The Normal Newborn
After delivery, a member of your midwifery team will visit you and your baby within 1-2 days in the community and will see you there in the first week. A midwife will weight your baby, and assess your baby’s heart, lungs, and the umbilical stump. There are a lot things about newborn babies that can be overwhelming and scary. This helpful Normal Newborn Behaviour Brochure lists many of the common questions that you have and what is not normal. When you home visits are done consider joining New Baby Time.
Routine Newborn Screens
Midwives will ensure that you are offered and receive the routine newborn screens. After six weeks, you and your baby will be discharged from midwifery care and will see a family doctor or a nurse practitioner or visit a walk-in clinic for on-going well baby assessments.
Critical Congenital Heart Disease (CCHD)
The CCHD screen is ideally performed between 24 and 48- hours of age. This screen looks for the rare circumstances where the baby’s heart or the vessels coming out of the heart are not formed correctly. When these conditions occur, surgical correction leads to healthier outcomes for your baby. This test is painless for your baby. It simply uses an oxygen saturation monitor on your baby’s right hand followed by one of your baby’s feet. The oxygen saturation levels need to be in the normal range and similar to each other in both extremities of the baby. As a screen verses a diagnostic test, if your baby does not pass the screen further testing is required.
Ontario Newborn Screen
The Ontario Newborn Screen Newborn screening is done along with the CCHD screen ideally between 24-48 hours of age. This screen looks for rare treatable diseases that usually show no symptoms in the newborn period. Early detection of these diseases through newborn screening prevents serious health problems and can save lives. This screens for 30 treatable diseases. Much like the CCHD screen above, a positive result is not a diagnosis, but an indication for your baby that further testing is needed. This screen involves a obtaining a small amount of blood from your baby’s heal that is used to fill a special absorbent paper. We encourage you to hold and breastfeed your baby while the sample is obtained.
Bilirubin Screening or Testing
Jaundice is the medical term for a yellowish tinge of the skin. The yellow colour is caused by a substance called bilirubin, which is made normally in the body. Bilirubin is formed and produced when red blood cells are broken down. This is a normal occurrence for newborns as their system switches over to life outside the uterus. During this breakdown process, bilirubin is excreted mostly through the liver and out of the body in stool. Some is also excreted through the kidneys and out through urine (causing a brick-dust colour of urine). Under most circumstances, babies do this process without difficulty. Bilirubin levels become high when bilirubin is made faster than it can be removed. Babies with higher than normal blood levels of bilirubin, might appear yellow in colour when bilirubin builds up in the skin. Skin colour alone is not a good indicator of whether or not the jaundice is a problem. Some babies with darker skin may not have visible jaundice even at high blood bilirubin levels. Other babies who appear jaundiced outwardly may have bilirubin levels that are not dangerously elevated. If bilirubin levels become dangerously elevate, it becomes a blood toxin in the baby that can eventually damage the baby’s brain. Symptoms will include sleepiness, poor feeding, lethargy, poor tone. Some risk factors may make your baby more prone to concerning levels of bilirubin:
- Bruising and mild tissue injuries during delivery
- blood group and type differences between you and your baby
- Certain populations (Black, Mediterranean, or Asian populations) are at higher risk for inherited of increase red blood cell breakdown (such as deficiency of an enzyme called glucose-6-phosphate dehydrogenase [G6PD])
- Babies that are born before 38 weeks gestation
- If you have had a previous babe that required treatment for jaundice
- Newborn infection (sepsis)
Even without risk factors, some infants with risk factors have developed concerning bilirubin levels. Canadian Pediatric Society recommends screening (using a bilimeter) or testing of newborns (using a blood test) all newborns when they receive their other screens as above. If your baby is born at Grand River Hospital and has a stay longer than 24-hours, all the above screens will be offered there prior to your discharge. If you have a hospital delivery and you go home before 24-hours or if you have a home birth a member of your midwifery team will discuss screening options and locations with you.
Infant Hearing Program
All newborns in hospital and community settings will be offered universal hearing screening as part of the Infant Hearing Program. Hearing screening identifies infants who should have more in-depth testing for hearing loss as early as possible. Hearing screenings are provided for infants under the age of 2 months.
Two out of 1,000 babies have hearing loss at birth. Two more develop hearing loss by the age of five. These children may hear some sounds but miss others, making it harder to learn speech and language. Early detection and intervention is critical for a child’s language and literacy development.
Screen in Kitchener-Waterloo are done with Erin Oak and the Kids Ability Centre in Waterloo. Screening a baby’s hearing accurately requires special training and equipment. The screen is reliable, quick and gives results right away. It measures the ear’s or brain’s response to soft sounds played in your baby’s ear and, if needed, may use small stickers placed on your baby’s head. The technology used for the hearing screen is safe and will not hurt your baby. The screening is done by two-months of age. If you do not receive an appointment from Erin Oak by the time your baby is one-month old, please contact them to book community hearing screening appointment: 1-877-374-6625 extension 3.
The Ins and Outs of Newborn Care
Input with Breastfeeding
Breastfeeding will occupy much of your time with a new baby. Breastfeeding exclusive breastfeeding is recommended by the World Health Organization as the best nutrition for your baby for the first six-months of age. On-going breastfeeding with other foods has ongoing benefits for your baby in the first two years of life. Many think that breastfeeding is all natural and automatic. Although some natural reflexes are involved with breastfeeding, much of breastfeeding is learned behavious. There is learning for you and learning for your baby. There are terrific community resources available to start this off right. Waterloo Region Public Health has a terrific on-line program to get you started. Also, Breastfeeding Buddies has classes and on-going resources and supports to meet many needs. Helping with and ensuring that breastfeeding is off to a good start will be one of the many focuses of your midwifery community visits.
When to Feed Your Baby
Newborn babies feed frequently often every 2 to 3 hours around the clock. Usually babies will give you cues that they are hungry well before crying and upset. Sometimes upset babies take longer to settle into breastfeeding. A great way to start recognizing your baby’s cues is through bonding and relaxing with your baby skin-to-skin. Going with your infant’s cues is usually enough for providing the right amount of feeding for your baby. When your baby is satisfied with feeding they will give you cues that they are full. In some circumstances such as if your baby was born early, if your baby loses too much weight initially, or if you baby has issues with higher bilirubin, your midwife may recommend a more regimented feeding schedule.
There are a variety of positions for breastfeeding both sitting upright and lying down. The important thing for selecting a position is that you are relaxed and comfortable and you feel well supported especially for your arms and back. Also of importance is that you feel you have control of your baby and your baby is close to you.
Learning how to get your baby on the breast with a good latch has benefits both for you and your baby. For you a shallow latch will be pinching and painful to you. It may cause nipple damage and other complications to your breasts. A deeper latch also gives your baby more milk release. Win! Win! To help with a good latch wait for a big wide mouth and swoop your baby in with chin up. Only a little areola of the breast is visible. If a pinching feeling persists, ensure that the baby’s lower jaw is down and the bottom lip is out. If not, this can be corrected with gentle pressure on the baby’s lower jaw.
Sometimes the baby gets angry and frustrated and will baby on and off of the breast looking for milk. This is very common the night before the full milk comes in where the baby just seems unsettled. This behaviour can cause nipple pain as well. To help this, hand express to get colostrum to the surface and then latch. During the feed use breast compressions to increase the milk flow to your baby.
Good Drinking vs the Chin Wiggles
When babies are drinking well, you will feel pulling at your breast without pinching, your baby will be relaxed with deep jaw movements and there will be short pauses with swallows. Sometimes babies start out with a good latch and drinking well, but then get sleepy and slip more onto the nipple at the end of the feed. The sucking often becomes more of a chin wiggle rather than a full draw and can be more painful. This is a non-nutritive suck or flutter suck. If this kind of sucking is pinching your nipple, break the latch. If the baby wakens and roots actively, burp the baby, change the baby’s diaper if needed then offer the other breast. To keep the baby going with nutritive feeding, you can try breast compressions to stimulate further drinking.
Input with Supplementation
In some cases, newborns may need to receive breast milk indirectly or may need to have a part of their feed supplemented with formula. This can happen either if they are able to be at the breast or if they require more calories or glucose than from the breast alone. In the first few days the breasts produce colostrum which is the best for your baby. Because colostrum comes out in small amounts, getting colostrum using a breast pump is difficult and frustrating. The easiest way to get colostrum out in the first few days is by hand expression. To avoid your baby becoming confused by the feel of an artificial nipple verses how to get onto a breast, a good way to provide supplement in the first few days is by a small cup or a spoon. As the amounts needed for supplementation will depend on your baby’s size and age, a lactation specialist or a midwifery team member will give you specific guidance on feed frequency and volumes each day.
Input with Formula
If your infant requires exclusive formula feeding or you choose this option, please read the Formula Feeding Guide. For newborns, the regular cow’s milk ready-made formula that is labelled for the 0-3 month age group recommended. Powdered formula is not recommended for newborns.
Output the Other End of Things
One of the best indications of how much you baby takes in is how much and what comes out the other end. When your midwife visits, you will be asked about output. The amounts your baby takes in with each feed and how big your baby’s stomach is increases each day especially in the first week. Conversely, how much comes out each day will increase as well. Please refer to the Best Start chart for what to expect. Wet diapers are very subtle to see at first (unless the baby goes on you). What can be helpful is a diaper that has a colour indicator strip on it. These usually change from a yellow colour to a blue colour. Any little area on the strip that is blue counts as a wet diaper. Usually wet diapers a clear to pale yellow in colour. Sometimes in the first week a baby may have an orange or brick-dust colour wet diaper. This is not blood. The orange colour is from urate crystals and are usually a results of concentrated urine the normal processing of bilirubin. This colour of urine is normal in the first few days and does count as a wet diaper.
Infant stools change a lot in the first week in colour and consistency. The initial stools are called meconium. When your baby was inside still, they were fed through the umbilical cord. What is in your baby’s intestines at birth is a combination of dried blood and mucous. The result is a dark brown/black sticky gooey poop. Sometimes the stickiness makes the initial diaper area difficult to clean. Using a gentle oil such as an olive oil or coconut oil on the diaper area before diapering can help to make for faster clean-ups. When the colostrum starts to go through the baby’s system the stools start to change colour to a fudge brown and starts to become less sticky. This is called a transitional stool and is a good sign that you baby has had good colostrum. When the milk first comes in the stools will change in colour ranging from dark green to yellow and seedy to some orange. All these are normal stools and the colour will have to do with how much fat is in the milk at the feed before. What it is not normal for your newborn to have whitish or pale-coloured stools. Please refer to infant stool colour card in your blue folder to monitor your baby for this issue in the first two-months of age.
Other Infant Stuff
When babies are inside and for some time after birth some of the baby’s systems are do not yet function. When the baby is inside pores, sweat glands, and oil glands are not yet functioning. After birth they slowing begin to function. What may result is a sudden break-out of newborn acne. This can occur on the baby’s face, chest, back, and scalp. Newborn acne is normal and a sign that the pore and oil glands are now functioning. Sweat glands can take a bit longer to develop so newborns can get both cold and overheated. Generally think to put one extra layer on your baby than you have on yourself (if your baby is not skin-to-skin with you). The other gland that does not function fully at birth is the lacrimal gland. The lacrimal gland is the gland on the inside of our upper eyelid that produces tears. This gland will start to produce tears sometime in the first few months of age. You will know when this occurs Adjacent to this the tear ducts in the top and bottom corners of you baby’s eyes close to the nose is similarly slow to fully function. The combination of these two things mean it is very common for newborn babies to get build-up in the corner of their eyes. This is a normal finding and not a sign of infection. Keep the eye area clean with a moist clean washcloth.
Bathing Your Baby
Your newborn does not need a full bath very often. Possibly once or twice per week. Ensure all your supplies are within reach. To prevent skin dryness, moisturize you baby’s skin after a bath with simple oils such as coconut oil, olive oil, or shea butter. Your baby will need regular washing of the diaper area your baby stools. For boys remember to clean all the fold including the wrinkles on the testes. Do not try to retract the hood of the penis for cleaning. Just clean it on the outside. For girls wipe always from front to back. Clean any obvious stool out of the folds. Girls have natural white discharge which is normal and protective. This does not need to be wiped away unless it contains stool.