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Caring for your Baby

For your consideration

Making informed decisions is an important parental responsibility. Many of these occur within the first 48 hours. The following information may help you to make some of these decisions.

Breast milk versus formula feeding

Feeding is one of your baby’s most pleasant and important experiences. One of your first choices is the method you will use to feed your baby. Breast feeding (nursing) provides the best nutrition for your baby (nature knows best), and mothers feel a special closeness with their newborn while nursing. Breast milk also has antibodies which help protect the baby against infection. For mothers who cannot breastfeed due to a medical condition or who simply wish to bottle feed, a number of perfectly good formulas are available. It is important to nurse or feed iron-fortified formula for the first 12 months. Nature designed cow’s milk for calves, not for your baby.

We recommend “demand feeding,” meaning that you feed the baby whenever he/she appears hungry. This helps establish communication between you and your baby, and avoids periods of hunger. Remember that not all crying indicates hunger. If it has been less than 2 hours since your baby’s last feeding, look for another reason for the crying. Your baby does not need anything other than breast milk or formula for the first 4 – 6 months. Do not begin solid foods too early. Babies cannot properly digest many of the foods that we eat. If solid foods are started too early, there is a higher chance of food allergies. We will discuss when and how to add new foods at your baby’s regular checkups.

Breast-Feeding Essentials

What is good about breast-feeding?

Babies who are breast-fed have fewer infections and allergies during the first year of life than babies who are fed formula. Breast milk is also inexpensive and served at the perfect temperature. Breast-feeding becomes especially convenient when a mother is traveling with her baby. Overall, breast milk is nature’s best food for young babies. How often should I breast-feed my baby?

The baby should nurse for the first time in the delivery room. The second feeding will usually be 4 to 6 hours later, after he awakens from a deep sleep. Until your milk supply is well established (usually 4 weeks), nurse your baby whenever he cries or seems hungry (demand feeding). During the first few weeks, babies can receive enough milk by nursing every 1 ½ to 3 hours. If your baby cries and less than 2 hours have passed, he can be rocked or carried in a front pack. However, if he is hungry, feed him. Waiting more than 2-and-1/2 hours can lead to swollen breasts (engorgement), which decreases milk production. (Feeding less frequently is OK at night, but no more than 5 hours should pass between feedings.)

Your baby will not gain enough weight unless he nurses 8 or more times per day at first. The risks of continuing to nurse at short intervals (more often than every 1 and ½ hours) are that “grazing” will become a habit, your baby won’t be able to sleep through the night, and you won’t have much free time.

How long should each feeding last?

During the first week, bring in your full milk supply by offering both breasts with each feeding. Try 10 minutes on the first breast and as long as your baby wants on the second breast (at least 10 minutes). Alternate the breast you start with at each feeding. You may need to stimulate your baby to take the second breast.

After your milk supply has come in (by day 8 at the latest), encourage your baby to nurse as long as she wants to on the first breast (up to 20 minutes). This is so your baby can get the high-fat, calorie-rich hind milk. You can tell your baby has finished the first breast when the sucking slows down and your breast becomes soft. Then offer the second breast if your baby is interested. Alternate the breast you start with at each feeding.

How do I know that my baby is getting enough milk?

In the first couple of weeks, if your baby has 3 to 4 good-sized bowel movements per day and 6 or more wet diapers per day, he is getting a good supply of breast milk. (Infrequent bowel movements are not normally seen before a baby is 1 month old.) Also, most babies will act satisfied after completing a feeding.

Your baby should be back to birth weight by 10 to 14 days of age if breast-feeding is going well. Therefore, the 2-week checkup by your baby’s health care provider is very important.

The letdown reflex is another sign that you are making enough milk.

What is the letdown reflex?

A letdown reflex develops after 2 to 3 weeks of nursing. It is when you feel tingling in your breast or have milk leak out just before feeding (or when you are thinking about feeding). It also happens to the opposite breast while your baby is nursing.

Letdown is enhanced by getting good sleep, drinking fluids, having a relaxed environment, and reducing stress (such as not expecting much housework to get done). If your letdown reflex is not present yet, take extra naps and ask your family or friends for more help. Also consider calling the local chapter of La Leche League, a support group for nursing mothers.

Do I need to give my baby an extra bottle?

Do not give your baby any routine bottles during the first 4 weeks after birth because this is when you establish your milk supply. Good breast milk production depends on frequent emptying of your breasts. Extra bottles take away from sucking time on the breast. If your baby is not gaining weight well, see your health care provider or a lactation nurse.

After your baby is 4 weeks old and nursing is well established, you should offer your baby a bottle of pumped milk or 1 ounce of formula once a day so that he can get used to a bottle and the artificial nipple. Once your baby accepts bottle feedings, you can occasionally leave your baby with a sitter and go out for the evening or return to work outside the home. You can use pumped breast milk that has been refrigerated or frozen.

Does my baby need extra water?

Babies do not usually need extra water. Even when they have a fever or the weather is hot and dry, breast milk provides enough water.

What should I do if my breasts are swollen or engorged?

If your breasts are badly swollen (engorged), it can decrease your milk production. To prevent engorgement, nurse your baby more often. Also, compress the area around the nipple (the areola) with your fingers at the start of each feeding to soften the areola. For milk release, your baby must be able to grip and suck on the areola as well as the nipple. Every time you miss a feeding (for example, if you return to work outside the home), pump your breasts. Also, whenever your breasts hurt and you are unable to feed your baby, pump your breasts until they are soft. If you don’t relieve engorgement, your milk supply can dry up in 2 to 3 days.

How do I pump and use pumped breast milk?

If you want to pump your breasts, you can use a breast pump. Ask your health care provider which breast pump he or she recommends. A breast pump is usually necessary, but sometimes pumping can be done by hand. Ask your provider about using the Marmet technique to pump by hand.

Pumped breast milk can be stored for 2 to 3 days in a refrigerator and up to 6 months in a freezer. To thaw frozen breast milk, put the container of breast milk in the refrigerator (it will take a few hours to thaw) or place it in a container of warm water until it has warmed up to the temperature your baby prefers.

What should I do if I have sore nipples?

Clean a sore nipple with water after each feeding. Do not use soap or alcohol because they remove natural oils. At the end of each feeding, the nipple can be coated with some breast milk to keep it lubricated. For cracked nipples, apply 100% lanolin after feedings. You can buy lanolin without a prescription. Try to keep the nipples dry with loose clothing, air exposure, and nursing pads.

Sore nipples usually are caused by the baby not latching on properly or a feeding position that causes the nipple to be rubbed or pressed incorrectly. When feeding, position your baby so that he directly faces the nipple without turning his neck. At the start of the feeding, hold your breast and squeeze the nipple and areola between your thumb and index finger so that your baby can latch on easily. Throughout the feeding, hold your breast from below so the nipple and areola aren’t pulled out of your baby’s mouth by the weight of the breast. Slightly rotate your baby’s body so that his mouth applies pressure to slightly different parts of the areola and nipple at each feeding.

Start your feedings on the side that is not sore. If one nipple is extremely sore, temporarily limit feedings to 10 minutes on that side. The pain will not improve, however, until your baby starts to correctly latch on and is correctly positioned during feeding.

Does my baby need vitamins or fluoride?

Breast milk contains all the necessary vitamins and minerals except vitamin D and fluoride. Starting at 2 months old, you need to give your baby vitamin D (200 IU per day). Until separate Vitamin D drops become available, use Vitamin ADC drops (0.5 ml per day). You can get vitamin drops without a prescription at your supermarket or pharmacy.

Starting at 6 months, children who are breast-feeding and not drinking any water (with fluoride) need 0.25 mg of fluoride each day to prevent tooth decay. Talk to your health care provider to get a prescription for fluoride drops.

Do I need to take vitamins?

You can take a multivitamin tablet daily if you are not following a well-balanced diet. You especially need 400 units of vitamin D and 1200 mg of both calcium and phosphorus per day. A quart of milk (or its equivalent in cheese or yogurt) can also meet this requirement.

Should I avoid taking medicine?

Almost any drug a breast-feeding mother takes will be transferred in small amounts to her breast milk. Therefore, try to avoid any medicine that is not essential, just as you did during pregnancy.

Some commonly used medicines that are safe for you to take while nursing are acetaminophen, ibuprofen, penicillins, erythromycin, cephalosporins, stool softeners, antihistamines, cough drops, nosedrops, eyedrops, and skin creams. Most nonprescription cold and cough medicines are fine, but avoid pseudoephedrine because it can reduce milk production in some mothers. Sulfa drugs can be taken if your baby is more than 4 weeks old AND does not have jaundice. Avoid aspirin because of a small risk for Reye’s syndrome. Talk to your health care provider about all other drugs. Take drugs that are not harmful immediately after you breast-feed your child so that the level of medicine in the breast milk at the time of the next feeding is low.

Drinking a lot of caffeine-containing beverages or herbal teas, or smoking cigarettes, can cause restlessness, crying, even diarrhea. Alcohol can cause drowsiness, so limit yourself to 1 beer or glass of wine per day. Diarrhea in the baby can also be caused by some laxatives. Used in moderation, these products should not cause any symptoms. Foods in the mother’s diet (such as chocolate) do not have a significant effect on the baby.

Some of the dangerous drugs that can harm your baby are tetracyclines, chloramphenicol, antithyroid drugs, anticancer drugs, or any radioactive substance. Women who must take these drugs should not be breast-feeding or should request a safer form of treatment. Another group of drugs that should be avoided because they can suppress milk production are ergotamines (for migraine), birth control pills with a high estrogen content (most birth control pills are OK), vitamin B6 (pyridoxine) in large doses, and many antidepressants.

Do I need to burp my baby?

Burping is optional. Its only benefit is to decrease spitting up. Air in the stomach does not cause pain. If you burp your baby, burping 2 times during a feeding and for about a minute is plenty. Burp your baby when switching from the first breast to the second and at the end of the feeding.

When can my baby start using a cup?

Introduce your child to a cup at approximately 6 months of age. Total weaning to a cup will probably occur somewhere between 9 and 18 months of age, depending on your baby’s individual preference. If you stop breast-feeding before 9 months of age, switch to bottle feeding first. If you stop breast-feeding after 9 months of age, you may be able to go directly to cup feeding.

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Formula (Bottle) Feeding

Should I use formula?

Breast milk is best for babies, but breast-feeding isn’t always possible. You will need to use a baby formula if:

If you want to breast-feed but you think you are not making enough milk, don’t stop breast-feeding. Talk to your health care provider or lactation nurse before you stop. Any bottle feeding, before breast-feeding has been well established, could reduce your supply of breast milk and make it difficult to continue breast-feeding.

What type of formula should I use?

If your child is less than 1 year old, discuss which formula to use with your health care provider.

Baby formulas are designed to give your baby all known essential nutrients in their proper amounts. Most formulas are made from cow’s milk. A few are made from soybeans. Soy formula is used for babies who may be allergic to or have difficulty digesting the type of protein in cow’s milk. The American Academy of Pediatrics recommends you use iron-fortified (not low-iron) formula to prevent anemia.

Most formulas are available in three forms: powder, ready-to-serve liquid, and concentrated liquid. Powder and ready-to-serve liquid are best if you are using it to supplement breast milk. You must mix concentrated liquid before using. It forces you to prepare 26 ounces at a time. Powder and concentrated liquid formulas are less expensive per feeding than ready-to-serve formulas.

When can I give my baby regular milk?

Regular, whole cow’s milk should not be given to babies before 12 months of age. This is due to increased risks such as iron deficiency anemia and allergies. Skim or low-fat milk should not be given to babies before they are 2 years old because the fat in whole milk is needed for rapid brain growth.

How do I prepare formula?

Mix concentrated liquid formula with water in a ratio of one to one. Mix each level scoop of powdered formula with 2 ounces of water. Never make the formula for your baby more concentrated by adding extra concentrated liquid or extra powder. Never dilute the formula by adding extra water. Careful measuring and mixing ensure that your baby receives the proper mix of formula.

Do I need to boil the water first?

Most city water supplies are quite safe. If you make one bottle at a time, you don’t need to use boiled water. When using tap water for preparing formula, use only water from the cold water tap. Let the water run for 2 minutes before you use it. (Old water pipes may contain lead-based solder and lead dissolves more in warm water or standing water.) Fresh, cold water is safe. After you prepare the formula with the cold water, you can heat the bottle to the right temperature. Ask your health care provider if you are not sure whether your water supply is safe for your baby.

If you have well water, you need to boil your water for 10 minutes (plus 1 minute for each 1000 feet of elevation above sea level) or use distilled water until your child is 6 months old.

If you prefer to prepare a batch of formula, you must use boiled or distilled water and closely follow the directions printed on the side of the formula can. This prepared formula should be stored in the refrigerator and must be used within 48 hours.

What temperature does the formula need to be?

In the summertime, many children prefer cold formula. In the wintertime, most prefer warm formula. By trying formula at various temperatures you can probably find out what your child prefers. If you do warm the formula, check the temperature of the formula before you give it to your baby. If it is too hot it will burn your baby’s mouth. Be especially careful if you heat the formula in a microwave because the formula can get too hot very quickly.

How often should I feed my baby?

Your health care provider will tell you when and how often to feed your baby. In general, your baby will probably need:

If your baby is not hungry at some feedings, increase the time between feedings.

How much formula should I give my baby?

Newborns usually start with 1 ounce per feeding, but by 7 days they can take 3 ounces. The amount of formula that most babies take per feeding (in ounces) can be calculated by dividing your baby’s weight (in pounds) in half. For example, if your baby weighs 8 pounds, your baby will probably drink 4 ounces of formula per feeding. No baby should drink more than 32 ounces of formula a day. If your baby needs more than 32 ounces and is not overweight, consider starting solid foods. Overfeeding can cause vomiting, diarrhea, or excessive weight gain.

How should I hold the baby during feedings?

Feeding should be a relaxing time—a time for you to provide both food and comfort for your baby. Make sure that both you and the baby are comfortable:

How long should I feed my baby?

Gently remove the bottle from time to time to let your baby rest. A feeding shouldn’t take more than 20 minutes. If it does, you are overfeeding your baby or the nipple is clogged. A clean nipple should drip about 1 drop per second when the bottle of formula is turned upside-down.

Do I need to burp my baby?

Burping is optional. It doesn’t decrease crying. Burping helps your baby spit up less. Air in the stomach does not cause pain. If you burp your baby, be sure to wait until your baby reaches a natural pause in the feeding process. Burping two times during feeding and for about a minute is plenty. More burping may be needed if your baby spits up a lot.

How long can I store formula?

Prepared formula should be stored in the refrigerator. It must be used within 48 hours. Prepared formula left at room temperature for more than 1 hour should be thrown away. At the end of each feeding, throw away any formula left in the bottle.

Does my baby need to drink water?

Babies do not routinely need extra water. However, when a bottle fed baby has a fever or the weather is hot, they should be offered a bottle of water twice a day. Run the water from the tap for 2 minutes before you use it for drinking. Keep some of this water in your refrigerator.

Do I need to give my baby vitamins?

No. Baby formulas contain all the vitamins and minerals your baby will need.

Do I need to give my baby fluoride?

From 6 months to 16 years of age, children need fluoride to prevent cavities. If the water supply where you live contains fluoride and your child drinks at least 1 pint of formula made with water each day, this should be enough. Otherwise, fluoride drops or tablets should be given. Formula-fed infants should receive fluoride supplements without vitamins. You can get a prescription for fluoride drops from your child’s health care provider.

Another way you can help your baby’s teeth is by making sure your baby does not sleep with a bottle. Milk, juice, or any sweetened liquid in the mouth can cause severe decay of your baby’s first teeth. Liquids tend to pool in the mouth during sleep. The sugar in these drinks is changed to acid by bacteria in the mouth. The acid then etches the tooth enamel and causes decay.

Prevent tooth decay by not using the bottle as a daytime or nighttime pacifier. If you cannot stop the nighttime bottle or replace it with a pacifier, fill the bottle with water.

Circumcision: Pros and Cons

What is a circumcision?

Circumcision involves removing the foreskin, or ring of tissue, that covers the head of the penis. It is usually done the day your newborn goes home from the hospital.

Fewer children in the U.S. are being circumcised now than several years ago. In 1979, 90% of American males were circumcised compared to 60% now.

The following information should help you decide what is best for your son.

What is the history of circumcision?

Followers of the Jewish and Muslim faiths perform circumcision for religious reasons. Nonreligious circumcision became popular in English-speaking countries between 1920 and 1950. At this time it was thought that circumcision might help prevent sexually transmitted diseases. Circumcision never became a common practice in most parts of the world. Over 80% of the men in the world are not circumcised.

What is the purpose of the foreskin?

The foreskin on the penis is not some cosmic error. The foreskin has a purpose.

What are the pros?

Some of the reasons you may want to circumcise are:

What are the cons?

Some of the reasons not to circumcise include:

Recommendations

Circumcision of boys for religious purposes will continue. The need to circumcise other boys is open to question. Just because a father was circumcised doesn’t mean that the son needs to be. Because the foreskin comes as standard equipment, you might consider leaving it intact, unless your son will be going to a school where everyone else is likely to be circumcised. The risks and benefits are both too small to swing the vote either way. This is a parental decision, not a medical decision.

Hepatitis B vaccination

What is hepatitis B?

Hepatitis B is a serious public health problem that affects people of all ages in the United States and around the world. Hepatitis B is caused by a highly infectious virus that attacks the liver and can lead to severe illness, liver damage, and in some cases, death.

The best way to be protected from hepatitis B is to be vaccinated with hepatitis B vaccine, a vaccine used in the U.S. for more than two decades and proven safe and effective.

What kind of vaccine is it?

The hepatitis B vaccines used in the United States are a recombinant DNA vaccine, which means it is produced by inserting the gene for HBV into common baker's yeast where it is grown, harvested, and purified. HBV infection cannot occur from receiving hepatitis B vaccine.

How is this vaccine given?

It is recommended that the hepatitis B vaccine be given in the deltoid muscle for children and adults and the thigh for infants.

Who should get this vaccine?

Hepatitis B vaccine, usually a three-dose series, is recommended for all infants beginning at birth. All older children who did not get all doses of hepatitis B vaccine as an infant should complete their series as soon as practical. Most states require hepatitis B vaccine for school entry. Adolescents who are just starting their series will need two or three doses, depending on their age and the brand of vaccine used.

Who recommends this vaccine?

The Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP) all recommend this vaccine.

How safe is this vaccine?

Hepatitis B vaccine is very safe. Globally, more than one billion hepatitis B vaccine doses have been administered. In the United States, more than 30 million adults and 40 million infants and children have received this vaccine. The majority of children who receive this vaccine have no side effects. Serious reactions are rare.

What side effects have been reported with this vaccine?

Of those children experiencing a side effect, most will have only a very mild reaction such as soreness at the injection site (3%–9%) or low-grade fever. Adults are slightly more likely to experience such mild symptoms. Serious allergic reactions following hepatitis B vaccination are rare.

How effective is this vaccine?

After three properly administered doses of vaccine, at least 90% of healthy young adults and more than 95% of infants, children, and adolescents develop protective antibodies and subsequent immunity to HBV infection.

Why is this vaccine recommended for all babies when most of them won't be exposed to HBV for many years, if then?

There are three basic reasons for recommending that all infants receive hepatitis B vaccine. First, babies and young children have a very high risk for developing chronic HBV infection if they become infected at a young age. Most of the serious consequences of HBV infection (i.e., liver cancer and cirrhosis) occur among persons with chronic HBV infection and persons with chronic HBV infection are most likely to spread the infection to others.

Second, early childhood infection occurs. About 16,000 children under 10 years of age were infected with HBV every year in the United States before routine infant hepatitis B vaccination was recommended. Although these infections represented only 5%-10% of all HBV infections in the United States, it is estimated that 18% of persons with chronic HBV infection in the United States acquired their infection during early childhood. Many of these childhood infections occur among infants born to mothers who are not HBV-infected.

Most early childhood transmission occurs in households where a person has chronic HBV infection, but transmission has also been recognized in daycare centers and schools. The most probable ways children become infected with HBV are from skin puncture (e.g., biting) or from having their mucous membranes or cuts and scratches come in contact with infectious body fluids from an infected person. HBV remains infectious for at least seven days outside the body and can be found on and transmitted through sharing of inanimate objects such as washcloths or toothbrushes.

Third, long-term protection following infant vaccination is expected to last for decades and will ultimately protect against acquiring infection at any age.

Why should your child be protected against hepatitis B if he or she won't ever inject drugs or be sexually promiscuous?

HBV can be transmitted in many ways in addition to sexual contact and injection drug use. On the average, any baby born in the United States has a 5% chance of acquiring HBV infection during his or her lifetime. By avoiding obvious means of exposure, people can reduce their odds of becoming infected. But while there are degrees of risk involved in contracting HBV infection, there is no such thing as "no risk."

Will your child need a booster shot later in life?

At the present time, booster doses are not routinely recommended for persons with normal immune systems. Although the level of protective antibodies in the blood of a vaccinated person seems to decline with time, the immune system retains an immunization “memory” and if the person is exposed to HBV, the system “kicks in” and provides the needed protection.

Experts are continuing to monitor the long-term effectiveness of hepatitis B vaccine and will issue recommendations on the need for booster doses if evidence shows they are necessary.

Pacifier: to use or not to use?

Why use a pacifier?

The amount of extra sucking babies do when they are not feeding varies. This extra sucking is a beneficial self-comforting behavior. Some babies suck on their thumb or fingers almost constantly. If you have a baby like this, you may want to try to interest him in a pacifier. Another consideration is that the American Academy of Pediatrics (AAP) recently recommended that pacifiers be offered to infants as a potential method to reduce the risk of SIDS. The recommendation states that the pacifier should be offered to an infant when being placed for all sleep episodes, including daytime naps and nighttime sleeps. They recommend pacifier use for infants up to 1 year of age, which includes the peak ages for SIDS risk and the period in which the infant's need for sucking is highest. For breastfed infants, the recommendation suggests that pacifiers should be introduced after breastfeeding has been well established (generally around 1 month of age).

To be accepted as a substitute for the thumb, the pacifier has to be introduced during the baby's first 2 months. The orthodontic type of pacifier allegedly is best because it prevents tongue-thrusting during sucking, but the regular type also is fine. You will probably need to try different pacifiers to find the shape your baby prefers.

The biggest advantage of a pacifier is that if you can get your child to use one, he won't suck his thumb. Thumbsucking can cause a severe overbite if it continues after your child's permanent teeth come in. A pacifier exerts less pressure on the teeth and causes much less overbite than the thumb. Also, you can control your child's use of a pacifier as he grows older. In contrast, it is much more difficult to stop your child from sucking his thumb because the thumb belongs to him.

When should I give my baby the pacifier?

Start the pacifier by 1 to 2 months of age if your baby shows a tendency to become a thumbsucker. Otherwise one is probably not needed. Some babies can soothe themselves without sucking. The peak age for thumbsucking or using a pacifier in infants is 2 to 4 months. In the following months, the urge to suck normally decreases. A good age to make the pacifier less available is when your child starts to crawl. A pacifier can interfere with normal babbling and speech development. This is especially important after 12 months of age, when speech should increase dramatically. It's hard for a child to talk with a pacifier in his mouth.

To make sure your child doesn't become overly attached to a pacifier (for example, walk around with it in his mouth all the time), consider the following recommendations:

What safety precautions should be taken?

Observe the following precautions for using a pacifier: