause irritation, you may need to switch to a different type of diaper cover.

If these treatments don’t work, you also may consider applying a diaper rash cream to the irritated area after you clean and dry it. To choose a cream that’s safe and effective, visit http://www.cosmeticsdatabase.com. If the diaper rash persists, consult your baby’s caregiver.

Constipation

Constipation is the production of small, hard, dry stools that can be painful to pass. The condition is more common in formula-fed babies than in breastfed babies, because formula is harder to digest than breast milk.

If you’re breastfeeding your baby, about a month after the birth you may notice that she has begun pooping only once a day or even once a week. This change doesn’t indicate constipation. Instead, it shows that her digestive system has begun to efficiently use more of your milk. If you’re still concerned, call her caregiver.

In Their Own Words

To give my baby some time without a diaper, I spread a plastic garbage bag on the floor, cover it with a towel, then place her on her tummy on the towel. We play together while her bottom airs and she gets some tummy time.

—Yuko

Diarrhea and Vomiting

Diarrhea (frequent, watery bowel movements) and vomiting are serious conditions for babies because they can cause dehydration quickly. Formula-fed babies experience diarrhea and vomiting much more often than exclusively breastfed babies, probably because formula is harder to digest than breast milk and also may be exposed to more contaminants. Symptoms of diarrhea include more frequent stools that may smell foul, look bloody, or contain mucus. An affected baby may appear ill, weak, or listless. If you see any of these signs, call your baby’s caregiver for advice.

BABY CLOTHES AND EQUIPMENT

As you prepare for your baby’s arrival, you may wonder if you need all the items available in baby stores and departments. See page 160 for a list of typical baby clothing and equipment. After reviewing your options, choose the items that appeal to you and are appropriate for your family.

BATHING YOUR BABY

Newborns need bathing only once or twice a week.17 You can bathe your newborn with a wet soft cloth, but a tub bath may be a more enjoyable experience for you both. Babies stay warmer and calmer when immersed in warm water than when given a sponge bath. The warm water also may soothe fussy babies, and it won’t increase the risk of infection in the cord or a newly circumcised penis.

To give your baby a tub bath, fill a sink or baby bathtub with comfortably warm water. Hold your baby securely with his head resting in the crook of your arm or the bend of your wrist, with your hand gently grasping his arm. Lower him into the water so it covers his body, but not his head and neck. With your free hand, use only water to clean his eyes and face. Next, wash his hair with mild soap, massaging his head with your fingers or a soft brush. Wash his body with water or with a mild baby soap. Let your baby enjoy the warmth of the water. When the bath is done, make sure his skin and hair are completely dry before dressing him.

Many parents enjoy bathing with their babies as a way to relax together. To bathe with your baby, fill the bathtub with comfortably warm water. Get into the tub first and have someone hand you your baby. If no one is available, line your baby’s car seat with a towel (to keep him warm and the car seat dry if you return him there after the bath), set him in it next to the tub, then pick him up once you’re in the water. Lay him on his back on your thighs so the water covers his body but not his neck and head. Enjoy relaxing in the water together. Wash his body with water or with a mild baby soap. When you’re done bathing your baby, hand him to someone who can wrap him in a warm towel or place him back in his towel-lined car seat.

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CORD CARE

Many different rituals and treatments have been used to promote the separation of the umbilical cord from a baby’s abdomen while preventing infection. However, researchers have studied only a few for their effectiveness.

One such study compares two treatments: cleaning the cord with rubbing alcohol at each diaper change or letting the cord dry naturally. While the results show that infection didn’t develop from either treatment, the cord that dried naturally separated a day earlier than the cord treated with rubbing alcohol.18 These findings suggest that the best cord care requires minimal intervention.

To care for your baby’s cord, follow these recommendations:

• Wash your hands before touching the cord.

• Use baby soap (or no soap) to bathe your baby, to maintain the acid pH of her skin that helps reduce bacteria growth.

• To keep the cord dry and clean, fasten your baby’s diaper, diaper wrap, and plastic pants below the cord.

• If the cord is soiled, gently clean it with warm water and let it dry thoroughly.

• If the cord area is red, emits a foul odor, oozes pus, or bleeds bright red blood in a spot larger than a quarter, call your baby’s caregiver. (Note: When the cord falls off, some dark brownish-red blood or clear yellow sticky fluid at the separation site is normal.)

• If your baby leaves the hospital with a cord clamp attached, have her caregiver or the hospital staff remove it at a later date. (Or you can remove it if given clear instructions from a medical professional.) Do not cut off the cord clamp.

Your Baby’s Communication

Although your baby can’t talk, he can communicate his needs, likes, and dislikes through infant cues. Your baby may let you know he’s hungry by rooting, sticking out his tongue, being wakeful, or sucking on his hand. He may yawn and half-close his eyes to tell you he’s sleepy.

If you don’t respond to your baby’s early cues, he may begin to fuss and cry to let you know he’s hungry, lonely, uncomfortable, or overstimulated. By the time you see this late cue, it may take longer to satisfy his needs because you must first calm him. For example, feeding your baby is harder if you wait until he cries than if you respond to his early feeding cues. (See Chapter 18.)

As you get to know your baby, you’ll be better able to interpret the cues described in the following sections.

ENGAGEMENT CUES

When your baby is calm, quiet, and alert, she has subtle ways to get your attention and keep it. Her body relaxes, her eyes brighten and open wide, and she stares at you intently. If you ignore these engagement cues or look away, she may vocalize or move her arms to catch your attention. When you return her gaze, a quiet exchange begins as she explores your face. When she needs a brief rest to process what she has seen, she may turn or look away until she’s ready to return her gaze to you.

During these exchanges with your baby, be sensitive to her needs by returning her gaze when she wants your attention and by letting her rest without coaxing her to look at you.

From birth your baby can imitate some of your facial expressions. For example, shape your mouth into an O and hold the expression for ten seconds where your baby can clearly see you; repeat this action several times. If your baby is quiet and alert, she’ll shape her mouth into an O. You can also do this exercise when sticking out your tongue or lower lip; your baby will mimic these expressions as well.

When your baby is around six weeks old, she’ll begin to smile and coo to initiate an exchange and in response to your smile. (These endearing interactions make many parents fall deeper in love with their babies!)

Your baby can best teach you what calms or agitates her. When your responses to soothe your baby are effective, she becomes calmer and less fussy, and she relaxes into your body as you hold her. If your responses overstimulate her, she may stiffen, arch her back, or spread her fingers wide as if trying to push something away. If you miss these disengagement cues, she may cry loudly.

To help you learn more about your baby’s cues and abilities, consider taking a parent-infant class or consulting with your baby’s caregiver or nurse, your childbirth educator, or other experienced parents.

CRYING

Contrary to traditional thought, you won’t “spoil” your baby by responding whenever he cries. When your baby cries, he’s not manipulating you for your attention; he simply has no other way to tell you he needs something. Crying is often your baby’s last attempt to communicate that he’s hungry, overstimulated, tired, or uncomfortable. He may cry because he has gas and needs to be burped. He may cry because he has a wet or dirty diaper (especially if he’s feeling cold), a diaper rash, or sore circumcision site. He may cry if he’s ill or simply because he wants to be held and rocked.

Responding to your baby’s crying helps develop his trust in your ability to meet his needs. Try to respond before he becomes so upset that he can’t calm himself easily. Your baby will become more agitated if you are upset, so try to stay as calm as possible by talking quietly to him and moving slowly and calmly around him.

Soothing your baby is easier if you know why he’s crying. But occasionally, you might not immediately know the reason for his distress, which can naturally be frustrating. In those cases, try comforting him with any of the following calming techniques. Give each one several minutes to work before trying another, and be careful not to overstimulate your baby.

• Try feeding your baby first. Some babies need to nurse frequently before taking a longer (more than one hour) rest between feedings.

• Take a bath with your baby. The warm water may calm him, and he may even breastfeed.

• Give your baby a gentle massage.

• Take your baby for a walk in a baby carrier or stroller.

• Try the Five S’s (see page 379).

If nothing seems to calm your baby and you find yourself losing your temper, put him safely in his bed or car seat and take a short break. If after five to ten minutes your baby is still agitated and you still feel angry and frustrated, never shake or roughly handle him, no matter how upset you are. Instead, call your partner, a relative, a friend, or a neighbor to help you.

Although at first you may have trouble figuring out exactly why your baby is crying, let your instincts and feelings guide you. You’ll become more comfortable in your ability to calm your baby with time, practice, and advice from your baby’s caregiver, a supportive relative or friend, or a new-parent group.

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The Five S’s

Dr. Harvey Karp suggests calming babies using a five-step method called the Five S’s. This method provides babies with a familiar and comforting womb-like environment. Some babies need all five steps, while others are calmed by just a few.19

Swaddling

Swaddling increases how long your baby sleeps by preventing her from startling herself awake.20 You can swaddle your baby in a large, lightweight blanket; a commercial swaddling blanket; or sleep sack with her arms tucked inside. Your nurse, midwife, or doula can show you how to swaddle your baby, or there are many commercial swaddling products on the market. (For example, Dr. Karp offers an instructional DVD.) You can also provide a swaddle-like environment by tucking your baby snugly inside a baby carrier, sling, swing, or bouncy seat. Visit our web site, http://www.PCNGuide.com, to learn an effective double swaddle technique.

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Side or stomach position

Hold your baby in your arms on her side (which may aid digestion) or on her stomach with gentle pressure against her abdomen. Being held on her back may cause her to startle easily.

Shushing

Make a shushing sound near your baby’s ear or use white noise (continuous noise such as a fan or radio static) loudly enough so she can hear it over her crying.

Swinging

Repetitive motion such as swinging helps soothe babies. Swing your baby by swaying, rocking, jiggling, or gently bouncing with her on an exercise ball. You also can gently swing her from side to side in a hammock made by holding two corners of a blanket while someone else holds the other two corners. To give yourself a chance to eat or rest, consider using a baby swing.

Sucking

Let your baby suck on a pacifier or your finger. Feeding her can also calm her; however, you’ll have likely already tried this as a calming technique, because hunger is a typical reason for crying.

Colic or Fussy Periods

When babies are between three and twelve weeks old, most have predictable fussiness in the evening and early night (a time some parents call “fuss and feed”). In the past, this fussy period was called colic,defined as three or more crying episodes each week for three or more weeks, with each episode lasting three hours or longer.21

Dr. T. Berry Brazelton, an expert in infant development, states that this fussy period is a normal “touchpoint” or parenting challenge.22 His research reveals that an overload of stimuli (such as bright lights, loud noises, and feelings of hunger) throughout the day causes the predictable fussiness. As the day progresses, the baby’s immature nervous system begins to cycle into shorter sleep periods, more frequent feeding, and more fussiness.23 At the end of the fussy period, babies usually settle into their longest stretch of sleep that may last three hours or longer.

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If your baby is fussy or colicky, use the suggestions on page 378 to calm him. Because overstimulation often causes excessive crying, use a calming technique consistently for several minutes before trying something new. Remember that the calmer you are, the easier it is for your baby to settle down.

Although all babies have gas, if your fussy baby seems especially gassy, use comfort holds that provide pressure against his abdomen, such as those illustrated at right, to help alleviate the pressure. You may have heard the suggestion to give your baby simethicone (Mylicon) drops; however, research hasn’t found them to treat gas any more effectively than a placebo.24 Some parents give their babies “gripe water” to alleviate gas. This supplement generally contains potentially gas-reducing ingredients such as fennel, spearmint, and ginger.

Parents sometimes mistake colicky symptoms for those of gastroesophageal reflux (GER or reflux). With this condition, some of the acidic stomach contents flow up into the esophagus, making the tissue inflamed and painful. Babies with GER often arch and stiffen during feedings, may spit up or cough, may have sour breath, and are especially uncomfortable when placed on their backs. The difference between colic and GER is that reflux symptoms are constant during the day and night. Also, GER can be treated with medication and by positioning the baby upright after feedings and for sleep.

If your baby is constantly crying in addition to vomiting, spitting up, or having a cold, a fever, or constipation, consult with his caregiver.

Fussy periods can be stressful to new parents, and you may want to ask your baby’s caregiver, other parents of colicky babies, or members of a parent-baby support group for advice on soothing your baby and coping with the stress. If you’re spending several hours each day soothing your baby, take a break now and then. Let a trusted person relieve you so you can take a walk. Or take your baby on a walk with another new parent and baby. As with most parenting challenges, these fussy periods will end with time, your growing confidence as a parent, and your baby’s increasing maturity.

Your Baby’s Sleeping and Waking Patterns

After a period of wakefulness after the birth, many babies sleep for much of the first day. They rouse only briefly and might not be interested in feeding. Other babies, however, are awake, fussy, and feed frequently during the first day.

After babies have adjusted to their new environment, they sleep twelve to eighteen hours in a 24-hour period, typically in short but frequent intervals. As long as a baby feeds well and is growing well, how long she sleeps at any one time isn’t a concern.

When your baby is older, she may awaken at night to feed and then fall back to sleep. If your baby awakens because she’s hungry, she’ll root, suck on anything close by, and wave her arms and legs vigorously. If you don’t respond to these early feeding cues, she’ll cry. For more information on feeding your baby, see Chapter 18.

SLEEP LOCATION

Upon first learning they’re pregnant, many expectant parents plan on creating a separate nursery filled with adorable decorations and a lovely crib. However, experts recommend that babies sleep in the same room as their parents in the early months to reduce the risk of sudden infant death syndrome or SIDS (see page 391).

Some parents choose to have their baby sleep in a cosleeper or in a basket, bassinet, or crib near their bed. This placement allows parents to quickly respond to the baby’s needs and to comfort him with the sounds of their breathing.

Other parents find they get more sleep if they tuck their baby in bed with them. Because a newborn has long wakeful periods at night just as he did while in the womb, where he was snug and warm, he may sleep better with his parents in their bed than by himself in another location. Many families put their babies in a crib, bassinet, or cosleeper at the beginning of the night, and then move them into their bed as morning approaches to get a few more hours of sleep.

As your baby grows older and needs you less at night, you can move him to a crib or his own bed in your room or another room. Or he can continue sleeping in your bed with you. It’s your decision.

Wherever your baby sleeps, you need to place him in a safe space and position him on his back on a firm surface to reduce the risk of SIDS. See page 392 for more information on safe sleeping spaces.

YOUR BABY’S SLEEP-ACTIVITY STATES

Experts have identified six sleep-activity states that babies experience: deep sleep, light sleep, drowsiness, quiet alert, active alert, and crying. While each state has specific characteristics, the way that babies change from state to state varies. Some babies move gradually from one state to another, while others make abrupt transitions. Some spend more time asleep or in a quiet-alert state than others; some spend more time crying. Your baby’s temperament affects his states; you can’t control them.

Identifying the following states in your baby will help you give him appropriate care.

Sleep States

In deep sleep your baby is still and relaxed; her breathing is rhythmic. She occasionally jerks or makes sucking movements, but rarely awakens. She doesn’t need anything from you at this time, so use it as an opportunity to rest and take care of yourself.

Light sleep is the most common sleep state in newborns. Your baby’s eyes are closed, but they may move behind her eyelids. She moves, makes momentary mewing or crying sounds, sucks, grimaces, or smiles. She breathes irregularly. She responds to noises and efforts to arouse or stimulate her. When your baby moves and makes sounds, wait a few moments to see if she’s awakening to a drowsy state and needs care, or if she’s falling back to deep sleep.

Awake States

When your baby is drowsy, he appears sleepy, his activity level varies, and he may yawn or startle occasionally. His heavy-lidded eyes, which open and close for brief periods, lose focus or appear cross-eyed. He breathes irregularly and slowly reacts to sensory stimuli. If you hope he’ll fall asleep, try shushing or patting him to help him settle down. If you hope he’ll awaken, try picking him up, singing to him, or dancing with him.

Tummy Time

Because babies need to sleep on their backs and spend time in car seats and swings, the back of their heads can become flattened from contact with a firm surface. To prevent your baby from developing a misshapen head and to give her an opportunity to lift her head and strengthen her neck muscles, frequently place her on her tummy when she’s awake for as long as she’s happy in that position. Also limit the amount of time your baby spends in car seats and other baby equipment that put pressure on the back of her head. Many babies fuss when they’re first learning to lie on their tummies. Over time, they’ll tolerate tummy time and eventually will begin to enjoy longer sessions. Here are ways to provide supervised tummy time:

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• Lay your baby across your lap.

• Lay your baby on the floor with a nursing pillow supporting her chest.

• Lay your baby on an exercise ball, hold her steady, and roll the ball gently forward and back.

• Hold your baby tummy-side-down while practicing postpartum exercises. (See page 343.) In addition, holding your baby upright in your arms or in a baby carrier (such as a Moby Wrap or ERGObaby carrier) will provide tummy-time benefits.25

Quiet alert is the most pleasing and rewarding state for parents. Your baby lies still and looks at you calmly with bright, wide eyes. He breathes with regularity and focuses attentively on what he sees and hears. By providing him something to look at, listen to, or suck on, you encourage him to spend longer times in this state. (See pages 385–386 for information on playing with your baby.)

Active alert is the state that indicates your baby is starting to need something, although he might not know what it is yet. He can’t lie still; he may be fussy. His eyes are open but not as bright and attentive as when he’s in a quiet-alert state. He breathes irregularly and makes faces. Hunger, fatigue, noises, and too much stimulation readily affect your baby and may lead to fussing or crying.

When your baby reaches this state, try to determine what he needs. If he shows feeding cues, feed him. If he looks away, he probably needs less stimulation. If you act immediately, you may bring him to a calmer state before he begins to cry.

Crying is your baby’s last attempt to tell you he can’t cope any longer. If he’s hungry, overstimulated, tired, sick, gassy, frustrated, wet, cold, hot, or lonely, he may have first tried communicating with subtle cues. If his needs continue to go unmet, he communicates his distress by crying. In this state, he also moves his body actively, opens or closes his eyes, makes unhappy faces, and breathes irregularly. Sometimes, crying is a way to let himself enter another state. More often, however, he needs you to feed or comfort him.

RECORDING YOUR BABY’S SLEEPING AND ACTIVITY PATTERNS

At times, your baby’s apparently inconsistent sleeping and activity patterns may puzzle you. However, by charting your baby’s feeding, sleeping, quiet-alert, and crying or fussing periods for a week, you can see when and how long your baby typically sleeps, is awake and content, or cries. You may notice that she has a fussy period at a certain time. Or you may learn that she takes a long nap at roughly the same time every day.

After charting for a week, you may discover that your baby’s sleeping and activity patterns are somewhat consistent. As your baby matures, the patterns will continue to change. Visit our web site, http://www.PCNGuide.com, for a sample chart that you can use to record your baby’s patterns.

Your Baby’s Growth and Development

Your baby has a unique appearance, temperament, and personality. His activity level and sleeping and eating patterns differ from those of all other babies, as do his responses to pain, hunger, or boredom.

Some babies are easy to care for; others are more difficult. For example, you may need additional patience and flexibility if your baby reacts to stimuli intensely, adapts to changes in his environment slowly, has a high activity level, and has mostly unpredictable feeding, sleeping, and activity patterns. As you get to know your baby’s temperament, you’ll learn to care for him in an effective and satisfying way.

Although your baby’s temperament will probably change little over time, his abilities will quickly change. Because normal development patterns vary widely from one baby to the next, don’t worry if your baby develops later or earlier than another baby. If, however, you notice that your baby misses some developmental milestones (see below) or is consistently older than the approximate age when he reaches a milestone, consult with his caregiver. Early detection and treatment may improve your baby’s long-term development.

Developmental Milestones

Here’s a list of developmental behaviors or characteristics and the age when your baby is most likely to begin showing them. If your baby was premature, these milestones may occur somewhat later.

Behavior or Characteristic

Approximate Age

Looks or stares at your face for short periods

Birth to 4 weeks

Holds up his head for a few moments while lying on his stomach

Birth to 4 weeks

Pays attention to sound by becoming alert or by turning toward it

Birth to 6 weeks

Smiles or coos when you smile, talk, or play with him

3 weeks to 2 months

Lifts head and shoulders while lying on his stomach

2 to 3 months

Holds his head steady when upright

2 to 3 months

Brings his hands to his mouth

3 months

Laughs and squeals

6 weeks to 41/2 months

Rolls over from front to back or back to front

2 months to 6 months

Grasps a rattle placed in his hand

3 to 41/2 months

YOUR NEWBORN’S SENSES

While getting to know your baby over the first weeks after the birth, you may wonder what she can see, hear, and taste. For years, experts underestimated a newborn’s abilities. At one time, it was believed that a newborn responded only to a wet diaper, hunger, or gas. It also was thought that a newborn couldn’t see at birth; when she finally could see, she could do so only in black and white. These beliefs, however, are incorrect.

After years of study, experts now know that newborns have amazing capabilities, some of which are described in the following sections.26

Vision

When your newborn is quiet and alert, he can focus on objects 7 to 18 inches away. His vision at birth is about 20/200 and will be about 20/20 by six months.27 He prefers to look at human faces (especially eyes), round shapes, high contrast of dark and light colors, complex patterns, and slowly moving objects—especially shiny ones. He may be sensitive to bright lights and will open his eyes wider when the lights are dimmed. His eyes might cross or might not seem to focus. As his eye muscles strengthen and mature, his eyes will track together.

Hearing

Your baby heard your heartbeat, your voice, your partner’s voice, and other internal and external noises while inside you. After she’s born, she responds to voices, especially higher pitched voices (this is why people unconsciously raise their voices’ pitch when talking to babies). She may become calm or alert when she hears familiar voices or sounds, or when she hears white noise (such as a dishwasher or a washing machine) or familiar music. She also startles at sudden, loud noises.

Smell

Your baby has a refined sense of smell. Within the first week after the birth, he recognizes differences in smells and can even tell the difference between the smell of your milk and another mother’s milk. In fact, the smell of your milk when you hold him may excite him to root and suckle.

Taste

Your baby can taste things that are sweet, sour, salty, or bitter; however, she prefers sweet tastes. When offered something that’s bitter, salty, or sour, she turns away.

Touch

Your baby enjoys being stroked, rocked, caressed, gently jiggled or bounced, and allowed to nestle into your body while being held. He also likes warmth. Infant massage is a great way to touch your baby (see page 385).

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INFANT MASSAGE

Infant massage is an excellent way to calm and soothe your baby and to communicate your love and care. Many communities offer infant massage classes, or you can follow these instructions to give your baby a massage:

1. Give your baby a bath. Then, after making sure the room is comfortably warm, remove the towel or receiving blanket and lay your baby on her back on the floor and kneel in front of her, or lay her on her back on your lap.

2. Put a little vegetable oil or olive oil on your palm, then rub your hands together to warm them. (Don’t use baby lotion or oil. Baby lotion will soak into her skin too quickly, and baby oil and other petroleum products aren’t healthy for babies.)

3. When you begin touching your baby, keep at least one hand on her until the massage is over. Massage her arms, legs, and other areas that she enjoys having touched. Use as much pressure as she finds pleasurable. Tell your baby what you’re doing, or sing a song. Don’t massage your baby’s belly if her stomach is full, and stop the massage if she’s not enjoying herself.

4. If she’s enjoying the massage (and she probably is), here are some motions to try:

• Stroking with open palms

• Stroking with thumbs or fingers

• “Raking” with fingertips

• Tapping lightly with fingertips

• Massaging your baby’s arms or legs with a gentle wringing motion

• Doing whatever makes your baby happy

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PLAYING WITH YOUR BABY

For you, play is a way to have fun and perhaps get some exercise. For your baby, play is a way to exercise and learn about himself and the world around him. When your baby grabs and shakes a rattle or plays peek-a-boo with you, he’s discovering that he can make things happen. When you talk, coo, laugh, hug, and kiss your baby, he’s learning that his responses affect you. There are many ways to play with your baby every day, such as:

• Singing and talking to him, or dancing with him

• Caressing, touching, and cuddling when changing or feeding him

• Massaging him (See above.)

• Playing games such as peek-a-boo or playing with age-appropriate toys

• Having him do exercises with you (See page 343.)

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Advice from the Authors

To learn more information about wearing your baby in a sling or carrier, try these tips:

• Read “Ten Reasons to Wear Your Baby,” a great article by Laura Simeon. You can find it online by using the article title as a search term.

• Read Babywearing by Maria Blois.

• Learn about different types of slings and carriers at http://www.birthandbeyond.com/howtochbaca.html and http://www.wearyourbaby.com.

• Visit http://www.youtube.com and use “wear your baby” as a search term to find videos that show how to use various slings and carriers.

Play doesn’t always need to focus on your baby. He absorbs information from you no matter what you do together. For example, your baby will enjoy hearing you read aloud from a novel or even a newspaper’s business section. If you’re meeting friends for coffee, your baby will enjoy experiencing new sights, sounds, and smells. Even when you’re putting away silverware, your baby can begin to hear numbers if you count each fork out loud as you place it in the drawer.

Use a baby wrap, sling, or carrier to keep your hands free while keeping your baby close as he experiences your everyday activities.

Medical Care for Your Baby

Making sure your baby is healthy during the weeks and months after her birth will help her become a physically and emotionally healthy child and adult. The following sections describe ways to monitor your baby’s health, reduce her risk of catching diseases, and treat illnesses or conditions that she may have, including when to call for medical help.

Well-baby Care

To make sure your baby is growing well and developing normally, he should have periodic routine well-baby exams by his caregiver. Three to four days after the birth, the caregiver will assess your baby’s feeding, check for jaundice, and discuss any concerns you may have. Your baby may have another checkup when he’s a week or two old to assess his weight and feeding, give you a chance to ask questions, and possibly repeat newborn screening tests. (See page 371.) Going forward, your baby’s caregiver will let you know when to schedule additional appointments.

Vaccinations

Vaccines are biological agents, prepared in a laboratory, that can protect babies and children from specific diseases and their common complications—including death. An administration of a vaccine is called a vaccination (or immunization). Vaccinations have been one of the most significant health contributions in the last century. The success of some vaccinations has nearly or completely eradicated serious diseases such as polio and diphtheria.

Health care professionals recommend that babies and children receive vaccinations against several diseases according to a schedule that’s updated every year by the U.S. Centers for Disease Control and Prevention (CDC). Visit http://www.cdc.gov/vaccines/recs/schedules to see the current vaccination schedule.

Because vaccines introduce a foreign substance to the body, each one has potential side effects after injection. Although the risk of side effects is extremely low, some parents decide not to have their children vaccinated. To these parents, the risks of suffering the possible side effects of a vaccine outweigh the risks of getting the illness. Other parents decide against vaccination because they might not understand the importance of vaccinating their children against diseases that are rarely seen today, such as polio, diphtheria, or even measles. Other parents decide not to vaccinate because of religious or cultural beliefs.

Tips to Protect Your Baby’s Health

• Before picking up your baby, before feeding her, and after diaper changes, wash your hands well with soap and water. If you can’t wash your hands, use an alcohol-based hand sanitizer.

• Keep anyone with a cold, cough, sore throat, rash, fever, or other signs of illness away from your baby. If you’re ill, wash your hands thoroughly before feeding and caring for your baby.

• If you participate in group activities such as parent-baby groups, be sure all participants understand and respect that they should attend only if they and their babies are healthy.

• If your baby is premature or has a chronic health condition, ask her caregiver for additional wellness guidelines.

Choosing against vaccination is a decision not to be made lightly. Parents need to make sure their reasons reflect current information. For example, thimerosal (mercury) was once used as a preservative in vaccines and is thought by some to increase the risk of autism. However, manufacturers haven’t used thimerosal in childhood vaccines since 2001.28 The only exception is the influenza vaccine in a multidose vial, which babies shouldn’t receive. (After they’re six months old, babies should receive the influenza vaccine from a single-dose vial that doesn’t contain thimerosal.)

When deciding whether to vaccinate your baby, gather as much reliable information as possible. Some illnesses are more common than others; some vaccines have more side effects than others. To make an informed decision about vaccines, get the current facts from reliable resources such as your baby’s caregiver, the CDC hotline at 800-232-SHOT (7468), the National Vaccine Information Center (http://www.nvic.org/), or The Vaccine Book: Making the Right Decision for Your Child by Dr. Robert Sears. Visit our web site, http://www.PCNGuide.com, for information about individual vaccines and the diseases they protect against. Many public health departments publish local data about infectious diseases, which can tell you how many cases of diseases such as pertussis, measles, and meningitis have occurred in the past month and year where you live. This information can tell you what illnesses pose the most risk to your baby, which may influence your decision about certain vaccinations.

If you still have trouble making a decision about vaccinations, talk with your baby’s caregiver. Most caregivers are willing to discuss your concerns and can help you individualize your approach to vaccination. For example, you may find making the decision more manageable if you consider each vaccine separately. You may decide not to follow the recommended schedule and instead choose to avoid multiple vaccinations at one time by spreading them out over a longer period. (If you’re charged a copay for each visit, you may factor this increased cost into your decision.)

If you choose to vaccinate your baby, his caregiver will give you a form that shows completed vaccinations. Many child-care centers, preschools, and schools require proof of certain vaccinations before admitting a child. To find out what vaccinations are required where you live, ask your baby’s caregiver. This form is also a reminder of upcoming vaccinations.

If your baby has a reaction to a vaccine, make sure to inform his caregiver so he or she can record it on your baby’s vaccination form. You may also want to contact the National Vaccine Injury Compensation Program (VICP), which provides compensation to people who may have been injured by vaccines. For information about VICP, call 800-338-2382 or visit http://www.hrsa.gov/vaccinecompensation.

TAKING YOUR BABY’S TEMPERATURE

Take your baby’s temperature anytime she seems sick (listless, weak, unusually fussy, loss of appetite, runny nose, and so on). To quickly assess whether your baby has a fever, compare the warmth of her chest, abdomen, or back to the warmth of the back of your neck. Both areas should feel about the same temperature. Don’t assess your baby’s temperature by feeling her hands or feet; a newborn’s hands and feet are often cold even though her body is warm.

If your baby feels too warm, take her temperature under her arm (axillary temperature), on her skin (temporal artery temperature), or in her rectum (rectal temperature). Don’t use ear probe thermometers, temperature strips placed on the forehead, or pacifier thermometers; they aren’t accurate.

Determining whether your baby has a fever depends on which method you use to take her temperature. Your baby’s caregiver will tell you when to call for further advice—typically, when your baby’s temperature is below 97.4°F (36.3°C) by any method or when her axillary temperature is over 99.5°F (37.5°C) or her temporal artery or rectal temperature is over 100.4°F (38°C).

To take an axillary temperature, place a digital thermometer under your baby’s arm. Center the bulb in her armpit, making sure her clothing doesn’t touch the bulb. Lower your baby’s arm and hold it firmly against her body for five minutes or until the thermometer beeps. Remove it and read the temperature.

A temporal artery thermometer (TemporalScanner) is accurate, noninvasive, and quick when used correctly (moving the probe on the thermometer across your baby’s forehead starting above her nose and moving toward her hairline). Several studies of this thermometer have shown it’s more accurate than rectal thermometers and ear thermometers (which aren’t accurate in babies younger than six months).29However, it’s also more expensive than a digital or rectal thermometer.

To take a rectal temperature, lubricate the bulb end of a rectal thermometer with nonpetroleum jelly or an ointment such as A&D ointment. Position your baby on her back and hold her ankles in one hand and the thermometer in the other. Gently insert the bulb end into the rectum until you can no longer see the tip (about 1/2 inch). Hold the thermometer in place for about three minutes. Remove it and read the temperature. After use, clean the thermometer with cold water and soap or with alcohol.

WHEN TO CALL FOR MEDICAL HELP

If you’re worried about your baby’s health, write down his temperature and any symptoms that worry you, then call his caregiver. Here’s other information your baby’s caregiver may wish to know:

• Physical symptoms, such as abnormal temperature, breathing difficulties, coughing, vomiting, diarrhea, constipation, fewer wet diapers than usual, or rash

• Behavioral symptoms, such as listlessness, weakness, loss of appetite, unusual fussiness or irritability, change in typical behavior and activity level (for example, loss of interest in surroundings or in feeding)

• Any newborn warning signs (See page 393.)

• Home treatment you’ve provided and your baby’s response to it, including any medications (What and when?)

• General considerations, such as any recent exposure to illness or someone at home or at day care who’s ill

Visit our web site, http://www.PCNGuide.com, to download a work sheet to help you organize your thoughts. Keep a pad and pen handy to write down any advice and suggestions your baby’s caregiver may have.

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COMMON HEALTH CONCERNS

The following sections discuss common conditions in newborns that can cause new parents concern but often clear up with minimal treatment.

Newborn Jaundice

After the birth, your baby has a normal excess of red blood cells that break down into a substance called bilirubin, which she excretes in her bowel movements. If your baby develops jaundice, she has an excess of bilirubin that causes her skin or the whites of her eyes to become yellow by the third or fourth day after the birth. About half of all newborns have some mild yellowness in their faces by this time, which disappears without treatment.

Occasionally, the yellowness in your baby is more pronounced on the third or fourth day after the birth and may require treatment. To confirm that your baby’s chest is yellow, press your fingers on her breastbone. If the skin looks yellow when you remove your fingers, jaundice may be a concern; call your baby’s caregiver to schedule an evaluation.

To diagnose jaundice, your baby’s caregiver may take a blood sample from your baby’s heel, then use a blood test to measure the bilirubin level. If the level is high enough to warrant treatment, your baby’s caregiver will help you make sure your baby is getting enough milk. Inadequate feeding may cause jaundice because a baby who feeds poorly has fewer stools and can’t rid her body of bilirubin.

If necessary, your baby will receive phototherapy, a procedure that shines a special type of cool light on your baby’s skin, causing the bilirubin level to drop. Phototherapy usually continues for two to four days, until further blood tests show that the bilirubin has fallen to a safe level. Your baby can receive phototherapy in three ways.

1.  In the hospital, special overhead lights (called “bili lights”) are shined on your baby’s naked chest or back. Soft pads protect her eyes from the light.

2.  At your home or in the hospital, your baby is wrapped in a special blanket to receive phototherapy. You can hold and feed your baby without removing her from the light source.

3.  At your home or in the hospital, your baby lies on her back in a net hammock over a phototherapy source.

Jaundice that appears on the first or second day after the birth (early jaundice) is more serious than when it appears on the third or fourth day. It may require intensive treatment, such as phototherapy or, on the rare occasion when the bilirubin level becomes very high, a blood exchange transfusion to lower the bilirubin to a safe level and prevent possible hearing loss or severe neurological damage. If your baby develops jaundice after the first two weeks, have her caregiver evaluate her.

In addition to inadequate feeding, causes of jaundice include prematurity, bruising during labor or birth, exposure to certain drugs given to the mother in labor, liver or intestinal problems, sepsis (infection), and blood incompatibilities such as Rh (see page 135) or ABO incompatibility (when the mother’s blood type is O and the baby’s is A, B, or AB). Sepsis and blood incompatibilities are typical causes of early jaundice.

Rashes

In the first week after the birth, some newborns develop red blotches with waxy yellow or white pimples in the middle (erythema toxicum). This characteristic newborn rash appears on the trunk, arms, and legs; doesn’t cause itching; and disappears without treatment.

For the first few months, it’s common for your baby to periodically have mild facial rashes (smooth pimples, small red spots, or rough red spots). These rashes rarely require treatment. Small white spots (milia) on your baby’s nose, cheeks, and chin occur when tiny skin flakes are trapped in small pockets on the skin surface. Milia disappear within a month or two of their appearance. Red bumps (baby acne) may appear on your baby’s face in the first several weeks, due to increased oil production that began when some of your hormones transferred to him before the birth. Applying breast milk as a “lotion” may help reduce the rash.

Prickly heat is a common warm-weather rash that appears on overdressed babies. Found most often on the shoulders, trunk, and neck, prickly heat looks like clusters of tiny pink pimples surrounded by pink skin. As it dries, the rash becomes slightly tan. Prickly heat may look worse than it feels to your baby. To avoid this rash, don’t let your baby become overheated.

A yellowish, scaly, patchy condition called cradle cap may appear on your baby’s scalp and behind his ears. Daily washing or brushing of the scalp may help treat or even prevent cradle cap. Gently comb or brush out the scales using a baby comb, fingernail brush, or soft toothbrush; then wash your baby’s scalp with mild soap. Repeat this process every day or every other day until the scales are gone. Massaging your baby’s scalp with breast milk or vegetable oil before washing also may help treat or prevent cradle cap.

Colds

Although it’s normal for your baby to have a slightly stuffy nose or make a rattle-like noise when she breathes through her nose, she may have a cold if she has a very runny nose and goopy eyes, is fussier than usual, has trouble eating and sleeping, and perhaps has a slight fever.

To reduce your baby’s risk of catching a cold, minimize the number of people she comes into contact with, especially when she’s younger than three months. People with colds and other illnesses should stay away from your baby. Make sure all those who want to handle your baby wash their hands thoroughly first.

When your baby has a cold, consult with her caregiver. He or she may suggest using a cool-mist vaporizer near your baby and putting her in a semi-reclined position (such as in a car seat) to sleep. You can clear your baby’s nostrils by dripping saline or breast milk into each one, then gently “milking” her nose to clear the mucus. (Breast milk soothes the mucous membranes and contains antiviral and antibacterial properties.) You also can run a hot shower or bath, then take your baby into the bathroom (but not into the tub or shower) to breathe the steam to ease congestion.

Don’t give your baby cold medications such as decongestants and cough medicine; they aren’t safe for infants.

MEDICATIONS

Use the following guidelines if your baby’s caregiver prescribes medications or vitamins.

• To dispense liquid medication, use a medicine dropper placed between your baby’s cheek and gum; don’t squirt it on his tongue. Hold your baby in a semi-upright position and let him suck the medicine as you gently squeeze the dropper.

• Another way to give your baby liquid medication is to pour it into an empty bottle nipple, then have him drink it all. When the nipple is empty, fill it with water and have your baby drink it all as well. This ensures that your baby receives a full dose because he’ll drink any remaining medicine that was coating the nipple.

• Don’t mix medication in with pumped breast milk, formula, juice, or water. If your baby refuses to finish the whole bottle, you won’t know how much medication he’s received.

• Give only the medication your baby’s caregiver specifies. Aspirin—even baby aspirin—is no longer recommended for babies and children because of its association with Reye’s syndrome, a serious disease.

SUDDEN INFANT DEATH SYNDROME (SIDS)

Sudden infant death syndrome (SIDS) is the sudden death of a baby younger than one year that remains unexplained after a thorough investigation. The cause of SIDS isn’t fully understood.

Almost every parent worries about SIDS at some time. You may have read about the condition or even know someone whose baby died of SIDS. Although there’s no way to minimize the loss and grief caused by SIDS, the following facts may help put your fears and worries into perspective:

• SIDS is rare, occurring in about 1 in 2,000 babies in the United States.30

• SIDS deaths most commonly occur in babies who are between two and four months old.31

• No one—including parents—is to blame for SIDS. It can’t be predicted or prevented.

• Death occurs quickly and painlessly; it isn’t the result of suffocation, asphyxiation, or regurgitation.

• SIDS isn’t caused by vaccinations. In fact, SIDS deaths are statistically more common in babies who haven’t been vaccinated.

• SIDS isn’t contagious.

For parents faced with a loss by SIDS, support groups can help. The baby’s caregiver, a public health nurse, or a childbirth educator can help locate a group. Other resources include First Candle (800-221-7437 or http://www.firstcandle.com) and the American SIDS Institute (800-232-7437 or http://www.sids.org).

You can take steps before and after your baby’s birth to help prevent her risk of SIDS.32 During pregnancy, eat a healthful diet, don’t use cocaine or heroin, don’t smoke and avoid exposure to secondhand smoke, and have regular prenatal care to help reduce your baby’s risk of prematurity.

After your baby is born, breastfeed her. Breastfeeding can lower the risk of SIDS.33 Also avoid overdressing your baby. To keep her warm, swaddle her or use a blanket or sleep sack. Don’t expose her to secondhand smoke, and place her in a safe position in a safe location to sleep (see page 392).

Safe Sleeping to Reduce the Risk of SIDS

Make sure that everyone who cares for your baby places him on his back to sleep. Placing him on his tummy or side to sleep increases his risk of SIDS. If your baby is unhappy on his back or wakens easily, try swaddling him.

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Also make sure your baby’s sleep space is safe. Use a firm, flat surface and avoid waterbeds, couches, sofas, pillows, duvets, quilts, comforters, soft materials, loose bedding, soft toys, lambskins, and bumper pads in cribs. Make sure there isn’t space between the mattress and headboard or walls, or between the crib mattress and the crib slats. These spaces may entrap your baby and lead to suffocation.

The American Academy of Pediatrics (AAP) recommends that to reduce the risk of SIDS, babies should sleep in the same room as their mothers, but not in the same bed (bed-sharing).34 This recommendation is controversial,35because other experts recommend bed-sharing for such benefits as frequent and convenient breastfeeding, reduced crying, and better sleep for both parents and babies. For more information on bed-sharing and other cosleeping arrangements, read Sleeping with Your Baby: A Parent’s Guide to Cosleeping by James J. McKenna, an international authority on cosleeping and its impact on the reduction of SIDS.

Parents who choose to bed-share need to follow safety guidelines. A baby shouldn’t share a bed with a parent who has consumed sedatives, medication, alcohol, or any substance that causes extreme drowsiness or unawareness, which increases the risk of rolling onto the baby and smothering him. A baby also shouldn’t share a bed if a parent is a smoker. If a parent is markedly obese, he or she shouldn’t sleep next to the baby to avoid causing a depression in the mattress that baby could roll into on his stomach.

Some parents use pacifiers to help their babies fall asleep. Analyses of several small studies show a small decrease in SIDS with pacifier use, leading the AAP to recommend pacifiers to help babies fall asleep after they’re a month old. This recommendation is controversial, because breastfeeding may just as effectively help babies fall asleep. (However, no studies have analyzed this effect of breastfeeding.) In addition, despite parents’ efforts to have their baby take a pacifier, only he can decide whether he’ll do so.

Babies with Special Circumstances

Babies who are born early or small for their gestational age may have needs that require special care.

PREMATURE BABIES

A baby is premature if she’s born before the thirty-seventh week of pregnancy and weighs less than 51/2 pounds. Thankfully, advances in care have increased the survival rates of even very premature babies and have greatly reduced the long-term respiratory and neurological problems experienced by premature babies born just a decade ago. Today, babies born as early as twenty-four weeks gestation can thrive.

Newborn Warning Signs

If any of the following signs appear in the first month after the birth, report them to your baby’s caregiver.

Warning Signs & Possible Problems

Fever (axillary temperature above 99.5°F/37.5°C)

• Infection

Temperature below 97.4°F/36.3°C (whether taken axillary, by temporal artery, or rectally)

• May indicate infection caused by Group B streptococcus (GBS) or other bacteria.

Your baby’s face, chest, and the whites of his eyes are yellow.

• Jaundice (See page 389.)

Changes in your baby’s behavior, such as listlessness or unusual fussiness or irritability

• Illness such as a cold, viral illness, or diarrhea

Problems with the umbilical cord, including bright red bleeding, redness around the cord, or a foul odor or pus-like discharge

• Infection or other problems with the cord (See page 377 for more information on cord care.)

Problems with a circumcision, including continuous bright red oozing or bleeding, swelling, foul discharge, or an inability to urinate

• Infection or bleeding from the circumcision site

Problems with feeding, including a breastfed baby who feeds fewer than 7 or 8 times in 24 hours, or any baby who feeds poorly

• Difficulty with breastfeeding, jaundice, illness, or prematurity (See Chapter 18 to learn about feeding problems.)

Fewer wet diapers than expected: In the first week, expect the number of wet diapers to at least equal the day of life (for example, at least 3 wet diapers on day 3). After day 7, expect 6 or more wet diapers in 24 hours.

• Inadequate feeding or illness (See page 413 for signs that your baby is getting enough milk.)

Problems with bowel movements, including no bowel movement in any 24-hour period in the first month after the birth. After your breastfed baby is a month old, it’s normal from him not to have a bowel movement for a day or longer.

• Inadequate feeding (See page 369 for a description of normal bowel movements in newborns.)

Problems with breathing, including blue lips, a struggle to breathe, flared nostrils, or deep indentations of the chest when breathing

• Prematurity, illness, or heart or lung problems

Call 911 if your baby can’t breathe easily.

Every day in the womb before term improves a baby’s chances of survival and normal development. If a baby’s born before term, she looks different than a full-term baby does. She’s small, limp, and frail. Her skin is reddish and appears tissue-paper thin, and she has little to no fat or muscle. Her head appears disproportionately large. Vernix caseosa and lanugo (fine, downy hair on her body) are abundant, her fingernails and toenails haven’t grown out, and her tiny ears are soft and hug her head. Her cry is feeble, and she may be more difficult to soothe than a full-term baby.

A premature baby is physically vulnerable until she grows older. She sucks weakly, and her swallow and gag reflexes are unreliable. She may need to be fed by a tube into her stomach. Because her body temperature is unstable (often below normal), she usually stays in a temperature-controlled isolette. Because her lungs are immature, her breaths are irregular, rapid, and often shallow; she may need oxygen to help with breathing. Her ability to absorb food is less efficient than a full-term baby’s, although her need for nutrients—especially calories, protein, iron, calcium, zinc, and vitamin E—may be greater.

If you give birth to a premature baby, the experience can be upsetting and frightening. Your baby will need special medical attention that may separate her from you, but she also needs to feel your touch and hear your voice, even when inside an isolette.

Your baby’s nurse may encourage Kangaroo care, in which you hold your baby so her bare skin lies against your bare chest (see page 293). Your closeness, breathing movements, and warmth will help regulate her breathing, keep her warm, and comfort her (and thus you). With regular Kangaroo care, premature babies typically grow faster. If you’re at risk for preterm labor, contact the newborn nursery to learn about their policies on Kangaroo care and how to arrange for it. (For more information on preterm labor, see page 136.)

If your baby is too immature to breastfeed, you can express milk and have it fed to her through a tube that passes from her mouth to her stomach. Your milk differs from the milk of a mother whose baby is full-term; its composition is designed to meet your premature baby’s nutritional needs. It also contains antibodies and immune boosters that help protect her from infection and disease.

Feeding, touching, and caring for your premature baby will help you both cope as she grows stronger. For additional support, you may want to contact a group that provides information, assistance, and emotional support to parents of premature babies. The group may have a library of helpful books and also may supply you with clothing small enough for your baby. For more information about premature babies, check with your childbirth educator, caregiver, or local hospital.

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BABIES WHO ARE SMALL FOR GESTATIONAL AGE

Babies who are small for gestational age (SGA) are smaller in size and weight than expected at birth, given the length of time they were in the womb. This condition has several possible causes, including an inadequate transfer of nutrients across the placenta to the baby; the effects of some drugs (such as tobacco) taken during pregnancy; some congenital and genetic malformations; and certain infections, such as toxoplasmosis. Sometimes the cause is unknown.

SGA babies present challenges to parents that are similar to those of premature babies. SGA babies don’t move easily from state to state (for example, from active to quiet alert or from drowsy to deep sleep—see pages 381–382). They’re often fussy and more difficult to soothe than newborns of normal size and weight. Parents spend lots of time calming and quieting SGA babies; successful soothing techniques include frequent feeding, gentle rocking, quiet talking, and maintaining a calm environment.

Parents soon learn that SGA babies can handle only one source of stimulation at a time. Too much stimulation—such as talking to the baby while jiggling or feeding him—overwhelms and agitates him, typically making him cry.

If your baby is SGA, he’ll become less intense and fussy as he matures. In the meantime, your sensitivity to his special needs will help you both cope.

Key Points to Remember

• Every newborn has a unique appearance and temperament. Babies teach their parents what they need by giving cues.

• Crying is often your baby’s last attempt to communicate that she’s hungry, overstimulated, tired, or uncomfortable. Try to respond to your baby’s early cues so you meet her needs before she cries.

• Creating a womb-like environment will help calm your crying baby. The Five S’s method (see page 379) can be an especially effective tool.

• Swaddling and cosleeping may increase how long your baby sleeps.

• Be aware of newborn warning signs (see page 393) to know when to seek medical help.

• Learn about vaccinations so you can make an informed decision about vaccinating your baby.

• You can significantly reduce the risk of SIDS by always placing your baby on her back to sleep.