Family Birth Center

TABLE OF CONTENTS In the left column, check U, N, or C to indicate your educational needs. U = Understand N = Need more information C = Teaching completed by the nurse and/or doctor U N C Family-centered maternity care Security instructions for all mothers Security instructions if your baby is in the NICU Caring for yourself Why am I bleeding? Why am I having cramps? Why do I sweat at night? What can I do about hemorrhoids? What is an episiotomy? Hygiene Pain control options Breast care Your diet Activity Cesarean birth Driving Sex after childbirth Birth control Baby blues and depression When to call your obstetrician or primary care provider Treatments your baby will have before going home Vital signs Blood sugar Hearing screen Hematocrit Vitamin K Erythromycin ointment Immunizations Newborn screening Pain Your family and the new baby Family time Why are my other children acting up? Young children Older children Caring for your baby Crying Playing and learning Urine Bowel movements Diaper rash Cord care i

1 2 3 3 3 3 3 3 4 4 5 5 6 7 8 9 9 9 9 10 10 10 10 10 10 10 10 11 11 11 11 11 11 11 11 12 12 12 13 13 13 13

N C Circumcision care Care of the uncircumcised penis Hand washing Bathing your baby Dressing your baby Clothing care How to use a bulb syringe Taking your babys temperature Car seats General tips on caring for your baby When to call your pediatrician or primary care provider Create a safe sleep environment Sudden Infant Death Syndrome The dangers of shaking Shaken Baby Syndrome Formula feeding Formula brands Formula preparations General tips on using formula Breastfeeding Breastfeeding: getting started The first 24 hours Babys second night Expressing milk when your baby is unable to nurse Storing breast milk Breast/nipple care Latching on Positioning How to tell if your baby is getting enough milk What to do if you suspect your milk supply is low Flat or inverted nipples Engorgement Sore nipples Plugged ducts and mastitis Nutrition while nursing Weaning/Supplementation Jaundice in your newborn What is it? What causes jaundice? How is jaundice treated? Getting your babys birth certificate Choking first aid and CPR for infants up to one year old Conscious choking infant Unconscious choking infant CPR for infant up to one year old Frequently used phone numbers TIGR TVOn-demand patient education television system 13 14 14 14 14 15 15 15 15 16 16 17 17 18 18 19 19 19 20 21 21 22 22 23 24 24 25 25 27 27 28 28 28 29 30 30 31 31 31 31 32 32 32 33 33 34 35

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Family-Centered Maternity Care

Congratulations on your new baby!

The staff of the Family Birth Center at Womens and Childrens Hospital wants to give you and your family the teaching and support you need in learning to care for yourself and your new baby. We want to make sure this is truly a family experience, so we welcome your family to participate as you and they wish. This booklet will give you much information on how to care for yourself and your baby. Your doctor and nurses will review this information with you during your stay. The booklet can also be used as a resource after you go home. Have your support person(s) read this information also, so they can help in caring for you and your baby at home. Thank you for choosing the Family Birth Center at Womens and Childrens!

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Security instructions for all mothers

Become familiar with the hospital maternal-newborn staff and our routines. Please be sure to check for proper identification before giving your baby to anyone. If you have questions or are unsure about who can handle your baby, even if they are wearing hospital clothing or have a hospital name badge, press your call light and a staff member will assist you. This will not offend staff members. You will be assigned one nurse per shift who will care for you and one nurse who will care for your baby. The oncoming nurse will introduce him or herself to you as soon as possible. If your nurse or another staff member takes your baby, you are encouraged to ask where they will be and how long the baby will be gone. You also may go with your baby, if you wish. Call your nurse if the baby is not transported in a crib. Your baby should always be transported in a crib. Your baby should not be taken off the unit before discharge. Toys should not be in the babys crib. Never leave your baby alone or unsupervised in your room. If you leave your room or want to take a shower or nap, ask the nurse to take your baby to the nursery. Babies are watched in the nursery at all times. Whenever possible, put your babys crib by the side of your bed that is farthest from the door. This will allow you to see visitors and hospital staff before they approach your baby.

Your baby will be released only to you or the person youve designated to wear the special matching ID band. We work with a company that provides the opportunity to take a picture of your baby while in the hospital. If you do not speak with the photo representative, please ask your babys nurse about pictures prior to discharge. You should not be contacted by any other person or company while in the hospital. If you want to buy your babys photo, complete the order card you received during your hospital stay and return it to the photo staff before your discharge. You have the option to contact the photo company for up to one year after your babys birth to order pictures. Consider the risk you may be taking if you let your babys birth announcement be printed in the newspaper, or have signs or displays posted outside your home. Your photo representative will talk with you about picture opportunities on our web site.

When you are ready to leave the hospital, Missouri law requires that your baby ride in an approved car seat. Not only is it safer for your baby, its the law! If you have any questions or concerns at any time during your stay, please ask your nurse or press your call light.

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Security instructions if your baby is in the NICU

NICU is located on the second floor, just past the Intensive Care Unit. There are signs to guide you to the entrance. To make sure your baby is safe, we have a locked unit. We ask that you identify yourself and who you are visiting each time you visit. There is a doorbell system just outside the unit. For your privacy and for confidentiality, a visitation policy can be obtained from the NICU. NICU can be contacted by calling (573) 499-6180.

Why am I having cramps? For the last 9 months, your womb has grown and stretched to hold your baby. As your womb shrinks to its normal size, you may feel cramps called after birth pains. After birth pains feel like the cramps you may have experienced during your period. You are likely to feel after birth pains more after your second or third baby than after your first baby. If youre breastfeeding, the cramps may be stronger during and after feedings because breastfeeding helps your womb return to its pre-pregnant state faster. Your womb should be back to its normal size in about 6 weeks. Why do I sweat at night? You may wake up at night sweating. Sweating is not a sign of infection. Its one way your body can get rid of extra water you carried while you were pregnant.

Caring for yourself

Why am I bleeding? While you were pregnant, your womb was lined with blood and tissue. Now that your baby has been born, that lining is not needed. The bleeding, or discharge, from your vagina is that lining, which is called lochia. This happens whether you deliver vaginally or by cesarean section. The day your baby is born, the lochia will be bright red. Soon it will be light red. By about the third week, it will be yellowwhite. The lochia may last up to 6 weeks. You may notice more bleeding after you have breastfed. Also, heavy lifting and too much exercise or activity can make you bleed more and make the lochia bright red. Make sure you rest whenever you can. Call your doctor right away if the lochia turns bright red again at home or is heavier than a heavy period. Also, do not douche, have intercourse, or use tampons during the first 6 weeks without asking your doctor.

To make yourself more comfortable, you may need to change your gown and possibly your sheets.

What can I do about hemorrhoids? Hemorrhoids are common after delivery. If your hemorrhoids are painful and you think you need medication, consult your care provider. You can try the following to help relieve discomfort associated with hemorrhoids:

Eat fresh fruit, bran cereal, and a balanced diet to prevent constipation. Use Kegel exercises to strengthen pelvic floor muscles. Use ice packs. Ask your provider about medications.

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What is an episiotomy? An episiotomy is a small cut made down from the birth canal, or vagina. An episiotomy is done if the baby needs more room to be born. This cut is made to keep the skin from tearing. After delivery, the cut may need to be stitched. The stitches dissolve in about 2 to 4 weeks. If you are unsure if you had an episiotomy, ask your doctor or nurse. If the stitches are causing you some discomfort, a sitz bath may be used to help. A sitz bath moves warm water over your stitches. This will help ease pain and swelling. The bath will also help keep your bottom clean and help you heal faster. The bath can be used 3 to 4 times per day. At home, use your plastic sitz bath, or sit on a towel in a tub of warm water 2 to 3 times a day. To prevent infection, make sure the tub is clean and you wash your feet before getting into the tub. You can also use Tucks pads, which need to be changed with each pad change, or Dermaplast Spray.

Hygiene Hand washing Hand washing is the key to preventing the spread of germs to your baby. Always do the following:

Wash your hands before picking up your baby. Make sure all visitors wash their hands before touching the baby. Wash your hands well after using the bathroom.

Perineal care When youre able to get up to go to the bathroom, a nurse will show you how to do peri-care. Peri-care is cleaning your perineum, or bottom. To decrease the risk of infection: Your nurse will give you a peri bottle. Each time you go to the bathroom fill the bottle with warm water and rinse your bottom from front to back. Keep doing this until all bleeding stops.

Put on a clean sanitary pad each time you go to the bathroom even if the one you have on is only slightly soiled. Put soiled pads in a bag or wrap them in tissue before putting them in the wastebasket. To keep from getting germs from the rectum into the birth canal or episiotomy, wipe from front to back and wipe only once with each tissue. Use the sitz bath or tub as previously described.

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Pain control options It is normal to have discomfort after delivery. This discomfort may come from your episiotomy or from cramping associated with your uterus working to return to its pre-pregnancy size and shape. You should expect your nurse and/or physician to ask you about your pain. There are many ways of treating discomfort without pain medication as well as with pain medication. If you are having pain, let your nurse or provider know right away. Breast care Wear a supportive bra for comfort. If you are bottle feeding:

How to perform a breast self-exam Women older than 20 years should perform monthly breast self-examinations (BSE). If you still have menstrual periods, you should perform the examination a few days after your period ends. During this time, your breasts are not tender. If you are not menstruating (such as in menopause), BSE should be performed on the same day each month. Use one of the following techniques that work best for you. Facing a mirror Stand before a mirror and compare both breasts for differences in size, nipple inversion (turning in), bulging, or dimpling. Note any skin or nipple changes, such as a hard knot or nipple discharge. Inspect your breasts in the following 4 positions: 1. 2. With your arms at your sides With your arms overhead

You may want to wear a supportive bra for the first week both day and night. Avoid any nipple stimulation. Do not pump your breasts. While in the shower, try to keep your back to the water as much as possible. This will help prevent engorgement (see page 28).

You are encouraged to hold the infant close during bottle feedings to promote bonding. If you are breastfeeding: Do not scrub your nipples while showering.

3.

With your hands on your hips, flex firmly to flex your chest muscles

Let your nipples air dry after showering. Expressed colostrum or breastmilk placed on the nipple will serve as a natural lubricant; allow to air dry. Nurse the infant often if you experience hard, full breasts (engorgement). Practice proper positioning (see page 25). 4. Bent forward, inspect your breasts

In these positions, your pectoral muscles are contracted, and a subtle dimpling of the skin may appear if a growing tumor has affected a ligament.

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Lying down First, check the right breast using the following steps: 1. 2. 3. 4. 5. 6. Place a pillow under your right shoulder. Put your right hand under your head. Check the entire breast area with the finger pads of your left hand. Use small circles and follow an up-anddown pattern. Use light, medium, and firm pressure over each area of the breast. Feel the breast with the surfaces of the second, third, and fourth fingers, moving systematically and using small, circular motions from the nipple to the outer margins. Gently squeeze the nipple for any discharge.

Your diet This is not a time to crash diet. Your body needs care with good foods. As a general rule, you should drink to thirst and eat to hunger. You should include water, milk, juice, and soup. Eat a variety of foods every day including grains, vegetables, fruit, meat, milk products, fish, poultry and fats. Here are some other tips for a healthy postpartum recovery: Iron Continue to take your iron/prenatal vitamins every day unless your doctor tells you to stop.

Iron is vital to your red blood cells and carries oxygen to your cells. It is the most difficult nutrient to get enough of in your diet. Take iron pills with a high vitamin C drink, like orange juice. Vitamin C helps your body use iron. Iron should also be taken one hour before a meal or two hours after a meal. You may need to increase your fiber since iron can sometimes cause constipation. Iron-rich foods include meats, beans, vegetables (spinach, greens, potatoes with skins, cooked peas), breads, ironfortified cereals, raisins and prunes.

7.

Second, repeat these steps on your left breast using your right hand. In the shower You can perform a BSE while youre in the bath or shower. Some women discover breast masses when their skin is moist. Follow the following steps: 1. 2. 3. Raise your right arm. With soapy hands and fingers flat, check your right breast. Use the same small circles and up-anddown pattern described previously. Repeat on the left breast.

Fiber Tips to increase fiber in your diet:

Cook and eat fruits and vegetables with their skin, at least 5 servings per day. Eat whole fruits rather than drinking juice. Use brown rice instead of white. Use whole wheat bread instead of white. Eat beans regularly.

4.

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Protein Protein-rich foods include:

meat fish nuts beans milk yogurt ice cream eggs

Supplements Check with your doctor if you have questions about supplements. Activity During the first few weeks after your baby is born, friends and family members will probably want to come visit. Having visitors is fine, but rememberyou need your rest and your baby can get sick easily.

Calcium Women require 800mg of calcium a day in their diets. If you are breastfeeding, you need 1200mg each day. Examples of calcium-rich foods and the amount of calcium in each are:

Ask family and friends to help with jobs like cooking and cleaning. You should limit your activity to caring for yourself and your baby as much as possible. Sleep is very important. Try to get at least 8 hours of sleep per night and take naps when you can. Ask your doctor before starting any exercise program.

Low fat milk, 1 cup = 200mg Yogurt, 1 cup = 350mg Broccoli, 1 cup = 35mg Orange juice (fortified), 1 cup = 300mg Tofu, half cup = 150mg

Exercises to tighten stomach muscles Exercise is a good way to help your recovery and increase your energy levels. Below are some exercises you can begin within 24 hours after a vaginal delivery: Before starting any exercise program, please ask your doctorespecially if you had a cesarean section.

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Exercise 1 1. 2. 3. Lie flat on your back with your knees bent. Inhale. Exhale and pull your buttocks up rotating your pubic bone toward your head. Hold for 3 seconds and then inhale and relax. Repeat these several times each day.

Exercise 4 1. 2. Lie flat on your back. Raise one knee about 4 inches so that the back on that knee is level with the top of the other knee. Reach toward the raised knee with the opposite hand, lifting your head and shoulder so that your trunk twists. Relax for a count of 4, and then repeat the exercise with the other knee. Do this exercise 2 times.

3.

4.

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Exercise 2 1. Lie flat on your back. 2. 3. 4. Place your fingertips below your navel so you can feel the muscles tighten. Slowly lift your head and touch your chin to your chest. Then slowly lay your head back down on the bed. Relax. Do this exercise 5 times.

Exercise 5 (Kegel exercise) 1. Pull in the muscles in your pelvis as if you were trying to stop the flow of urine. Hold in as long as you can, then relax. Some find it easier if they think of their pelvic floor like an elevator. As you tighten and pull the pelvic floor muscles up, its like youre taking them to another floor. Repeat this several times per day.

Exercise 3 1. 2. Lie flat on your back with your knees bent. Breathe in, then breathe out, squeeze your stomach muscles and hold them tight. Count to 5, then relax. Do this exercise 4 times.

2.

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Cesarean birth Ask your doctor about exercises that are right for you. Showering and tub baths may be started after 7 days. Frequent rest periods and limiting activity to caring for you and your baby is very important. Do not lift anything heavier than your baby unless it is OKd by your doctor.

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Incision care Keep the incision clean and dry. Remember, no tub baths unless instructed and approved by your physician. Take only showers until incision is completely healed. Wash the incision first, then the rest of your body. Pat the incision dry.

after delivery. Your periods may not be regular the first month or two. If youre breastfeeding, you may not have a period until after you wean your baby. But just because you arent having a period doesnt mean you cant get pregnant. Several forms of birth control are available and briefly described below. Ask your doctor or nurse for more information:

You will probably go home with Steri Strips in place. It is OK to shower with them on. They will fall off in a week to 10 days. Do not remove them before they fall off. Do not use any lotions or powders on the incision.

Birth control pills are synthetic hormone pills you take by mouth on a monthly schedule. Depo Provera is a synthetic hormone given in a shot every 3 months. A diaphragm is a rubber, balloon-like cap that covers your womb opening. A condom is a thin rubber sheath that fits over the penis. Condoms are most effective when used with contraceptive foam, jelly or suppositories. Contraceptive foam, jelly or suppositories are put into the vagina. These are most effective when used with a condom or diaphragm. Tubal ligation for a woman or vasectomy for a man make the woman or man sterile and are permanent.

Driving Do not drive for 1 week after vaginal delivery or 2 weeks after a cesarean or until you are pain free when you stomp your foot on the floor and are not taking narcotic pain medications such as Percocet. Sex after childbirth Your doctor may tell you that you can have sex 4 to 6 weeks after giving birth. When you can have sex depends on how your stitches are healing and if your internal organs are sore. You also need to be ready emotionally. Your vagina may be dry for the first 6 weeks to 6 months. Use water-soluble gel or contraceptive foam or jelly before having sex. If your vagina is tender, have your partner insert a finger into your vagina and gently rotate it around the opening to help relax the muscles. Sex may be more comfortable for you if youre on top, or if you and your partner lie side by side. Birth control You need to use some form of birth control to keep from getting pregnant. If youre bottle-feeding, your first normal period may be anywhere from 2 to 6 weeks

Before you go home, discuss birth control options with your partner, and ask your doctor about the risks and benefits of each option. Also, ask your nurse for more information. Baby blues and depression It is normal to feel more emotional the first couple of weeks after you have a baby. There are physical and hormonal changes occurring in your body and there is stress that comes with a new baby in the house. To reduce these effects, sleep when your baby sleeps until you are fully rested. When others offer to help, ask if they can do specific tasks such as laundry, go to the store, or prepare a meal. Plan to take a Page 9

shower and dress each day. Feelings of anxiety, sadness, or hopelessness; difficulty sleeping or sleeping most of the time; noninterest in the baby; uncontrollable crying; or fear of harming the baby may mean you have postpartum depression, and you should immediately call your primary care provider. When to call your obstetrician or primary care provider Call your obstetrician or primary care provider right away if you have any of the following:

Nurses will check these about every half hour until your babys vital signs are stable. Blood sugar During the admission process, a small sample of blood may be drawn from your babys heel. One of the things this blood will be used for is to test your babys blood sugar. The process of birth uses a lot of the babys energy. We want to make sure your baby has not been too stressed and is able to maintain a normal blood sugar. If your babys blood sugar is within a normal range, the test should only have to be done once. If it is not within normal range, your babys nurse will talk with you about it. Hearing screen All babies will have a hearing screen completed prior to discharge. You may ask your babys physician or nurse if your baby has received a screen. Hematocrit This is another test that may be done at the time the blood sugar is done from the same sample of blood. This test makes sure your babys red blood cells are within normal limits. Vitamin K All newborns receive vitamin K after they are born. Vitamin K helps your babys gut produce the bacteria necessary to absorb food and helps starts the clotting process. Erythromycin ointment Before one hour of age, an erythromycin ointment is placed in your babys eyes. This is to protect your babys eyes from harmful bacteria that may have been passed on during the birth process.

Fever of 100.4F (38C) or higher. Depression, blue feelings or inability to cope. Vaginal bleeding that is heavier than a heavy period or bright-red. Increased pain, tenderness, redness, swelling, or yellow/green and foul smelling discharge from your episiotomy or incision. Pain that is not relieved by your pain medicine. Any red, warm, or painful areas of your breasts or flu-like symptoms.

Treatments your baby will have before going home

Vital signs Right after your baby is born and during admission in the newborn nursery, nurses will begin taking your babys vital signs. These include:

temperature heart rate respirations checking your babys color pain evaluation

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Immunizations Getting your infants immunizations on time is very important. The Hepatitis B vaccine will be offered to your baby before you leave the hospital. Your babys doctor will talk to you about it. It is our goal to start your infants immunizations before they leave the hospital and it is important that they continue to receive the immunizations as instructed by your physician. Newborn screening It is mandatory by state law that your infant receives a newborn screening between 2472 hours after birth. It is done by a heel stick. The test is then sent to the state for results. When planning a discharge time, please take this into consideration. Pain Potential pain will be assessed every 8 hours until you leave the hospital. It will also be assessed with painful procedures. The Neonatal Infant Pain Scale (NIPS) is a tool used to assess infant pain. Comfort measures will always be initiated for increasing pain scores. Medications are also an option if comfort measures dont help. If you have questions about your infants pain, please see the physician or nurse caring for your infant right away.

used to having a new baby in the family, they will stop many of these behaviors. Young children Children who are 5 years old or younger may:

have accidents after being potty trained want a bottle or pacifier again hit the baby have more temper tantrums ignore you get into things while youre busy with the new baby

Your family and the new baby

Family time Your babys care can take a lot of time. It is important for all family members to be involved with the new baby. Encourage them to play and to help care for your baby. Why are my other children acting up? Children may react differently to the arrival of a new baby. As the children get

This type of behavior is normal. Try not to scold or punish unless the behavior is dangerous. Praise young children for good behavior. Get them involved with taking care of your baby by having them do small things to help. Also, try to set aside a special time to spend with each childa time when you wont have to do anything for your baby. Older children Children who are 6 years old or older may:

cry or be moody be careless around the baby become sloppy

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This type of behavior is normal. Try to talk to your children about their feelings. Find ways to let older children help take care of your baby.

a break from the constant needs of your baby. Playing and learning No one else in the world is just like your baby. Your baby is an individual with a personality right from the start. Dont worry if your baby doesnt do the same things, in the same ways, at the same time, as other babies. Just give your baby lots of love, understanding, and attention so he or she will grow and feel special. It is equally important to play with your baby. Play helps babies learn and grow. Some simple games you can play together will help your baby learn to focus his or her eyes and to use his or her hands and fingers. Babies love to look at faces. Hold your baby about a foot away facing you. Talk, smile, or sing. Early on your baby will watch your face. Soon your baby will start to coo. When youre changing your babys diaper, or bathing, or holding your baby and he or she coos or gurgles, smile and repeat the sound. This will help your baby learn to communicate and relate to people. Watching brightly colored mobiles swing and turn helps your baby learn to use his or her eyes to follow things. Also, babies like to look at bright pictures so try to hang some pictures where your baby can see them. Youll be surprised how quickly your baby learns new things. Remember that your baby is totally dependent on you. Warm, close contact with you is important while your baby gets use to this new world. Babies are special. Enjoy your baby.

Caring for your baby

A babys needs are pretty simple: feeding changing sucking comfort love sleep Normal behaviors for a newborn include: yawning hiccups sneezing passing gas coughing crying spitting-up cooing looking around following sounds awake and sleep periods recognizing the voices of caregivers Crying A crying baby can be very frustrating. It is common for babies to have a fussy time, usually in the late afternoon or evening. If your baby is acting much more fussy than usual, check the following:

Is your baby hungry? Does your baby need to be changed? Is your baby acting sick? Or does your baby just need to be held?

You cannot spoil your baby. If you have a fussy baby and are feeling overwhelmed, place your baby safely in the crib, step out of the room, and take a few deep breaths. If needed, call someone to come stay with your baby for awhile while you leave. This does not mean youre a bad parent. You just need

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Urine Your babys urine should be clear yellow in color and should not have a strong odor.

Your baby should have wet diapers at least 6 to 8 times per day or with each feeding.

This is called thrush. It is especially important to check for thrush if you are breastfeeding, because you can get the yeast infection on your nipples and breasts. Call your doctor if your baby has a yeast infection and you are breastfeeding. Cord care Clean the cord with water only if it becomes soiled.

Bowel movements Bowel movements will vary with each baby. Breast fed babies will have more frequent and loose yellow stools while formula fed babies tend to have more solid stools.

Keep the diaper folded down below the cord to allow for drying and to keep urine from getting to the cord.

Your baby may have a stool after each feeding or only 2 to 3 per day. You will learn your babys pattern. Some straining with stools is normal. Be aware of what your babys normal pattern is, so you can detect when the baby might be constipated. If the stool is hard and dry, do not use laxatives, enemas, or suppositories. Consult your pediatrician.

Circumcision care A little oozing of blood is normal at first. The site will be checked before you leave the hospital to make sure there is not too much blood.

Use Vaseline as instructed by your babys nurse for the first 48 hours. Place a good amount of Vaseline over the circumcised area to prevent the penis from sticking to the diaper and to avoid irritation. Yellow crust may form on the circumcised area. This is normal. Do not try to wipe it off. Do not rub the circumcised area when washing it until it is healed. Simply take a clean wash cloth with clean warm water and squeeze the water over the area. If your baby has a plastic ring around the penis, it will fall off in 7 to 10 days. You do not need to use any Vaseline with this plastic ring. Call your pediatrician if you note any increased redness, oozing, foul odor, or pus at the circumcised area. Also, consult your pediatrician if you notice a decrease in your babys wet diapers.

Diaper rash Diaper rash is usually caused by urine, stool and soap residue. Be sure and clean diaper area well with each change.

If you notice a rash, stop using wipes and clean area with warm, clean water and a clean wash cloth. Exposing your babys bottom to air a couple times per day may also help. For mild diaper rash, you can use an over the counter preparation such as A&D or Desitin. Use for 24 to 48 hours. If there is no improvement, or the rash gets worse, your baby may have a yeast rash. Consult your pediatrician. If your baby has a yeast rash, you should also look in the babys mouth to see if there are white patches on the tongue or cheek that do not wipe off.

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Care of the uncircumcised penis Clean the penis during your babys bath.

Place everything you will need for the bath within arms reach. Use lukewarm water and check the temperature of the water with your forearm before placing your baby in tub. Hold your baby so its face does not get in the water. Do not leave your baby unattended in the water for any amount of time. Wash the face first. Be sure to get all creases and skin folds. Until your baby is older, make the bath a quick one to prevent chilling. We recommend that you do not use baby powder. It can be inhaled into the lungs. Oils are not recommended due to the chance of clogging pores. Baby lotion is safe to use on your babys skin.

If the foreskin moves easily on the penis, it may be gently pulled back and the penis washed and rinsed. Allow the foreskin to slip back over the head of the penis. If the foreskin is tight, clean the whole penis washing away any white secretions without trying to push the foreskin back. For more information about the care of your babys uncircumcised penis, ask your babys doctor.

Hand washing The most important thing you can do to help prevent illness in your baby is good hand washing.

Germs are easily carried and passed on to others by our hands and may cause serious illness. To protect your baby from illness or disease, wash your hands before preparing formula or food (breastfeeding), after using the bathroom, or after changing diapers. Ask other people to wash their hands before touching your baby too.

Dressing your baby Dress according to temperature. If you need a sweater or coat to feel warm, dress your baby in equally heavy clothes.

If your baby is sweating, he or she is too hot. Remove blankets or some of the clothing. Never put your baby in front of an air conditioner or fan. If it is windy or cold, cover the babys head with a blanket or hat when going outside. Do not expose your baby directly to the sun for any extended period of time in the summer. If you are going to be in the sun, use a sunscreen with an SPF of 15 or greater for babies over 6 months of age. Babies under 6 months should not be exposed to the sun for any extended period of time. Use sunscreen as directed by your pediatrician. In general, you should dress your baby in the same number of layers you have on to be comfortable, plus one

Bathing your baby Give a sponge bath only until the umbilical cord falls off and is healed and the circumcision has healed at least 24 hours.

Bathing 2 to 3 times a week is usually enough if the diaper and face area are kept clean daily. Mild soaps without perfumes or deodorants are best to use. Pick a warm spot that is without drafts to give the bath.

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additional layer. It is very important in the winter to dress your baby warmly. Clothing care Wash your babys clothes separately from the family wash.

Taking your babys temperature Temperatures should be taken under your babys arm. Do not take your babys temperature rectally.

Use a mild detergent. If the family has a history of allergies, you may want to use a free and clear or fragrance free detergent on the familys clothes. If you have a clothesline, hanging your babys clothes in the sun decreases germs and freshens them.

Hold the bulb of the thermometer in the middle of the armpit for 3 to 5 minutes if using a glass thermometer. With a digital thermometer, hold the bulb in the middle of the armpit until there is a reading. The normal temperature range is 97.6F to 98.6F (36.4C to 37.3C). If the temperature is below 97.4F (36.3C), put a hat on your baby and wrap in more blankets and dress warmer. Recheck your babys temperature in one hour. If it is not up, call your babys doctor. If the temperature is greater than 100F (37.8C), give a lukewarm sponge bath. Start with the head and work down. Check the temperature again in half an hour. If its not coming down, call your babys doctor. Do not use any medicine until you talk with the doctor.

How to use a bulb syringe Use a bulb syringe only if your baby has a stuffy nose or if you see something in the nose. Heres how to use a bulb syringe: 1. Squeeze the ball portion to deflate it and then place the tip gently in the nose about one-eighth of an inch. Release the bulb. Withdraw from the nose and squirt on a tissue. You may have to repeat steps 1 and 2 several times. Wash the bulb syringe in warm soapy water between uses and be sure the water that gets inside is squirted out.

2. 3. 4.

Car seats All infants should always ride rear facing until they are 1 year old AND weigh at least 20 pounds.

Car seats should be placed in the back seat, facing the rear of the car. Never place a rear facing car seat in front of an air bag. Never put your baby or any child in front of an air bag. Infant only Convertible Over head T-shield

Types of infant cars seats:

See TIGR TV car seat video and/or the Car Seat Safety brochure available from your nurse. Page 15

General tips on caring for your baby Do not add honey to your babys milk or place on the pacifier. Honey can carry bacteria that can cause a dangerous infection called botulism in your baby.

Do not smoke around your baby or other children. Second-hand smoke in the air, on your clothing, and in your car is dangerous for all babies, especially those who were sick or premature at birth, or who have chronic illnesses.

Your babys hearing is fully developed. Be sure to talk, sing and read to your baby. The temperature of your house should be about 70F (21.1C). If its cooler, dress your baby in heavier clothes. If its warmer, use less or lighter clothing. Your baby will get use to whatever noise is present. Go about your usual activities. Babies usually have blood drawn from their heels while in the hospital. After going home, they sometimes fuss whenever anyone touches their feet. This will pass with time and lots of positive attention. Screen relatives and visitors for illnesses and colds before visits. Tell your babys doctor if your baby has been exposed to a contagious illness. Do not prop bottles. Use toys that are too large to swallow, with no sharp edges or easily broken off pieces. Set your homes water heater to no greater than 120F (48.8C). Never shake your baby. You will grow more confident in your parenting skills as time goes by. Never hesitate to ask questions. Avoid exposing your infant to adults/children with colds or other contagious illness. When to call your pediatrician or primary care provider Call your pediatrician right away if your baby has any of the following:

A temperature of 100.4F (38C) or higher or less than 98F (36.6C) when taken under the arm. Redness, foul odor, or drainage around the umbilical cord. Vomiting that is forceful and a large amount or vomiting after every feeding. Refusing to feed for more than 1 to 2 feedings. Extreme sleepiness or difficult to awaken, weak or floppy muscle tone. Constant crying even after being fed, changed, swaddled, and comforted. Frequent, watery, foul smelling stools (diarrhea). Bleeding. Convulsions or seizures. Color changesskin becomes pale or blue or baby becomes blue around the eyes or mouth. Rashes other than mild diaper rash. Jaundice. This is a yellowing of the babys skin. It usually starts on the face and then moves to the body. You may notice a yellowing of the whites of the

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eyes. (See page 31 for more information.)

Trouble breathing. Breathes fast (more than 60 times per minute), makes a grunting noise while trying to breathe, coughs a lot, nose flares with breathing, retractions (chest looks like it might touch the backbone). No wet diapers for 24 hours. Eye drainage, swelling or redness. Circumcision has drainage, bleeding or redness. White patches on the roof of the mouth and inside cheeks that wont rub off (thrush).

swings, car seat, etc. for a variety of experience and head positions. Always place your baby on his or her back to sleep for the first year of life.

Have your baby sleep on a firm, flat surface or mattress with any covering sheet tightly tucked under the mattress so that it will not become loose. Never place your baby to sleep on comforters, pillows, sheepskins, beanbags, couches, waterbeds, or other soft surfaces. Do not place any objects in the crib while your baby is sleeping. This includes stuffed animals, pillows, clothing, and bumper pads. Covers, including light blankets, must be kept away from your babys head and face. The best way to do this is not to use blankets at all. Instead have your baby sleep in sleepers, sleeping sacks, heavier jumpsuits, etc. If you use a light blanket, keep it below your babys arms and tightly tuck it below the mattress with your baby at the foot of the crib. The temperature of your babys room should be comfortable for you. Usually, about 70 degrees. Dress your baby as you would to be comfortable. Do not overdress or overheat your baby. Watch for sweating as a sign of overheating. No one should be allowed to smoke in your babys sleeping area or around your baby. Smoking during pregnancy increases the chance of SIDS three times and smoking after pregnancy doubles the chance. Smoking also contributes to asthma, allergies, and lung infections.

Create a safe sleep environment

By creating a safe sleeping environment for your baby, you can reduce the risk of Sudden Infant Death Syndrome (SIDS) and accidental death. Sudden Infant Death Syndrome While SIDS remains the leading cause of death in babies, the chance of it happening has been cut in half by changing the way we care for our babies. Until we know the underlying cause of SIDS, we will not be able to prevent all cases. However, we can decrease the chance of it happening by encouraging all parents and other baby caregivers to do the following:

Studies suggest breastfeeding may protect your baby against SIDS. Always place your baby on his or her back to sleep. If this is done from the start and done every time, your baby will sleep comfortably on his or her back. When your baby is awake, place your baby on his or her stomach to play. If your baby falls asleep on his or her stomach, turn your baby over. When awake, carry your baby, place in

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The American Academy of Pediatrics recommends that parents consider offering pacifiers to infants one month and older at the onset of sleep to reduce the risk of SIDS. The safest place for your baby to sleep is alone in a regulation safety certified crib with a tight fitting mattress. Such cribs are built so a baby cannot get his or her head caught between the slats or caught between the railings and the mattress. Beware of older, second-hand cribs, which may not meet regulations. Check to make sure a soda can cannot fit between the slats and that the mattress fits tightly to the sides. Placing your baby to sleep in an adult bed is not safe and can result in accidental death. Placing a standard crib, bassinet, or smaller regulation version, next to your bed allows you to watch your baby during sleeping hours and will help during breastfeeding. Having a baby share a bed has been shown to be a risk factor of SIDS in studies from many countries. It is particularly risky when soft adult bedding and smoking are present. Bed sharing with other children and adults, in addition to or other than the mother, is particularly risky. If your baby was premature or very sick and in the NICU, you may have observed the doctors and nurses not following some of these recommendations. It is not because the nurses and doctors do not believe that the recommended steps are important. When babies are premature or very sick, they are closely observed with monitors and people 24 hours a day. By the time the baby is ready to leave the NICU, the nurses will have worked hard to assure the baby now sleeps on his or her back, on a flat surface, without additional padding or covering. Premature, growth-retarded, or small-for-date babies, and multiple births are at an increased risk of SIDS, therefore is even

more important that these recommendations are carried out for the baby at home.

The dangers of shaking

Raising a baby is a hard but rewarding job. It is a job that requires a lot of patience. When you are tired, stressed, or angry, you have to be especially careful not to take out your feelings on your baby. When you are stressed, it is easy to forget that your baby is not crying, having temper tantrums, or wetting diapers just to add to your problems. One important thing to remember is NEVER SHAKE YOUR BABY OR A YOUNG CHILD! Babies have weak neck muscles and large heads. Shaking causes the brain to strike the inside of the skull, resulting in bleeding in the brain and sometimes brain damage. Shaken Baby Syndrome Babies and young children are at greatest risk for Shaken Baby Syndrome. This condition can sometimes cause so much damage that the baby or child will never be able to learn to crawl, walk, run or play! Sometimes the damage is so severe that the baby or child will die. Shaking can also cause bleeding within the eyes when the tiny blood vessels tear. This can cause the baby or child to have partial loss of sight or total blindness. Striking a baby or child in the head, or throwing them onto a bed or couch, or against a hard object, can cause the same kind of injuries. Even in play, babies and children can be injured. Tossing a baby or small child into the air is not a safe play activity.

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Here are some important things to remember:

Sometimes your baby is crying because she is hungry, wet, sleepy, or just wants to be held. Babies need to be comforted by being held, cuddled, and spoken to in a soft voice. This will not spoil your baby but rather will tell him that you love him or her. Massage therapy is a wonderful way to calm your baby. Ask your babys nurse about how to massage your baby. Babies are not just small adults. As your baby grows, he or she will go through some stages with behaviors that are frustrating to you. Remember that these things are all normal. Your baby will probably outgrow most of these negative behaviors. You have needs, too. When you are feeling tired, frustrated or stressed, talk to someone who will listen to your feelings. Call a minister, friend or relative.

Exercise Take a shower Read a magazine or book

Sit down, close your eyes, think of a pleasant place in your memory. Do not move for several minutes.

Formula feeding

Formula has all of the basic nutrients your baby needs for the first 6 months of life. Your baby wont need solid food or fruit juice until 4 to 6 months. Talk with your pediatrician before adding new formula, foods or juices in your babys diet.

Formula brands There are many different kinds of formula. Be sure you know what kind of formula your baby is taking before you go home. A formula fortified with iron is best for your baby for at least the first six months. Formula preparations Formulas come in powders, concentrate and ready-to-feed. The powder formula is the most economical, but the least easy to prepare. You should follow the directions on the formula for correct preparation.

Prevent injury. Be safe, not sorry. Dont shake a baby! Dont throw a baby! Instead, STOP and:

Take 10 deep breaths and 10 more. If you are feeling like you are at the end of your rope, put your baby in bed or in a safe place and take a break. See if you can find someone to watch your baby for a while. Call a friend or neighbor. Change your activity Shake a rug Do dishes or laundry Scrub a floor Beat a pan or pillow Take out the trash Do something for yourself Play favorite music Relax in a chair

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General tips on using formula Use formula before its use before date on the can. Do not buy damaged or dented cans.

Wash and dry the lid of liquid formula cans before opening. When preparing formula, always follow the directions on the label of the container. Never dilute formula to make it last longer. Feed formula at room temperature or warmed. NEVER use the microwave to warm formula. A microwave can cause hot spots in the formula and burn your babys mouth. Newborns will want to eat every 2 to 4 hours, around the clock. After the first few weeks, they will increase the amount they take at each feeding from about 2 to 4 ounces of formula. If your baby is a premature baby and was on a limited amount of formula, increase slowly or after asking your babys doctor. Tilt the bottle so that the formula fills the nipple and your baby does not swallow air.

Burp by sitting your baby up on your lap or placing your baby over your shoulder. Your baby may require burping after every ounce at first. Small babies may need to be burped every half ounce. Let your baby set the pace of the feedings. Allow your baby time to look around, play with the nipple, or pause in feeding. Never force your baby to take more than what he or she wants. With premature babies, it is best not to play with them or bathe them prior to feeding since they may tire easily. NEVER prop your babys bottle; eye to eye communication, warmth, and cuddling help your baby feel secure and let you get to know each other well. Providing nourishment is only part of what happens during a feeding. It provides you with a chance to give your baby your full attention and share a special warmth and closeness. Tell your babys doctor if the baby is not taking at least as much formula as when you went home from the hospital.

Typical Pattern of Infant Feedings with Iron Based Formula*

Age of Infant Birth to 2 weeks 2 weeks to 1 month 1 to 3 months 3 to 7 months 7 to 12 months Number of Feedings Per Day 6-10 6-8 5-6 4-5 3-4 Volume/Feeding -2oz. (15-60 ml) 3-4oz. (90-120ml) 5-6oz. (150-180ml) 6-7oz. (180-210ml) 7-8oz. (210-240ml) Total 3-20oz. (90-600ml) 18-32oz. (540-960ml) 25-36oz. (750-1080ml) 24-35oz. (750-1080ml) 21-32oz. (750-1080ml)

*These are only estimates. Each baby will be different, but this is a guideline to make sure your infant is getting enough formula. Consult your pediatrician if you have any questions.

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Breastfeeding
Experts agree that breast milk is the best food for a baby and should be continued for as long as possible. The American Academy of Pediatrics strongly recommends breastfeeding for at least one year. Breastfeeding offers special benefits for your baby:

Breastfeeding: getting started The following are some helpful hints for getting started. Call your nurse at the beginning of a feeding and she can help.

It is important that your baby is allowed to breastfeed as soon as possible after birth. If your baby is unable to nurse, it is still possible to breastfeed successfully. Pumping your breasts at regular intervals will allow you to establish your milk supply. Begin pumping within 12 to 24 hours after delivery. The key to successful breastfeeding is to allow your baby to feed as much as he or she wishes. Offer your breast every 2 to 3 hours, about 8 to 12 feedings per day. Do not limit the amount of time your baby feeds on each side, to make sure he or she gets enough milk. Breastfeeding at least 8 times per day will decrease the chance of your baby becoming jaundiced or losing too much weight. Time the feedings from the beginning of one feeding to the beginning of the next. Let your baby finish one breast before switching to the other side. Then you can be sure he or she gets the nutritious hind milk at the end of the feeding on the first breast. Your baby will usually come off the breast by himself or herself when he or she has had enough. Frequency of feedings is the number one determinate of adequate milk supply. Your baby should eat 8 to 12 times per 24 hours. Your milk supply is regulated by your babys need. How much milk you make is determined by how often and how well your baby nurses. Your baby may not burp much in the first few days but try to burp when the

Breast milk is the perfect food for your baby. Nutrients are provided from your system as needed. Changes occur in the composition of your milk, from the beginning to the end of a feeding, from feeding to feeding, and as your baby grows and develops. It is all your baby needs to grow and thrive for many months. Breastfed babies develop fewer illnesses in their first year of life. Studies provide evidence that breastfeeding can decrease the incidence or severity of common infant illnesses such as ear infections, diarrhea colds, bacterial meningitis, SIDS, diabetes, obesity, and asthma. Illness prevention is directly related to the length of time breastfeeding is continued. Breastfeeding provides special opportunities for bonding with your child. Breastfeeding is convenient. It requires no advance planning or equipment and your milk is always ready and the perfect temperature. Research indicates that breastfeeding can reduce a mothers risk of several medical conditions such as ovarian and breast cancer, hip fractures, and osteoporosis.

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baby gets sleepy, between breasts, and at the end of a feeding. As the baby gets more milk, he or she will burp more often. Burp by sitting your baby on your lap or placing your baby over your shoulder.

hours. Your babys feeding skills do not need to be perfect to obtain colostrum; he or she can get what they need, even when baby is sleepy and seems to only suck for a short time What Your Baby Really Needs It is natural for a baby to consume very little during the first day of life. To offer a baby a bottle may reduce concern of underfeeding, but, in most cases, it is not what your baby needs. Bottle-feeding and breastfeeding behaviors are very different. It is normal for babies to take small feedings inconsistently during day one of life. Sucking on pacifiers and bottles does not help a baby learn to breastfeed. Avoid these items unless they are medically indicated or there is mom/baby separation until breastfeeding is well established. A mother and baby should stay together during their hospital stay so that the mother will be able to respond to babys feeding cues. If there are unusual needs, nursery care is available. This is a special time between parents and babies. You are learning to read what your baby is telling you. Early cues include mouthing, rooting, and stirring from sleep. Offer your breast when you see these cues. Crying is a late cue, and sometimes it is hard to get a crying baby to the breast. Family-centered care takes into account the joy and importance of celebrating your babys birth with friends and relatives. If your baby requires special of intensive care, the support of family and friends may be crucial. Do not delay breastfeeding to accommodate your visitors needs. We can assist you with visitor control should your rest or infant feeding become compromised. Very few medications are contraindicated while breastfeeding. Babys second night Your baby is no longer back in the warm, comfortable womb where he or she

Tips to wake your baby to eat: change the diaper; burp the baby; massage your babys arms, legs, and body; give a lotion bath and/or provide kangaroo care. Your babys eyes do not need to be open to eat. Be ready to put baby immediately to your breast. Kangaroo care, also called skin-to-skin, not only provides special opportunities for bonding with your infant, but has positive effects on milk supply and prevents problems while breastfeeding. The infant should only have a diaper on and should be placed on its abdomen between the mothers bare breasts and covered with a baby blanket or gown. If your baby is unable to nurse, begin pumping within 12 hours after delivery.

The first 24 hours A mother provides the colostrum (early breast milk), warmth, and kindness needed to adapt to life outside the womb. You and your baby are learning to breastfeed together. It takes practice and patience. Unless there are medical indications, supplementing with formula during the first 24 hours is not needed. For most babies, the babys sucking reflex is most intense within the first 2 hours of birth. Breastfeeding right after delivery is ideal. Many babies tend to spend much of the first 24 hours sleeping. Some babies are only soothed by nursing often, which is also normal. Colostrum Colostrum is yellow and sticky and can be very hard to express by pumping. If you are saving milk for your baby, save every drop (literally!). If your baby is nursing, you do not need to start pumping in the first 24

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has spent the last 9 months, so there are all sorts of people touching him, new noises, lights, sounds, and smells. He has found one thing though that he likes to listen tohis cry. You find that each time you take him off the breastwhere he comfortably drifted off to sleep and put him in his cribhe loudly protests! In fact, each time you put him back on the breast he nurses to sleep. As you take him off and put him back to bed, he cries again and starts rooting around, looking for you. This goes on sometimes for hours. Something you can do when he drifts off to sleep at the breast after a good feed is break the suction by sliding your nipple gently out of his mouth. Do not move or burp him, just snuggle him until he falls into a deep sleep where he will not be disturbed by movement. Babies go into a light sleep state (REM) first, and then cycle in and out of REM and deep sleep about every half hour or so. If he starts to root and act as though he wants to back to the breast, that is finethis is his way of settling and comforting. For safety reasons, the American Academy of Pediatrics (AAP) does not recommend bringing your infant to sleep in bed with you. This might happen every once in a while at home too, particularly if you have changed his environment such as going to the doctor, church, mall, or grandparents! Do not let it throw yousometimes babies just need some extra snuggling at the breast, because for the baby, the breast is home. Another helpful hint is to let him suck on his thumb or fingers anytime he is the slightest bit disturbed or uncomfortable. Babies can soothe themselves by sucking on their hands. Babies need to touch and feel. His touch on your breast will increase your oxytocin levels which will boost your milk supply! Loosen his blanket so he can get to his hands.

Expressing milk when your baby is unable to nurse You can establish and maintain your milk supply by electric pumping. At first, the amount of milk you pump is not important. What is important is that your breasts are being stimulated at least 6 to 8 times per day by pumping. After your milk supply is well established, watch for a decrease in supply and take action as directed in the section, What to do if you suspect your milk supply is low on page 27.

If your baby is unable to nurse, begin pumping within the first 12 hours after delivery. Your nurse will be available to assist you with breastfeeding or pumping questions or problems at any time during you and your babys stay. Save all your milk even if it is only a few drops or teaspoons. Always wash your hands with soap and water before pumping. All pump parts that come in contact with milk should be washed in hot soapy water and rinsed well, then allowed to air dry on a clean towel. Be sure that your nipple is centered in the pump cup. When using an electric pump that can pump both breasts at once (a double pump), pump for a total of 10 to 15 minutes. Use a moderate suction setting for the first 24 hours, then increase to the maximum suction setting if that is comfortable to you. Using a double electric pump will help you maintain your milk supply. If your baby is not feeding at the breast at all, you will need a hospital grade breast pump. Ask your nurse. It may be difficult for you to experience let-down while pumping. Try to relax, look at a picture of your baby, and think

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about holding your baby against you. Sometimes it is helpful to try some deep breathing exercises before pumping. Get comfortable.

Remember, its not important how much milk you are getting at first. Pumping to stimulate your breasts 6 to 8 times per day is what is important.

Storing breast milk Save all expressed breast milk, even if its just a few drops or teaspoons.

Pour freshly pumped breast milk in a clean plastic container. Do not use glass containers. Ask your nurse for a plastic container while in the hospital. If your baby is in the hospital: label each bottle with your babys name and the date and time you pumped. Rotate your frozen milk supply. Use the oldest first. Transport your milk to the hospital on ice to keep it frozen. If some of the milk thaws, tell your babys nurse so that milk may be used if possible. Thaw frozen breast milk in the refrigerator overnight or place the bottle

in a bowl of warm water. NEVER WARM OR THAW BREAST MILK IN THE MICROWAVE. This may destroy the good properties of the milk and could also cause hot spots in the milk that might burn your babys mouth. Thawed breast milk is good for 24 hours. Thawed breast milk should never be refrozen. Freshly expressed breast milk should be put in the refrigerator as soon as possible. However, it is safe at room temperature for 6 to 8 hours. Breast milk that has never been frozen is good in the refrigerator for up to 5 days.

Breast/nipple care Here are some basic steps to keep your nipples and breasts pliable and free from problems:

Wash your hands with soap and water before each feeding. Do not scrub your nipples when you bathe

Storage Duration of Fresh Human Milk for Use with Healthy, Full-Term Infants Location Temperature Duration Comments Countertop, table Room temperature 6 to 8 hours Containers should be covered and kept as (up to 77 F or 25 C) cool as possible; covering the container with a cool towel may keep milk cooler. Insulated cooler bag 5 to 39 F or 24 hours Keep ice packs in contact with milk 15 to 4 C containers at all times, limit opening cooler bag. Refrigerator 39 F or 4 C 5 days Store milk in the back of the main body of the refrigerator Freezer compartment of a refrigerator Freezer compartment of refrigerator with separate doors Chest of upright deep freezer 5 F or 15 C 0 F or 18 C 4 F or 20 C Freezer 2 weeks 3 to 6 months 6 to 12 months Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, but some lipids in the milk undergo degradation resulting in lower quality

Reference: Academy of Breastfeeding Medicine (2004). Clinical Protocol Number 8: Human Milk Storage Information for Home Use for Healthy Full Term Infants. Princeton Junction, New Jersey: Academy of Breastfeeding Medicine.

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Bathe every day. You will want to wear a clean supportive bra every day. You will not need to wear it at night if you dont want to. Avoid any creams on your breasts or nipples. Pure lanolin may be used for irritation or dryness. Air dry nipples after feeding at least 5 minutes. When you are at home, keep your bra flaps down whenever possible. To protect and soothe nipples, apply some of your expressed breast milk to the nipple and areola (the dark area around your nipple) after nursing and allow to air dry. Change your nursing pads or bra whenever they become wet between feedings. Make feedings frequent to allow for a good milk supply.

Gently stroke your babys lower lip with your nipple until your baby opens his or her mouth very wide. Quickly pull your baby to your breast so that his or her nose, cheeks, and chin are all touching your breast. If your babys nose is blocked, pull his or her bottom upward and closer to you so your babys head will move back slightly.

Latching on Learning to breastfeed takes time and practice for both you and your baby. The way your baby attaches to or latches on to your nipple and breast is one of the most important skills to be learned in his or her first days of life. Here are some tips for helping your baby latch on:

Make sure your baby has as much of your areola (the dark area around your nipple) in his or her mouth as possible. VERY IMPORTANT: You should notice that your babys bottom lip is sticking out. If it is not, gently pull down on the babys chin to bring the bottom lip out or remove the baby from the breast and latch on again. Whenever you remove your baby from your breast, break the suction by gently placing a finger in the corner of your babys mouth. This will prevent injury to your nipple.

Get into a comfortable position. See the Positioning section on page 25 for several options. Your babys tummy should be against your tummy with his or her head at the level of your breast. Your hand should be positioned on your breast so that your thumb is on top with fingers below to support your breast.

Positioning It is important that you be comfortable while nursing.

Find a comfortable chair or rocker, or try nursing lying down.

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Use pillows to support your baby so your arms dont get tired. REMEMBER: Bring your baby to you, not you to your baby. Elevate your feet while nursing and lean back in the chair so your back doesnt get tired. Gather anything you might need and have it close at hand so it is not necessary for you to get up in the middle of a feeding. Some things you might need are a phone and a glass of water. The most common cause of nipple soreness is incorrect positioning of your baby on the breast. Your baby should be latched onto the breast well behind the nipple.

Cross cradle hold

Instead of holding your babys head in the bend of your elbow, hold your baby with the opposite hand. Your hand should rest between your babys shoulder blades and should support your babys back and the back of his or her head. Position your babys face directly in front of your breast instead of pushing your breast toward your baby.

Cradle hold Cradle your baby in the crook of your arm. Support your babys buttocks or thigh with your same hand.

Football hold

Turn your baby so that his or her tummy faces your tummy. Support your breast with the opposite hand, holding your thumb above the areola and your fingers below your breast. Gently rub your nipple across your babys mouth until your baby widely opens his or her mouth. Then pull your baby to your breast until his or her nose is just touching your breast.

Your baby will be tucked under your arm with his or her body wrapped around your waist. Your hand holds your babys head while you support your breast with the opposite hand and tickle the babys lower lip until your baby opens his or her mouth wide. Then quickly bring your baby to your breast to latch on.

Sidelying position

Your baby should be directly on his or her side up against you with your babys mouth at the level of your nipple.

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A rolled up blanket against your babys back will help hold him or her in place. Lying down for feeding may be more comfortable for you and it also may help increase your milk supply if this has been a problem for you.

black green stools) and begins to pass yellow, seedy, runny stools 3 to 4 times per day. A day or two after your milk comes in your baby wets 6 to 8 diapers per day with clear or light yellow urine. For newborns breastfeeding: one wet diaper the first day of life, then 2 wet diapers on the second day, 3 wet diapers the third day, 4 wet diapers the fourth day, 5 wet diapers the fifth day, then 6 to 8 diapers per day. If you have concerns about your babys nutritional status, contact your pediatrician right away.

How to tell if your baby is getting enough milk Its normal for parents to be concerned about whether or not their baby is getting enough to eat. You arent able to measure while breastfeeding. But there are ways to tell if your baby is getting enough milk. A healthy, term newborn who is nursing well, at least 8 to 12 times per 24 hours, should need no other nutrition than mothers milk. Your baby is most likely getting enough milk if:

What to do if you suspect your milk supply is low Feed your baby more often. Wake your baby up to nurse every 2 hours during the day.

Try lying down for an extra nap during the day or try nursing lying down as much as possible. Be sure and drink when you are thirsty. Caffeine-free drinks are recommended. If pumping breast milk and you notice a decrease in supply, increase pumping time. (For example, if you were pumping for 15 minutes, increase to 20 minutes.) Also, pump more often. (If you were pumping 6 times per day, try pumping 7 to 8 times per day.) Make sure your pump is working correctly and it is set on maximum suction. Continue taking prenatal vitamins. Be aware that increased stress may cause a decrease in milk supply. Relaxation exercises may be helpful. Talking about your feelings may also help. Ask for help with housework, cooking and childcare. Try these measures for 2 to 3 days. If you do not notice an increase in supply, tell your babys nurse or doctor.

Your breasts feel full before a feeding and softer after. (This is after your milk comes in 3 to 5 days after delivery.) Your baby has no trouble latching on. Your baby is nursing every 2 to 3 hours or at least 8 times in 24 hours. You can hear a rhythm of suckswallow-pause regularly during feedings. Your baby nurses at both breasts and appears content and no longer hungry after feedings. Your milk increases in amount. This will make your breasts feel full and firm between the second and fourth day of nursing. After about day 4, your baby stops passing meconium stools (sticky dark

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Limit caffeine intakesoft drinks with caffeine, chocolate. Smoking can decrease your milk supply.

Flat or inverted nipples Sometimes babies have trouble latching on if nipples are flat or inverted. Here are some suggestions if this is a problem for you.

Ways to prevent engorgement Nurse your baby as soon after birth as possible. The best way to prevent or lessen engorgement is to nurse your baby frequently, at least every 2 hours.

Try nipple rolling to help your nipple stand out farther. Grasp the nipple between thumb and forefinger and roll gently just before feedings. Place your thumbs on opposite sides of your nipple and spread outward. Rotate around the areola in a spreading motion. Place your thumb above the areola and your fingers below and gently push your breast against your chest wall. Pump several minutes prior to the feeding to help pull the nipple out.

If your baby is not eating well within 12 hours, begin pumping after feedings. You can help prevent engorgement by not skipping feeding in the first week of nursing.

Coping with engorgement If engorgement occurs, try these suggestions before feeding or pumping:

Place warm moist towels on your breast for 15 to 20 minutes. Take a warm shower with a gentle flow of water on your breasts. Gently massage breasts before feedings. Cabbage leaves worn in the bra have also been found useful for relief. You take the green leaves of the cabbage that has been refrigerated and place directly on the breast. Leave on until the leaves become wilted and then remove. Alternate this with the warm moist towels. If the engorgement prevents your baby from latching onto your breast, try hand expressing or pumping until your milk flows freely and your areola is softer. You can use ice packs on your breasts between feedings if it provides comfort to you. Remember, breastfeeding as often as possible will help prevent engorgement as well as decrease discomfort if engorgement occurs.

When your nipple stands out, your baby should be able to latch on. The suckling of your baby will also help your nipples to protrude more. Engorgement may also cause flat or inverted nipples. It may help to pump for a minute prior to feedings to help pull your nipples out more. You may wear breast shells in your bra to help your nipples protrude more. These are available from your babys nurse. Engorgement When your baby is 3 to 5 days old, your breasts may become very full and even feel hard and hot. This is known as engorgement. The colostrum you had when the baby was first born has been replaced by breast milk or mature milk. This can lead to sore nipples and painful feedings because the breast is so full that your baby cannot latch on properly to the breast. Remember: This is temporary and will not last long.

Sore nipples Nipple soreness sometimes occurs in the first few weeks of breastfeeding. Here are some ways to treat or avoid sore nipples:

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Make sure you are using correct positioning methods. (See Positioning on page 25.) Changing your nursing position may avoid repeated pressure on the same part of your nipples. Make sure your baby has as much of your areola in his or her mouth as possible. If only one nipple hurts, start the feeding on the other side. The babys suck is stronger at the beginning of a feeding. You may have to start your let-down with hand expression or pumping so your baby wont have to suck so hard at first. Try more frequent feedings. Encourage feeding at least every 2-3 hours. Babies that are very hungry suck harder. Avoid plastic liners in your bra. Change breast pads when they become wet. To remove your baby from your breast after feeding, gently insert your finger into the corner of your babys mouth to release the suction. Apply expressed milk to your nipples and areola after nursing. Let your nipples air dry, or dry the area with a hand-held hair dryer set on low temperature. If your nipples become cracked or scabbed, tell your babys nurse or doctor. After nursing, soak caffeinated tea bags in warm water. Gently squeeze the excess water from the bag and place them directly on the nipple. When they become room temperature, remove them. This can be done after every feeding to decrease nipple soreness. A thin layer of pure lanolin may be used for nipple soreness. This will not harm your baby or affect your milk.

Plugged ducts and mastitis A blocked or plugged duct is often felt as a lump under the skin. If your breast feels sore, use your finger to try to locate a hard lump that is painful to the touch. You might even notice a milk filled white blister on the nipple where there is a plugged duct. Mastitis is an infection in the breast tissue. It is not an infection of the breastmilk. It is important to continue to breastfeed or to pump while you have mastitis. Plugged ducts Symptoms Localized hard painful area on breast Red area Deep ache or itch Causes Tight bra that cuts into your breast tissue Weaning too fast Infrequent feedings or a disruption in feeding patterns Early introduction of solid foods Engorged breasts Nursing at one breast only. This may cause milk backup. Overly tired or stressed mother Lack of a supportive bra Treatments Feed often and for longer periods. Start nursing on the affected side. Drink more. Try to get more rest. Apply warm packs to breasts before and after feedings and massage the lump before and during feedings. Nurse your baby in a position that points his or her nose toward the lump. The suck will be stronger in that direction and help eliminate the blockage. If you have plugged ducts often, take 1000 to 2000 mg of vitamin C a day.

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Mastitis Symptoms Same as symptoms of plugged ducts, plus fever, chills, nausea, vomiting, aches (flu-like symptoms). Cracked nipples or previously cracked nipples Causes Normal germs from babys mouth Unresolved plugged duct Engorgement not treated or not responsive to treatment Mastitis is not an infection of the breastmilk. Do not stop breastfeeding. Treatments Same as treatments for plugged duct plus antibiotics prescribed by your doctor. Call your doctor if you think you may have mastitis. Continue to nurse often. Do not stop nursing. Rest as much as possible. Drink plenty of fluids. Nutrition while nursing A well-balanced diet is important for you while nursing. We recommend that you continue to take iron and multivitamin supplements while nursing. Do not smoke, drink alcohol, or use caffeine. If you are having a medicine prescribed for you, tell you doctor that you are breastfeeding. Protein Suggested intake is 60 to 80 gm per day. Good sources Meat Chicken Eggs Seafood Milk and milk products Beans Vitamins B vitamins are especially important.

Good sources: Breads and cereals Deep-green vegetables Nuts Raw fruits such as bananas and oranges Iron Suggested intake is 18 mg per day. Good sources: Meat and liver Seafood Egg yolk Soybeans Lima beans Dried fruits Fortified cereals Calcium Suggested intake is 1400 mg per day. Good sources: Milk and milk products Canned fish Some beans Some green leafy vegetables Liquids Suggested intake is 6 to 8 glasses per day, or 12 glasses if the mother has an infection such as mastitis or has plugged ducts or is trying to increase her milk supply. It is not necessary to drink milk to help your milk supply. Weaning/Supplementation When to wean your baby from the breast is a personal decision. It is not necessary to wean your baby if you must return to work or school. You can pump your breasts when you are away from your baby and save the milk for later feedings. It is best to slowly wean over several weeks to prevent engorgement and the chance of developing mastitis. Start weaning by doing the following:

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 Start by eliminating one nursing per

day. Give a bottle or cup instead. If time is not a problem, eliminate one feeding every few days. Start with a feeding that your baby is the least attached. Bedtime, naptime and the first morning feeds are usually the last to eliminate. Wear a bra continuously and avoid breast stimulation. Express only enough milk from breasts to relieve discomfort due to missed feeding. The law of supply and demand is at work; the need to express your milk when you are away will decrease over time. Use iron-based formula; refer to table on page 20 for information on typical patterns of infant feeding with iron based formula. Contact your doctor for if you have any questions.

ones are destroyed, bilirubin is released and removed by the liver. If the liver is still a little immature and cannot get rid of the bilirubin, the bilirubin builds up in the babys blood stream. This causes the babys skin and whites of the eyes to appear yellow. This is called normal or physiologic jaundice. It usually appears on the second or third day of life in healthy babies that are born full-term. It usually goes away within a week. Jaundice in premature babies Babies who are born premature are at greater risk of getting jaundice. It usually appears a few days later than in full-term babies and lasts a little longer. Other types of jaundice Other types of jaundice may occur if the babys blood type is different from the mothers. One of these types is called ABO incompatibility. In this type, the jaundice will appear within the first 2 days of life. Jaundice may also occur when the mother has Rh-negative blood and the baby has Rh-positive blood. It is usually noticed in the first day of life. The causes listed above are the more common causes. There are others, but they are rare. How is jaundice treated? Infants with physiologic or normal jaundice usually do not require treatment. If treatment is needed, phototherapy is usually used. This means the infant is treated with light, usually artificial lights called bililights. These lights may be placed over the infants crib, or in the form of a blanket that is wrapped around the baby. Since the light must get to the babys skin, the clothes are removed and the infant is placed in a warm area. The babys eyes are covered so they will not be damaged. The babys doctor will choose which method is best. The therapy will last until the amount of bilirubin in the babys blood is lowered and

If you wish to breastfeed for a long time, your baby will probably wean himself or herself naturally. Remember that the American Academy of Pediatrics recommends breastfeeding your baby for the first year of life.

Jaundice in your newborn

What is it? Jaundice is a yellowing of a babys skin. It usually appears first on the face and then spreads to the trunk and rest of the body. Most of the time the jaundice is so mild no treatment is needed. In some cases, it is more severe and will need treatment. What causes jaundice? Jaundice usually happens because the babys liver and other organs are not fully mature. The liver gets rid of a yellowish substance in the blood called bilirubin. Our bodies are always making new red blood cells and destroying the old ones. As the old

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remains at a safe level. The baby may need to stay in the hospital for a few extra days to get the full benefit of the treatment. If your baby has jaundice and you would like more information, please ask your babys doctor or nurse.

Choking first aid and CPR for infants up to one year old
This information cannot replace being certified in Infant CPR. It is intended as information only. We recommend that all parents take a class on safety and CPR for infants. If you would like to know more about becoming certified in Infant CPR, please call (573) 499-6101. Conscious choking infant When obstruction by a foreign object is strongly suspected:

Getting your babys birth certificate

While you are at the hospital, our Birth Records secretary will visit you and get the information for your babys birth certificate. This must be done before you leave the hospital. You will get a Proof of Birth sheet, which should be filled out by you and signed by your nurse. This will serve as a temporary birth certificate. It can be used for insurance or other situations where you need a birth certificate. After the Birth Records secretary collects all of the information, she will send it to the Missouri Department of Health, Bureau of Vital Records. She will then give you an application form for you to send in to get a copy of the birth certificate. Send it to: Missouri Department of Health Bureau of Vital Records PO Box 570 Jefferson City, MO 65102-0570 It takes about 6 weeks to process, so please allow enough time before sending the application. If you are not married to the father of the baby, you will need an affidavit to add the fathers name to the birth certificate. This is in your packet. If you wish to add the father to your babys birth certificate, you and the babys father will need to fill out this form. You both will need to sign it in front of a notary public. There are notaries available in the hospital, so tell your nurse when you might need this service.

If infant can cry, cough, or breathe, do not interfere. If infant cannot cry, cough, breathe, makes a high-pitched noise while inhaling, or has possible cyanosis (turning blue), use the following steps to relieve choking: Kneeling or sitting with the infant in your lap, hold the infant facedown, resting on your forearm. Use your hand to support the head and keep the head slightly lower than the chest.

1.

2.

Deliver up to 5 slaps to the back, between the shoulder blades, with the heel of your hand. After delivering back slaps, place free hand on the infants back and support the head with the palm of the hand; the palm of the other hand should support the face and jaw. Carefully turn the infant over, keeping the head lower than the body.

3.

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4.

Deliver 5 chest thrusts just below the nipple line at a rate of about 1 per second to create coughing to dislodge the foreign object. Repeat until the object is removed or infant becomes unresponsive.

CPR for infant up to one year old 1. Establish unresponsiveness. Call out for help.

5.

Unconscious choking infant 1. With infant on a hard, flat surface, open airway and look for object. If you can see the object, remove it. Do not perform a blind finger sweep. 2. Position infant. Place infant on a hard, flat surface. Open airway by placing one hand on infants forehead (head tilt) and using one finger of the other hand to pull up the chin (chin lift). Look for chest movement, listen for breathing and feel for warm air. If no breathing, go to next step. Give 2 slow breaths. Cover infants nose and mouth with your mouth and blow slowly. Watch for chest rise and fall. If chest does not rise and fall, reposition and try again. Position two fingers 1 finger-width below the nipple line.

2.

Begin CPR by covering the infants nose and mouth with your mouth and blow slowly. If chest does not rise and fall, reposition and try again. Check for the object each time you open the airway.

3.

4.

5. 3. If you are alone after 5 cycles (one cycle is equal to 30 pushes and 2 breaths) or about 2 minutes of CPR, stop and call an emergency phone number. Then continue CPR until help arrive 6.

Compress the breastbone 1/2 to 1 inch at a rate of at least 100 times per minute. Keep infants head tilted.

CPR Instructions reproduced with permission. Basic Life Support Friends & Family Guide 2006 Copyright American Heart Association.

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7. 8.

Give 30 compressions or pushes; count them out loud. Then give two breaths. If you are alone after 5 cycles or about 2 minutes of CPR, stop and call an emergency phone number. Then continue CPR until help arrives

For breastfeeding assistance, please call: Newborn Intensive Care Unit, Well Baby Nursery, Postpartum, your doctor or your babys doctor. For help in an emergency, call: 911 if it is available in your area. If 911 service is not available, write local emergency numbers below:

Frequently used phone numbers

Police Department: Sheriffs Department: Home Phone Number: Other Important Numbers:

Womens and Childrens Hospital Phone Numbers: Family Birth Center: 573-499-6100 Emergency Center: 573-874-9400 Family Birth Center Postpartum Unit: 573-499-6140 Birth Center Well Baby Nursery: 573-499-6265 Newborn Intensive Care Unit: 573-499-6180 Birth Records: 573-875-9377 Green Meadows Pediatric Clinic: 573-882-4730 Green Meadows Family Practice Clinic: 573-882-6191 HealthConnect 24: 24-Hour Medical Advice Line: 573-884-2401 or 1-888-884-2401

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TIGR TVOn-demand patient education television system

Hospital to Home: A Security Blanket for New Parents Ensure the continued health and well-being of you and your baby as you make the transition from hospital to home while watching this video on mother and baby care. Lochia, Afterpains, and Cesarean Care: lochia color change, warning signs, comfort techniques, perineum, sitz baths, Kegel exercises, hemorrhoids, rest, and signs of an infection. Baby Blues and Postpartum Depression: tips for the first few days, signs of postpartum depression, and partner care. Breastfeeding Basics and Warning Signs: lactation consultants, hunger cues, feeding guidelines, positioning and latch, engorged breasts, plugged ducts, signs of mastitis, sore nipples, pacifiers and nipples, signs the baby is getting enough, and when to call your healthcare provider. Formula Feeding: how much to feed, warming a bottle, propped bottle warning, cleaning bottles, and signs that your baby is getting enough. Basic Baby Care: umbilical cord care, circumcision care, diaper hygiene, types of stools, caring for rashes, cleaning tips, and bath safety. Warning Signs: signs of jaundice, constipation, diarrhea, dehydration, when to call your babys caregiver, and taking temperature. Crying and Safety: responding to baby, Shaken Baby Syndrome, SIDS, car seats, and other safety tips.

Newborn Care: A Guide to the First Six Weeks New parents get lots of advice and now Newborn Care provides the complete essentials for taking care of your new baby, solutions for common challenges, seven ways to calm a crying or fussy baby, reading cues, knowing when to call the doctor, and more. Appearance and Senses: peeling skin; milia; stork bites; vernix; head shapes; interaction; and what babies can see, hear, smell, feel, and taste. Baby Cues, Comfort Techniques, and Crying: signals for play, over stimulations, sleep and hunger, responding to cries, comfort techniques, holding, massage, movement, colic, and Shaken Baby Syndrome. Eating and Sleeping: hunger cues, benefits of breastfeeding and tips, formula feeding and tips, sleep patterns, and SIDS. Diapering and Cleaning: stool patterns, how to change a diaper, rashes, signs of dehydration, cleaning the umbilical cord, circumcision care, bathing safety, and keeping baby warm. Health and Safety: well-baby visits, immunizations, jaundice, taking temperature, when to call the doctor, car seat safety, home safety, playing, getting support, sleep, and communication. Better Breastfeeding: Youre Guide to a Healthy Start Its no secretbreastfeeding can challenge even the most confident parent, and Better Breastfeeding helps give you the assistance and motivation to provide your baby with the best start possible. How Breastfeeding Works: breast anatomy, milk supply, American Academy of Pediatrics recommendations, International Lactation Consultants Association guidelines, and health benefits for mom and baby.

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Latching On and Positioning: skin-toskin contact, rooming in, lactation consultants, 3D animation of asymmetrical latch, and breastfeeding holds. How Much Is Enough?: growth spurts, counting diapers, proper weight gain, and keeping a feeding log. Breast Care: nipple care, hand expression and pumping milk, breast massage, and warning signs. Breastfeeding Lifestyle: getting support, feeding in public, rest, nutrition, and returning to work.

Feeding: benefits of breast milk, benefits of pumping, when to pump, how to pump, how to get into a pumping routine, milk production for a pumping mother, and learning to breastfeed. Taking Care of You: emotional health, support, postpartum depression, physical health, and good nutrition.

Your Premature Baby, Volumes 13 Premature babies need specialized care and Your Premature Baby gives new parents the essentials they need to know. Learn from and receive comfort from parents with preemie success stories as they guide you through the NICU experience. Your Premature Baby is perfect viewing for antepartum families that are expecting a premature baby and current families with an NICU baby. Volume 1: Preemie Basics; Medical Care Defining Prematurity: parents feelings and causes of premature birth. Preemie Appearance and Behavior: what to expect, brain development, senses, and movement. The NICU: equipment, communicating with staff, isolette, respirator, monitors, and IVs. Common Medical Problems: Respiratory Distress Syndrome, apnea, jaundice, infection, and reflux. Volume 2: Interacting With and Feeding Your Baby Communication and Touch: parents feelings, what to expect, cues, interactions, over-stimulation, and touch. Kangaroo Care: what is Kangaroo Care, how to provide care, what are the benefits for the parents and the baby.

Volume 3: Going Home Preparing for Discharge: gaining confidence, rooming in, training for baby care, and car seats/bed. At Home With a Preemie: SIDS, preventing infections, responding to crying, precrying signals, soothing techniques, feeding, and sleep cycles. Early Development: corrected age and chronological age, physical growth, developmental milestones, and promoting healthy development. Possible Long-Term Complications: hearing impairment, vision problems, muscle tone, and learning disabilities. Dont Risk Your Childs Life (Car Seats) This video provides the most up-to-date, comprehensive information about the following: Which car seat is right for your baby How to use your car seat When to change your car seat The video also includes: Footage of airbag deployment with a rear-facing infant model to demonstrate the critical importance of infants riding in the rear-facing position Discussion of benefits for booster seats and solutions for installation problems due to vehicle incompatibility New child restraint models, including use of a riding LATCH Have confidence in your car seat selection and your childs life!

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Reviewed by the Center for Education and Development 10/19/93, rev. 6/00, 7/01, 02/04, 4/07, 9/08, 6/09, 3/10, 1/11 If you need ADA assistance, please call (573) 882-4997. An equal opportunity employer

One Hospital Drive Columbia, Missouri 65212 (573) 882-4141 Copyright 2011 by the Curators of the University of Missouri, a Public Corporation.