Guidelines for Baby Care

PARENTING AN INFANT:
Welcoming a new baby into your family is a most exciting, wonderful and life altering event. It is not an easy task to look after a newborn and young infant and parents must remember to be very patient with themselves. Please make sure you get as much sleep as possible. Look after yourselves as well as possible – that will benefit baby as well as mom and dad.
As your child’s paediatrician it is my pleasure and responsibility to help you navigate through this often challenging time. Make sure you ask all your questions during your office visits and, as needed, on the telephone. It is my job to provide you with information and advice, and yours to advocate on behalf of your child to get the information you need. Above all, trust your intuition.

And one more piece of advice: starting out with a new baby is akin to “being thrown in at the deep end” — it usually gets much, much easier and less exhausting by the time the baby is about four months old. You will get there ;-))

CORD AND NAVEL:
The baby’s cord will fall off by itself within the first three weeks after birth. If the cord is pulled off accidentally a small amount of bleeding may occur, but will stop when pressure (with a cotton ball) is applied for a few minutes.
Alcohol (rubbing alcohol, isopropyl alcohol) may be applied to the cord stump and can be used to clean and dry the groove around the cord when applied with a q-tip at each diaper-change and whenever the cord has become wet (while some parents report being told in the hospital not to clean the cord stump with rubbing alcohol, we have found that this is a useful procedure to decrease bacterial growth in that area – this has also been reported in evidence-based clinical studies). Keeping the diapers pinned below the navel will help the cord stump dry. Do not let the folded diaper rub against the cord stump. It is often better to fold the diaper out rather than in, to avoid contact between the baby’s skin and the plastic on the outside of the diaper).

JAUNDICE:
Many babies turn slightly – or even significantly – jaundiced, which means that their skin and often the white in their eyes, turns yellow. This is due to the surplus of blood that was needed while the baby was still in the uterus, being broken down. The red substance in our red blood cells, hemoglobin, is broken down and metabolized in the liver to bile pigments. This will sometimes challenge the capacity of the baby’s liver in the first few days and the baby might appear jaundiced. This usually peaks on day 3 and subsides, sometimes taking several weeks, thereafter. If the bilirubin count is too high, some babies require phototherapy (light therapy) in hospital during the first few days. Once you have gone home with the baby, you should not observe a significant worsening of the jaundice; if you do, please be in touch with us right away. Contrary to common advice, babies should never be exposed to sun-light (“put into the sun”) to decrease their jaundice.

BOWELS:
Many babies turn red in the face and grunt when they have a bowel movement. They are not constipated as long as their stools are soft and contain no blood. Do not worry about the colour of the bowel movement unless it is bloody (normally, green bile is excreted into the gut and stains bowel movements green if the passage is fast; otherwise they are yellow/brown because intestinal bacteria had enough time to change the green bile into a brown pigment) – green bowel movements are not a problem by themselves! Breastfed babies most often have soft, golden coloured bowel movements. The number of bowel movements varies with each baby. Some breastfed babies will have a bowel movement at least after each feeding; others as infrequently as once a week (and very rarely even less frequently).

BATHING:
Traditionally, babies are given sponge baths at first and once the cord has come off (and, if a circumcision was performed, the wound has healed) they may have a full bath in warm water. Please do not worry that water getting into the ears will cause an ear infection – it does not. Let nature keep your baby’s ears, nose and mouth clean. There is no need for special cleaning of ear and nose with cotton swabs and you might in fact push some earwax into the canal causing obstruction with impacted wax. If dry earwax is a problem several drops of extra virgin olive oil (not mineral oil, as it contains traces of nickel that may cause a rash in susceptible infants) applied with a medicine dropper into each ear every other day will loosen the wax and allow drainage (do not expect to see any wax coming out as the amounts are usually very small).
Your baby’s body may be washed with a soft cloth and a mild soap (e.g. unscented Baby Dove, Baby’s Own, Aveeno, Neutrogena), then rinsed with warm water and dried with a soft towel. Be sure to wash and dry between the skin creases. It is best to avoid soap for washing the face. Your baby’s head is best kept clean by washing with a mild soap and thoroughly rinsing with clean water. The “soft spot” on the infant’s head cannot be damaged by normal handling.
Many babies will develop cradle cap, a condition caused by dead skin staying attached to the surface. We recommend that you massage olive oil into the skin one hour before the daily bath and – using a tooth-brush, not a hairbrush (which is too soft) – gently but firmly remove as much of the dead skin just before the bath as can be easily removed. During the bath Baby Shampoo (such as Johnson & Johnson’s) may be used to remove the oil and residual skin flakes.
If your baby boy was not circumcised, the foreskin must not be retracted as this could break down adhesions between penis and foreskin that are normally present in younger children and tend to disappear spontaneously by the time the child is a teenager. Pulling the foreskin back too early could cause bleeding, inflammation and new adhesions. There is no hygienic reason to pull back the foreskin – the accumulated white material, called “smegma” actually kills bacteria and prevents inflammation.
Never leave your baby unattended in the bath or on the change table. Exercise extreme caution when adding hot water to the baby’s bath once the infant is already in the tub!

SLEEPING:
While in hospital, babies have their own bassinet which may be wheeled into the mother’s room (“rooming-in”); if, particularly during the first night, the mother is exhausted or the baby needs to be observed more carefully (breathing problems due to increased fluid in the lungs, so-called ”transient tachypnea of the newborn”) the baby may stay in the nursery. The head of the bassinet may be raised. Babies do not need pillows; they can in fact be dangerous. A flat, firm mattress is best. Babies tend to sleep better if it is possible for them to have their own bed; parents sleep better if the baby is in a separate room (although this is not always possible). Having the baby sleep close to the parents for the first six months is entirely acceptable: do not worry about “spoiling” the baby.
Until babies roll over themselves, they should sleep on their back. Studies have shown a clinically significant decrease in the incidence of sudden infant death syndrome if children sleep on their back. The American Academy of Pediatrics currently recommends that babies sleep in their own crib in their mother’s room for the first six months and then be moved into their own room. Co-sleeping is very commonly practiced but is associated with safety concerns and thus not recommended.
The temperature in the baby’s bedroom should be the same as the temperature of the household (i.e. approximately 70ºF i.e. 21ºC). Everyday household sounds do not bother a baby. There is usually no need to tiptoe in front of the infant’s room.
Many newborn babies tend to sleep a lot. There is no need to worry when they sleep past their feeding time at night; during the day it makes sense to wake the baby after three to four hours to help establish a day/night rhythm. If the baby sleeps in a bedroom illuminated by a bright night-light the melatonin-producing pineal gland responsible for regulation of the sleep-wake-cycle may not be able to regulate sleep patterns properly. The sleeping/eating routine should be relaxed and convenient for both parents and baby.

RASHES:
Many babies develop small white pimples on their face and nose called “milia”. They do not require treatment and disappear spontaneously over the first few months. Rashes on the face are very common and are often small red pimples called miliaria rubra or, much rarer, true newborn acne; they tend to worsen towards the sixth week of life and then disappear spontaneously without treatment. They are usually beginning to improve by eight weeks.
Diaper rashes are best avoided by frequent changing of baby’s diapers and washing the skin with olive oil (not perfumed baby oil!) rather than with soap and water. Cloth diapers should be laundered with bleach free and fragrance free detergent and should be rinsed well. We recommend that you try Liquid Ivory Snow as it leaves no residue (like regular Ivory Snow®) or Zero®. A diaper service may be very convenient. Do not use fabric softeners.
Diaper area creams should be used to prevent rashes. Vaseline is useful for the first few days, thereafter it tends to cause/aggravate rashes in most infants. Zinc oxide based products (15% zinc oxide products include Penaten®, Zincofax® and Sudocrem®) or higher concentrated 40% Special Care Zincofax® or Desitin® help to protect the skin against chemical burns caused by urine and stool held against the skin by the diaper. Powders should generally be avoided as they may be inhaled by the infant and lead to problems in the lungs. Used very sparingly cornstarch can be useful if it is carefully distributed so that it does not cake in skin folds between skin layers causing irritation and abrasions. It may be prudent to restrict the use of “diaper wipes” to specific circumstances (e.g. going out): they remove the protective fat film covering normal skin and expose the area to further damage. Avoid perfumed diaper wipes altogether. Using olive oil or coconut oil to clean the area is often very helpful.

CLOTHING:
Well-meaning parents often overdress their babies. A useful general rule is that a baby should have one extra layer (of clothing or blanket) compared to an adult in the same environment. If a baby has sensitive skin clothes worn next to the skin made of 100% cotton are preferable. Some babies are allergic to nickel contained in metal snaps and develop a characteristic rash where the snaps touch the skin. Nickel is also contained in mineral oil and hence skin contact with mineral oil should best be avoided.

CRYING:
Babies have many different reasons for crying; hunger is just one of them. Do not despair when a baby has been fed and is dry and safe and still appears miserable and cries. Sometimes you will not be able to calm the baby down, no matter what you do and how hard you try. This may be completely normal – or it may not! If the crying is persistent and/or unusual for the infant, have the child seen by your paediatrician! It is always best to err on the careful side, particularly if the baby does not calm down in the parent’s arms when carried or is lethargic or feeding poorly.
Many children have some gastro-esophageal reflux (GER) and the acid refluxing into the esophagus (food pipe) can cause irritation and discomfort. This is often outgrown by the time children are around four months old, although in some infants it takes until their second birthday. As long as the weight gain is good, we are much less concerned about GER than when the baby fails to gain weight and is diagnosed with gastro-esophageal reflux disease (GERD).
Many children have a very active feeding instinct and will continue to want to eat even when the stomach is full; the feedback loop from the stomach to the brain is immature and the baby does not understand that further food intake is not warranted at that time. This feed-back loop from the stomach (telling the brain “I am full!” often matures around four months of age.)Often babies will swallow a lot of air in between feedings (aerophagia), which makes them feel uncomfortable. Many children will over-feed and then self-correct by vomiting excess food. As long as their weight gain is very good, we are much less concerned about this kind of vomiting.
It is not harmful in and by itself for a baby to cry: sometimes babies will need to be given a chance to “cry themselves to sleep” and should not be interrupted – if the reason for the crying is being overtired or over-stimulated, the baby might fall asleep when left alone. Do not worry that picking up a crying infant will “spoil the baby”. Trust your intuition and do not feel that you need to do anything that is “counter-intuitive” for you.

FEEDING:
Although books can prepare you for breast feeding, real “learning” occurs “on the job” with your baby. Please do not hesitate to ask your nurse or physician for help if you need assistance. Getting the baby to latch on properly is the key issue. If, after the first three days, the baby is wetting four or five diapers a day, hydration is adequate. The inside of the mouth should always (i.e. not just immediately after a feeding) feel moist in a well-hydrated baby.
While it is reasonable to aim for a feeding schedule of approximately every three to four hours (from beginning to beginning of a feed), considerable flexibility is advisable. Any rigid approach will not be helpful. Do not expect your baby to be completely regular; particularly in the first few months the amount of food taken and the timing between feeds will vary greatly. Although feeding on demand (feeding whenever the baby wants to suck) is fine for the baby it is often unnecessarily exhausting for the mother; it is a great way to start for the first few weeks, but should not need to continue beyond a month of age when a certain amount of regulation of the feeding practice can be expected.
Pumped breast milk can be kept at room temperature for 4 hours, in the refrigerator at 15ºC for 24 hrs and if immediately frozen (e.g. in plastic bottles after pumping) it can be kept in the freezer (not in the freezer door) for 1-2 months. The milk should be thawed thoroughly under warm water or in a bottle warmer and used immediately.
If you should decide to use a bottle (either to feed formula only, or to supplement breast-feeding, or to feed the occasional bottle when you want to leave the baby with another person) you can choose between glass or plastic bottles that require sterilization, and bottles that use plastic bags that you do not have to sterilize. When using any plastic products you will want to use products that are Bisphenol A – free.
Nipples should be sterilized by boiling in water for two minutes every day. The opening in the nipple should allow the liquid to drip out slowly when the bottle is held upside down (1 drop/sec). Check the milk temperature on the inner surface of your wrist before feeding. It is best not to use a microwave oven to warm up formula as this can heat up the liquid heterogeneously with a much higher core temperature that can cause injury to the infant. If you do use the microwave, be sure to shake the bottle well after heating to ensure a consistent temperature throughout the liquid.
The standard cow-milk based formulas (Enfamil A Plus®, Similac Advance®, Goodstart®) are usually very well tolerated and equally recommendable. Some parents will prefer soya based formulas (Similac® Isomil) but concerns have been raised about their phyto-estrogen content.
If you breast-feed your baby, Vitamin D (400 I.U./day, easiest to use is 1 drop of Baby Ddrops containing 400 I.U./drop) – alternatively, but more difficult to administer, 1 ml of D-vi-sol or Tri-vi-sol or Jamieson’s Infant Vitamins) should be administered with a dropper directly into the baby’s mouth daily starting no later than at two weeks of age and continuing until you stop breastfeeding completely. This will prevent rickets due to Vitamin D deficiency. Formula contains sufficient amounts of Vitamin D, so no extra vitamins need to be given to a baby fed exclusively infant formula (though it will not harm the infant to give the extra 400 IU Vitamin D). Mothers should be taking between 1000 and 2000 I.U. of Vitamin D a day while breastfeeding (Materna® contains only 400 I.U. /day and an additional 1000 I.U. a day should be taken).
Fluoride supplementation is not recommended in Toronto as the city’s water supply is fluoridated and traces reach the baby providing sufficient fluoride intake even for breast-fed babies. Our Dental Associations have stressed recently that this recommendation applies for households using bottled water (that contains very little or no fluoride) as well. However, when it comes to using tooth paste, new recommendations now advise that a small amount of fluoridated tooth-paste may be used for children as young as one year despite the fact that much of the tooth-paste will be swallowed by the child. Even very young children may tolerate the us of an electrical tooth-brush surprisingly well – and the electrical tooth-brush cleans teeth more effectively than a traditional brush.

GENERAL COMMENTS:
Babies normally sneeze a lot – this is an effective way to clear mucus from their nose. Their airways are very narrow and a small amount of swelling of the lining of the nose due to trivial viral illnesses or to an allergen (ingested or breathed in) quickly results in a “stuffy nose”. This is not necessarily a sign of a significant allergy and may be entirely normal, particularly in two-month-old babies. Babies often breathe irregularly and noisily. Hiccups are common, particularly around feeding time. They are harmless and require no treatment. Trembling of arms, legs and chin is common in babies. This may be very noticeable when the baby is undressed for the bath or while falling asleep. Many newborns have swollen breasts. This is due to the effect of maternal female hormones and will usually disappear with time. Newborn girls sometimes have a whitish or even bloody vaginal discharge that goes away without treatment.
Sucking is important for a newborn baby: sometimes a soother (pacifier) will be helpful in babies with a very strong desire to suck; although soothers do not cause harm it is better to use them only after breast feeding has been well established. The Kip, Gerber or Nuk one piece orthodontic pacifiers are safest but rather large. If a three piece soother is used, make sure to replace it well before it comes apart. Never attach anything to a string around the baby’s neck (danger of strangulation).
Baby’s fingernails are best kept short to avoid scratching their delicate skin; this is best done with small cuticle scissors while the baby is relaxed or asleep.
Due to their softness, we do not recommend filing or biting infants’ nails. We do not recommend use of a nail clipper as the cutting edge is often difficult to determine and injury to the infant’s fingertip may result.
It is quite common for a baby’s eyes to appear crossed until six months of age. Thereafter babies can focus quite well and should no longer have crossed or wandering eyes. Please tell the physician if you notice this after six months of age.
If you have a baby boy, make sure you can observe a good and strong urine stream e.g. during diaper changes as the baby passes urine. If not, notify your doctor, as this could be a sign of an obstruction to the urine flow (in particular due to posterior urethral valves).

TELEVISION:
I agree with the recommendation of the American Academy of Pediatrics that infants and young children under the age of two years must not be exposed to any television or screen time, including TV as a background noise.

SAFETY:
Safety is important for babies and children of all ages. Whenever taking a baby in the car use an infant car seat as specified by the manufacturer. Remember that the majority of accidents happen when driving short distances. Always attach shoulder straps to head supports as per manufacturer’s specifications.
Toys should be checked for sharp or pointed edges as well as any loose parts that a child could swallow or inhale. Be sure that the distance between the bars of the crib does not allow the child’s head to pass between them.
Never leave plastic bags within children’s reach. Balloons can be dangerous: in an attempt to blow them up balloons can be inhaled and cause airway obstruction.
A good baby-sitter will give you the opportunity to leave home without your infant. It is wise to check on the references before hiring the babysitter and to be sure that the sitter is the kind of person you feel comfortable with leaving with your child.
Beware of falls (from tables, chairs, beds, sofas, stairs), hot items (tea, coffee, boiling water, pots and pans on the stove) and dangerous ingestants (medications, detergents, paint thinners such as turpentine).
If your child swallows a poisonous substance, call the Poison Control Centre at The Hospital for Sick Children for advice. Their telephone number is (416) 813-5900.
Set the hot water temperature in your house at a temperature that will not cause scalding if a child inadvertently turns on the hot water.
Install smoke and carbon monoxide detectors. Check their function and batteries regularly.