Saturday, 23 July 2011

Taking Care of the New Born

Published in "Panorama"

When a baby is born

Taking care of the newborn , exhilarating as the experience may be, can be pretty stressful , and a challenge especially for first time parents who are anxious for the baby's welfare. Expectant parents often fear the changes a new baby will bring, especially sleepless nights. The anticipation, anxiety - it all starts right from the onset of pregnancy gradually building up to the point of delivery and continues into the immediate postnatal period says Dr.Sunil Mathew, Paediatrician, Dr.Moopen’s Poly Clinic, Deira. "The paediatrician has to be involved, even before the delivery, especially in the case of first time parents and in all high risk pregnancies. Mothers with decreased foetal movements, bleeding, diabetes, hypertension, epilepsy, thyroid and renal problems, TORCH infections, and mothers who smoke or consume alcohol, are all high risk pregnancies . Evidence of IUGR ( Intra Uterine Growth Retardation )detected on ultrasonogram particularly during early pregnancy must be investigated and followed up. Usually in the last trimester, between the 32nd week and delivery, it is highly advisable for parents to meet the pediatrician . Because there are inputs which a pediatrician can give to the mother which puts her at ease with regards to her baby."

Immediately after the baby is born it will be evaluated through an Apgar score to determine its state of health, explains Dr.Mathew. “The baby's vital signs and responsiveness are tested, including its breathing, heart rate, muscle tone, reflex response and colour, on a scale of zero to two for each of the five factors. The scores are then added, with a score of 7 - 10 being considered as normal. Any score below 7 indicates the baby may need further assessment and rectifying measures. Besides this test, the baby's weight, length and head circumference are measured along with a preliminary screening for any congenital anomalies ."

Birth is a traumatic experience for the baby as well as the mother. Newborns are tiny, wet creatures when they first emerge. Very often their heads may appear bigger in comparison to the rest of the body and also slightly pointed as a result of passing through the birth canal. This is normal and temporary; the head assumes a rounded shape within a few days of birth, explains Dr.Mathew.

Some newborns may experience transient tachypnoea or wet lungs or Type II Respiratory Distress Syndrome soon after birth, reveals Dr.Mathew. "That is, these babies may breathe faster and harder than normal because of the presence of extra amniotic fluid in their lungs or because of the slow absorption of the fluid in the lungs. Normally, before birth, the lungs of the foetus are filled with the amniotic fluid. While a foetus is inside its
mother's womb, it does not use its lungs to breathe. It gets its oxygen supply from the blood vessels of the placenta. During the birth process, as the baby passes through the birth canal, some of the fluid inside its lungs is squeezed out. Once born, as the baby takes its first breaths, the lungs will fill with air and more fluid is pushed out of the lungs. If there is any fluid remaining, it is coughed out or gets absorbed into the body
through the bloodstream. In some babies, this does not happen; the extra fluid is either present in the lungs or it is absorbed very slowly. This makes it difficult for the baby to take in the oxygen properly. To compensate, it breathes faster and harder. Of course, in most cases, this condition resolves by itself within 24 - 72 hours."

Dr.Mathew cautions that these children need to be closely observed and monitored for sometimes, they may need extra oxygen. "Sometimes, even with an oxygen hood, the baby may have problems breathing. In such cases continuous positive airway pressure (CPAP) is sometimes used to keep air flowing through the lungs. In some preterm newborns and in those with central nervous and cardiovascular problems they might require ventilatory support to enable it to breathe normally."

It is usual for most babies to develop jaundice on the 3rd day after birth, reveals Dr.Mathew. This might appear early in babies born to mothers whose blood group is Rh negative or O positive ,or babies who have infection and in preterms. The jaundice lasts for between the 7th to 14th day, particularly if it is a preterm baby. As a normal course, between the 3rd and 7th days, the jaundice progresses, reaches a peak and then
disappears by the 8th day. However, the mother has to be vigilant and seek medical help if the baby has jaundice on the first day within 24 hours of birth or has jaundice persistently beyond 8 days in a term infant or after 14 days in a preterm infant. Both these conditions are abnormal and medical assistance has to be sought particularly if the mothers belong to the Rh -ve and O +ve blood groups.

The child may have a bump on its head, especially if the mother has had a vacuum delivery. The mother should consult the pediatrician if she notices this bump which could in fact contribute to the persistence of jaundice or a sudden rise in its severity. Dr.Mathew explains, "Vacuum delivery is a method of delivery which cuts short the second stage. That is, when the mother is having prolonged labour, the obstetrician goes in for vacuum extraction, following which some babies have a small swelling on the head, known as cephalhematoma. There could be a haematoma which can contribute to
the excess jaundice. That is the bulge, which contains blood and breaks down into the bilirubin which is responsible for the yellow colour in jaundice. The swelling remains for up to 7 - 14 days where the jaundice is because of cephalhematoma." Normally, some babies, because of the prolonged duration inside the birth canal, can have some swelling which resolves in 24 hours.”

Explaining skin appearance of a newborn, Dr.Mathew reveals, "It is not unusual for newborns to have rashes or tiny white marks in newborns. But these usually clear up within a few days of birth. No matter the complexion, or skin colour as determined by genes, some babies may be born with a white, cheesy coating called vernix which actually protects their skin. Some babies could be born with wrinkled skin and some babies, particularly those born prematurely, have a soft, furry appearance due to lanugo, a fine hair that develops while the baby is in the womb.

The umbilical cord usually falls of by itself by the 3rd to 7th day following birth. Do not pull off the cord prematurely as it can cause bleeding. During the time the cord is healing it should be kept clean and dry because it is a portal of entry for any infection. Observe the cord for infection which manifests with redness and tenderness of the skin surrounding it and foul-smelling, yellow discharge. Though infection does not occur frequently, once it occurs, it can spread quickly. Occasionally, the cord may not dry completely and will form a granuloma, a pink scar tissue. This may drain a light yellowish fluid. This condition will disappear on its own in a week's time and will not require anything except keeping it clean, explains Dr.Mathew.

Commonly, most parents tend to overdo things for the new arrival. "It is always better for the baby if it is roomed in with the mother," emphasizes Dr.Mathew. "It has been found that the monitoring of the baby is better; that visual and tactile contact is always preferred for the baby than for the baby to have a cradle. This is good, both for the bonding of the baby with the mother and also for the mother to be able to observe if something is wrong with the baby when she is in close physical contact with it."

There are a few issues which parents, especially mothers, need to keep in mind while taking care of their newborns, explains Dr.Matthew. “Most mothers these days pursue a dual career, one outside home and the other, housekeeping. The American Dietetic Association recommends lactating mothers consume 500 calories more per day than they would have pre pregnancy. Under the circumstances, it is natural for them to be anxious about breast-feeding the baby. So they tend to arrange for all powder milk and most of the times, grandparents, without meaning to do so, aggravate the anxiety in the mothers by attributing a child's cry every time, to its feeling hungry. The milk probably won't fully come in for a day or two following delivery, especially with first-time mothers. But the baby does receive nourishment from the colostrum, a thin, watery precursor to actual breast milk. As your baby suckles, this action triggers hormones to produce milk. Anxiety is a strong, negative influence on breast milk production. Even if the mother has less milk, this is enough for the baby to meet its needs for the first two weeks following birth. By this time, the output of milk increases and this is directly proportional to the amount the baby feeds."

Dr.Matthew continues, “A newborn usually needs a feed every 2 to 3 hours in the first month of life .Feeding the baby must usually be on demand once feeds are established. Each feeding should last no more than 15 to 20 minutes. Human milk will separate when left to stand, with the fat rising to the top. This does not mean it has spoiled. Simply shaking the container gently will restore the milk to a homogeneous consistency.”

Dr.Mathew emphasizes, "It is important for the mother to understand that the baby hardly requires much milk in the initial few days following birth. Also, a lot of people tend to give glucose water to the baby. The requirement of the baby as per the WHO is exclusive breast milk for the first six months of its life and this is sufficient for the baby and its healthy growth. Parents tend to aggravate problems by either giving concentrated glucose solutions or honey and powder milk. An article in a recent AAP News indicates that breast milk is still safe to use after being refrigerated for upto 72 hours. Milk kept at 15 C (59-60 F) - can be kept for 24 hours, if kept at 25 C (79 F) - 4-6 hours ,and if refrigerated at 0-4 C (32-39 F) -it could be kept for 8 days . Frozen milk kept in a
separate door freezer can be stored upto 3 -4 months”.

The mother should consult a pediatrician immediately if the newborn has any respiratory difficulty, crying excessively (high pitched)and displays irritability, refusing to feed, has lethargy, abnormal movements of limbs, excessive salivation, vomiting , gaseous distension of abdomen, is not gaining weight, has bluish discolouration of lips or excessive sweating over forehead while feeding. Failure to pass meconium in 24 hrs and urine within 48 hrs of birth is also considered abnormal, reveals Dr.Matthew.

It is normal for babies to sleep for 12 to 18 hours a day in the period immediately following birth. Mothers should see this as normal for the baby.

Babies' nails are usually soft and pliant; but they can cause injury to them. Newborns do not control their arms, hands and finger movements and may therefore inadvertently claw at their face or poke their eyes. Nails which extend beyond the finger tip should be trimmed using baby nail scissors. It is better to avoid clothing that pulls tightly around the neck, arms or legs .These clothes are not only safety hazards but are uncomfortable. A firm mattress covered with material that can be cleaned easily is best for baby while avoiding infant cushions that have soft fabric coverings. It is dangerous and detrimental to smoke, with a newborn around and must not be allowed.

Over enthusiastic parents apply all kinds of cream, lotion and soap to keep the babies fresh and clean. But these are all not required, emphasizes Dr.Mathew. "They tend to close the normal pores of the skin, though amild baby soap may be used. Babies need to be bathed, but if very frequent it can cause drying of skin .Never leave any baby alone in the bath even for an instant. A cap is very useful in preventing significant heat loss
through the scalp .Again, the trend is for using diapers; these may often irritate the babies' skin and cause rashes if not changed frequently. It is best to replace these with soft cotton cloth. Similarly, care and caution should be exercised when applying too much baby powder to the infant which could be inhaled.

Routine Injection of Vit Kand Immunisation -( BCG , OPV , Hepatitis B )must be initiated at birth prior to discharge from hospital. Hearing Screening, Eye Examination and head ultrasound must be done for all babies who have been ventilated, and in extreme preterms weighing less than 1500 grams. Developmental and Growth Assessment must be done at all newborn visits. The earliest milestone which the newborn displays and which brings joy to all is when he develops social smile meaning visual recognition of mother and smile response by 8 weeks. He is able to follow objects by 3 months and turn his head towards sound by 5 months . Failure to achieve any of the above milestones must be investigated and a paediatrician must be consulted .

Your baby needs lots of love and attention. As parents, if this is your second baby, do involve the older sibling in looking after the new arrival and do not forget to give equal attention. Create a safe environment for your newborn by childproofing your home.


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