Baby Care: Glimpses from my book

Care of the Normal Newborn

When an expectant mother who is in labour pains is finally wheeled into the labour room, the other relatives, including her husband, her other children, her parents, siblings and in-laws of all hues and colours go into a tizzy; while some immediately begin praying to the Almighty for a smooth passage for both the baby and the mother, others are busy making arrangements to receive the newborn into a happy, safe and well-planned home! There are all manners of expectations: birth of a son, birth of a “healthy” baby, birth of a “fair” baby and birth of a baby that “resembles”, say, the recently deceased grandmother, are but a few of them.

You should remember that most of these desires are deep-rooted in superstitions and wrong notions of the usefulness or otherwise of a “particularly” aligned baby, whether it is a matter of its sex, its size or skin colour or it being vested with the “spirit” of a dead relative. Whatever happens happens with the will of God, and you should be ready to accept His bounty, be it in line with your wishes or not. In fact, you may as well remember that the sex of the baby has been already decided by the father at the time of conception – and the mother has no say in the matter, at least biologically!

Accept the baby – whether it is a boy or a girl, fair or dark, normal or having defects: whatever has happened is the will of the Almighty.

When the baby is born, a cry is heard – a cry that is welcomed with laughter, joy and merry-making by all those awaiting the “good news”. Telephone calls are made, pedhas are distributed and so on. Thus a normal birth is a momentous event in the life of a family, to be rivaled perhaps only by that child’s marriage after a couple of decades!

The doctor or nurse who appears out of the labour room is immediately surrounded by the eager relatives of the just born baby, and bombarded with questions like:
Is it a boy or a girl?
What is the weight of the baby?
Did it cry immediately, or was there any delay?
Is the baby healthy?

What does the baby look like?

The average baby who is born at full – term weighs about 3 kg (6 ½ pounds), measures 50 cm. (20 inches) from head to heel and has a head size of about 35 cm. (14 inches).
A very large baby is often born to a diabetic mother, while a small baby indicates that the baby probably did not receive adequate nourishment from her mother during pregnancy.

At the time of birth, the baby’s head often has some soft bumps, owing to the difficult passage through the birth canal of her mother. These bumps are harmless and tend to disappear within some days or months. The eyes are closed at birth, and the lids are swollen. The hands are outstretched and the fists are often closed, but they may be open.

If no problem has occurred during the delivery process, the baby is dried with a warm towel by the delivery nurse or doctor. Her mouth is inspected for any secretions, and a suction machine used to remove them if present. After this, the child is dressed up with a full-sleeved top, diaper, cap and, if need be, socks. IF THE BABY APPEARS CLEAN AT BIRTH, A BABY BATH IS NOT NEEDED.


In normal deliveries, the baby is handed over to the mother soon thereafter, and nursed next to her. This is because early contact between the mother and baby encourages “bonding” of emotional ties between them and lays down the foundation of a mutually loving and caring relationship. If the father also joins the duo, then it is like the proverbial icing on the cake: the family bonds are strengthened.

After an alert phase of 45 to 90 minutes soon after birth, the baby will lapse into a state of sleep; this may continue for hours thereafter. In fact, the normal baby mostly sleeps, even in excess of 14-15 hours per day. She will wake up only when she wants a feed, when she wants to evacuate or when she is feeling uncomfortably warm or cold. After taking her feed, she needs to be “burped” (see below); after that, she
may again go to sleep! The baby sleeps like this through most of the day, but gets up to feed almost five to six times during the night. This is because Nature has provided the highest milk flow only at night.

Before the baby becomes hungry, she looks alert and quiet. As her hunger increases, she becomes increasingly fidgety and restless. If not fed soon, she will begin to bawl and cry.

If you look at the baby in good daylight, you may notice some of the following on the baby’s tender skin:

Red spots on her eyelids, forehead and/or on the nape of her neck
Pin-point yellow dots on her nose, chin and at times on her forehead and cheeks too.
Raised red blotches with a boil – like centre on the second day of life.
Soft downy hair on her forehead, arms, shoulder, back etc.
Bluish – black areas over her buttocks, legs and lower back.
Peeling skin over the tips of her fingers, palms, toes and heel.

All the above “curiosities” need no treatment, as they are not harmful in any way. Each of them will disappear without any treatment after a variable period of time.

Newborn babies have certain peculiarities that may look sinister, but are actually harmless and temporary in nature.

Breast – Feeding:

Once the baby has been handed over to the mother, she should, without wasting any time, immediately put her to the breast. Early initiation of breast – feeding will go a long way in engendering successful maintenance of breast – feeding in later infancy. The baby should be put to the breast in less than two hours after birth in normal deliveries, and within 6 – 8 hours in Caesarean deliveries. No pre - lacteal feeds, like honey, water, sugar – water or tea are needed. The milk secreted by the mother in the first 2 – 3 days is yellow, thick and appears “dirty”. This milk, also called “colostrum” is rich in protein and immunoglobulins (protective factors); it should NEVER be denied to the baby.


Never deny colostrum to the baby; it is a most useful milk!

Once the milk “comes in”, the mother should feed the baby “on demand”; usually, the baby will take feeds almost every 2 – 3 hourly, although some may demand feeds either more or less frequently. In the first 1 ½ to 2 months, babies should be fed both in the day as well as in the night, but more so in the night, since there is a natural surge in the secretion of milk during the nights. As the baby grows a bit older, one can train her to feed during the day, and to sleep during the night.

Exclusive breast – feeding is recommended for the first six months of life. Not even water needs to be given, as breast milk is 80% water, and adequately meets the need for water in most babies.

Routine Handling and Care:

It is best to allow the baby to sleep with the mother in the latter’s bed, as this permits the mother to feed the baby whenever she wants in whatever position of comfort she desires. It also allows the mother to detect when the baby is wet or has passed stool; when the baby is uncomfortable because she is feeling either warm or cold; or when the baby just needs to be held or cuddled.

In normal deliveries, the baby is generally given to the mother within an hour. It must be breast – fed at once. Afterwards, the baby is nursed WITH the mother in the latter’s bed. This is called ROOMING – IN.

Many parents are scared to pick up the baby for fear that they may hurt her. Believe me, the baby is much more hardy than you think: it can withstand some rough handling! Thus don’t be scared if her head goes back on her neck when you pick her up from the armpits, or if her back gets arched – she will usually be all right. The best way to pick her up is by first putting your hand under her back, then gently “loading” her on to the same forearm; then transfer her, head first, on to the other hand, and you are done. If you wish to carry her against your shoulder, support her wobbly head from behind. You may want to use a carry – cot or a back harness while taking her out: this is perfectly all right.

Babies tend to become cold in winter as their body’s temperature regulation system is not yet well developed. In cold climes, protect the baby from drafts of cold air, and if necessary, use a room – heater to keep the baby warm and comfortable. Woollens should be used, and a cap on the rather large head is a must, since babies can lose considerable body heat from her head by radiation. The tips of her fingers and toes may turn bluish if a sufficiently warm environment is not created for her.

Babies cannot maintain their body – temperatures as effectively as older persons. Hence, one has to take special care to see that they do not become cold in winter, or hot in summer.

Conversely, in summer, there is a possibility of the baby becoming hot and feverish if she is not kept open and cool. Coolers, open windows, fans and even air – conditioners are welcome if the heat is unbearable. Loose cotton dresses are recommended in this case. Sometimes, the baby may even be left naked for a short while.

Body Massage:

Touch therapy is being re – discovered as one of the most pleasant methods of treatment for all kinds of ailments in all age – groups. An oil massage is touch – therapy, but it is much more: it improves blood circulation, tightens the lax muscles, relieves tiredness, reduces skin dryness and in small, premature babies, it may even allow absorption of calories through the delicate, thin skin. Touch, in fact, sends pleasant signals to the developing brain, and this may aid in development of the baby’s nervous system.

A baby – massage need not become a point of conflict between the family and the Pediatrician if it is an act of love that is passed on from the mother to the baby, and if it is enjoyed by the baby as well.

Generally, the baby should be at least 3.0 kg in weight before massage is begun. Any non – irritant oil, such as baby oil, coconut oil, olive oil or almond oil can be used. Mustard oil is irritating to the eye and has an unpleasant smell as well, but we have known many communities where it is used too. Massage should be given before the bath; the oil should be warmed if it is cold, and rubbed between the palms to warm it before it is applied to the baby’s skin. The baby is laid on her back, and the massage is begun by symmetrically moving both hands of the masseuse over the trunk of the baby. The hands should move away from the midline, and the movement must encompass one horizontal region of the trunk after another in a rhythmic way, using gentle pressure. As the hands move towards the upper trunk, they should move outwards over both the arms of the baby, which are massaged similarly, from shoulder down to the hands.
The fingers are also given a gentle tug one by one, as is the thumb. The wrist, elbow and shoulder joints are moved in all possible directions, thereby giving a “passive” exercise to the baby. This is then repeated with the legs as well.

Most babies enjoy the massage and make cooing pleasurable sounds during the massage, especially when she is talked to. After the massage is over, the baby may be left for a short while in sunlight. Care should be taken to see that the rays of the sun do not directly fall on the baby’s eyes as this may hurt her. Sunning the baby allows the skin of the baby to manufacture Vitamin D, which is necessary for the health of bones and teeth.

Bath:

At birth, a newborn baby is covered with a light, creamy cheesy material called vernix. This vernix is not some dirt, but in fact, a barrier that protects the delicate skin against the assault of germs. Hence, a baby bath at birth is NOT recommended unless the baby is covered with mother’s blood or her own feces (stools). The skin, even in such a case, may be gently wiped off with a soft towel. The bath can, in fact, be put off till the second, or even the third day. Even later on, a bath is not really necessary on a daily basis; in cool climes, it may be given but two or three times a week, although most households have a daily massage and bath routine in place by the time the baby is brought from the maternity home.

Baby – bath is not a compulsory routine – it may even be skipped on alternate days.


A word about hiring professional services for the massage and bath. Most “bais” are partly or fully illiterate; they know their jobs well, but their advice should not be sought for ailments that the parents do not understand. It is not correct for these women to offer “household remedies” and “medical advice” for which the child’s doctor should be contacted. In the final analysis, it is much better if the baby’s mother herself gives the massage and bath as these two activities bring the mother and baby emotionally nearer to each other.

In the initial few days, while the umbilical cord stump is still attached to the baby, a sponge bath is recommended. The baby is swaddled in a warm, soft towel, and the part (s) to be sponged are successively exposed and cleaned with a soft sponge damped with a mild soap. The face may be sponged without soap. Creases, armpits, groins and the head behind the ears are given special attention. In the end, the private parts are cleaned, first with soap and then with clean warm water.

Once the cord has fallen off and the navel has dried, one can start giving dip baths. Do select a warm area in the house which is free from cold drafts of air. Keep all the needed items by the side and then pick up the baby to start the bath.

You will need: Soap
One large towel
Two napkins or washcloths
Cotton balls
Baby lotion/powder
Dress, pins and diaper/napkin

Fans and air – conditioners should be put off. Lay the baby on your straight legs; first check if she has soiled herself. If so, remove the nappy and first clean the nappy area before beginning the bath. The basin should be 2/3rds filled with warm water.

Now, supporting the baby with one hand, lay her in the tub with her head and face out, and begin by washing the head with a mild soap. As you do so, keep an eye for soapy rivulets running down her forehead. The eyes should be protected at all times! Wash off the soap with a mug of water, all the time, keeping one hand on the baby’s forehead so that the soap does not enter the eyes. Next, proceed to clean the face, the area behind her ears, the trunk, the extremities and finally, the bottom and her genitals. The routine must involve alternate scrubbing with soap and rinsing with warm water until the entire baby has been bathed.

The fun and enjoyment for the baby may be enhanced by talking to her all the time, tickling her in the ribs, making pleasant sounds, splashing a little warm water on her chest and showing her toys like ducks, dolls etc.

Cover the baby with a warm fluffy towel and begin drying her by dabbing her rather than wiping abrasively. Once dry, you may apply a bit of talcum powder by taking it on your palm, away from the baby, and gently rubbing it on her neck, armpits, and groins and genital areas. It is time now to brush her hair, dress her up, perhaps offer her a feed (if she is so inclined) and then let her go to sleep.

Use of hair – oil is NOT recommended.

Care of Eyes, Mouth, Ears and Nose:

Many caretakers fuss over these openings for no reason at all. Natural mechanisms already exist for keeping the baby’s various special organs clean and functioning well. For example, wax protects the eardrum against any object or insect that accidentally enters the ear canal. Thus, putting buds in the baby’s ear canals is not only unnecessary, but also dangerous. In the same way, the external nostrils of the baby are her only route for inhaling air with each breath. Yet, many a times, I have witnessed massage – bais putting oil drops in the baby’s nostrils. This will choke up the only inlet for baby’s breath, as babies cannot breathe with their mouths open. Secondly, as the baby inhales the oil drops, these descend into her lungs, where they may then cause a chronic cough, or even “oil pneumonia”, which is very difficult to treat!

Nature has in – built methods to keep the natural body – orifices clean.

The eyes have tears – a natural cleansing liquid, which forms a protective film over the baby’s delicate eye surface. No attempt should be made to put kajal, surma, etc. in the baby’s eyes. These substances can introduce infection in the eye, and there is no truth to the old women’s tales that they “enhance” vision in any way.

In the same way, you do not have to clean the nostrils or the mouth unless you find definite problems. If the nose is choked with sticky secretions, instill salt – water drops in them, and gently insert a wisp of linen or cotton – bud to remove the softened secretions. If the tongue looks whitish, and the patch (-es) do not go away even after the baby has taken a feed, remove them with a linen or cotton dipped in a little glycerine.

Care of the Genital Area:

It is very essential that the area of skin demarcated by the genital structures is kept immaculately clean and dry at all times. As soon as the baby has passed urine or stools, the bottom should be cleaned and dried immediately. If this is not done, nappy rashes may develop; if infection occurs in these rashes, girls can even develop a urinary tract infection. In boys, rough handling of the foreskin over the tip of the penis may cause scarring and ballooning of the tip of the penis area … a condition that can cause you to run to the doctor for urgent relief.

To clean the genital area in a small baby, use cotton wool or soft cloth dipped in water. In girls, the wiping is done from the front to the back to prevent soiling and infection of the tender urine area. Direct washing of the bottom in running water is also not a bad idea in a slightly older baby, and I have usually done so with my own children. Only, take care that the water is not too cold, and does not gush out too fast from the tap. After cleaning, pat – dry the area with a soft towel. If necessary, put a little powder into the cleft below the bottom, and within the groins.

If a rash is already present, consult the doctor for advice on creams that can be used for relief. Remember, if you keep the nappy area open and dry, the rash will heal faster!


Care of the Skin and Nails:

Since the newborn’s skin is very delicate, you should be very sparing in the use of cosmetics, powders, lotions etc. on her skin. Clothes should be thoroughly rinsed to remove even small traces of detergent from them; preferably, the baby’s clothes should be washed separately.

Nails should be trimmed either with blunt – nosed baby scissors, or with nail – cutters, albeit very carefully, and at least once a week, although the smaller babies may need trimming more often, since the finger nails grow more quickly in the first two to three months.

Care of Navel:

The umbilical stump may fall off anytime between the 3rd to the 10th day after birth; do not bandage it or dress it in any way. Clean it with surgical spirit daily to help keep it dry. After the cord falls off, the navel may remain moist for a few days; continue to clean it with spirit till it dries up. If the wetness persists for more than a few days, consult your pediatrician for further advice. If there is a small bud of wet tissue (called an umbilical granuloma), it can be treated with application of a small pinch of table salt two to three times a day for some days.

Sometimes, the umbilical area swells up like a balloon whenever the baby strains at stool, or cries a lot. This is nothing but an umbilical hernia; it occurs because of an intrinsic weakness of the baby’s stomach area muscles. No coins or bandages should be used to press the balloon down – it can be not only useless, but also dangerous to do so, as sometimes, the baby’s bowel can get trapped in the herniated balloon, and the baby will become very sick indeed, or may even die. Generally, as the baby starts sitting or walking, such hernias subside on their own - usually by one year of age.

Bowel Movements:

A normal newborn passes dark green sticky stools known as meconium on the first two to three days after birth. After this, usually on the fourth day or so, the baby is prone to pass large, watery, liquid stools which are greenish yellow in colour; as suddenly as they started, these watery stools return to normal within 24 hours. They are called “transition” stools and are a normal development. As such, they do not warrant any treatment.

Soon thereafter, a normal baby’s stools become what are known as “breast – milk” stools. These are golden yellow in colour; they are passed almost each time that the baby feeds. The usual timing with respect to the feed is when the baby is actually suckling, and their passage is heralded by the rather loud sound of evacuation of gas. The stool is semi – solid, appears to be composed of large – sized yellow granules accompanied by a small quantity of water. It is passed effortlessly, and is approximately as large as to cause the nappy to have a stain the size of a circle with a diameter of 2 ½ to 5 inches. It is sticky, but only just, and it smells like curd, not foul.

The baby may pass 8 – 10 such stools in a 24 – hour period, since it feeds that many times. Since passing of the stool creates wetness and soiling of the nappy, the baby immediately becomes “uncomfortable” and begins to cry so as to remind the parent to “clean” her up!

There are babies who pass some stool with every gas movement, and this becomes a nuisance for the already tired mother, who has to change the nappy almost 20 – 40 times in a 24 – hour day. Often, in such cases, parents worry if their baby has diarrhea, and consult the doctor, who may, if he is not aware of the “normalcy” of such a bowel movement, prescribe antidiarrhoeals or even, God forbid, antibiotics.

One thing more. The bottom must be always cleaned as soon as you become aware that the baby has passed a stool. See “Care of the Genital Area” above.

Frequently, babies also pass urine along with stools. This may cause them to cry before passing the stool as well.

Lastly, remember that some babies may not follow the above norm and pass stools just once a day, or once every 3 – 4 days. As long as the stools are of normal colour and appearance and the baby is thriving, it needs no treatment. The same is true for some babies passing normal, but slightly greenish stools.

Urination:

You may already be aware of this: most of the fluid in the mother’s womb in which the baby floats during pregnancy is the baby’s own urine. Not only does the baby pass urine regularly while inside, she also keeps “drinking” the urine continuously. After she is born, she will usually pass urine almost immediately. Thereafter, she may not pass urine for the next 24 hours or even 36 hours. This is because she does not get much liquid (mother’s milk) inside her during this time. Once the mother’s breast milk is established, the baby will pass urine more frequently, say almost once every 1-3 hourly, but even up to 5 – 6 times in 24 hours is all right.

While passing urine, or sometimes, even before doing so, the baby may cry because of a full bladder or because of the nappy becoming wet. She will stop crying as soon as she has been attended to.

Immunisations:

Usually, large hospitals and government or municipal maternity homes arrange to give the baby her first vaccines before she and her mother have been discharged from there. These vaccines include the B.C.G. vaccine, the zero dose of the first oral polio dose and the first injection of Hepatitis B. Later vaccines are given in the clinic.

Care of a Low birth weight Baby:

A baby which is born with a birth weight of below 2500 grams is considered to be of a low – birth – weight baby, or LBW baby. Such babies may either have not received adequate nourishment in their mother’s womb, or may have been born premature, or earlier than at 37 weeks gestation. The first category of babies is called “small for dates”; this may be due to maternal malnutrition or some disease like tuberculosis, high blood – pressure or something else.

Preterm babies, or “preemies” as they are called are usually sent home after some period of stay in the Neonatal Intensive Care Unit, or NICU, as it is called for short. At the time of their being sent home, they have usually become normal with respect to their ability to take breast feeds, to remain warm under blankets, to be free from the perils of prematurity like shaky hands and feet, fits, jaundice etc. and to sleep and wake at normal times to satisfy their hunger and other needs.

The biggest worry in case of a preterm baby is that she should not become cold. This can, quite literally, kill her. The second worry: whether she is able to get enough milk inside her.

During the early days following the arrival of a small baby at home, the main things to take care are:
The baby should be kept adequately clothed and covered to avoid “hypothermia”, a condition where the baby becomes cold due to a cold environment and rapidly takes a turn for the worse. Cold drafts of air from a fan or air – conditioner should be strictly avoided.
The baby should be given frequent, regular feeds on her mother’s breast – at least once every two hours – both during the day and during the night.
Rooming – in, where the baby sleeps with the mother in her cot – is recommended, because the mother will be better able to monitor the baby in this case, and attend to her various needs more quickly.
If the baby is unable to feed directly at the breast, the mother should remove some milk from her breast by manual expression and feed it to the baby with a small spoon, dropper or palada.

Everyone, including the mother MUST wash their hands with soap and water before handling or lifting the baby, as the baby is most likely to catch germs from the care – taker’s hands, rings etc. As the baby’s body defenses (or immunity) are weak, such germs may cause them to become sick rather soon … although the same germs are harmless inhabitants on the skin of the adults!
The cot, mattresses, pillow and her clothes should all be clean and maintained hygienically, with the covers changed regularly to avoid contamination of the baby with germs.
On the day of discharge from the NICU, the preemie should get all his vaccines which the full term baby would have received within the first few days of life.

Conclusions and Final Words of Advice:

It is a full – time occupation for a mother to look after her baby, and in recent times, it is heartening to see fathers too contributing in the care of the newly arrived baby. In some ways this was unavoidable, since more and more families are becoming nuclear and “shunning” the presence of grandparents in their homes. Old people may be slow, choosy about what they eat, need tender loving care and “be in the way’ of youthful enjoyment to a young, merry – making couple, but once the baby arrives, they learn very quickly that the patience, wisdom and fortitude of old age are indispensable. It is all too easy to brush away one’s aging parents quite literally “under the carpet” on days when guests come to party, but it is at the time of the arrival of the baby that their worth is realised and their attention and “services” are sought by the young parents.

Fathers of babies can certainly help in so many ways: they can help undress/dress the baby, they can help soak the soiled nappies, they can create a home environment that is conducive to a peaceful mother and child relationship, they can fix up doctor’s appointments and participate in their baby’s pediatric care, they can even make simple weaning foods for the baby with basic kitchen skills! On top of everything, it is they who can iron out the differences that may arise between their wife and their mother: this allows for a happy household and a warm baby – family unit!

A final word. The parents of the baby should realise that the moment the baby was conceived in the mother’s womb, their lives have been altered forever. They have to forget everything else, and learn to live for their baby. No amount of time – management, maid’s help, foster – care, ayahs etc. can actually release time for the parents to pursue their pre – child hobbies and dreams. If they try to balance their babies against their personal aspirations, the baby WILL suffer in some way or the other. The sooner a parent realises this, the better it is, both for themselves, and even more importantly, for the baby.

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