2                                                Care of normal                                                infants    ...
30    PRIMAR Y NEWBORN CARE                                                    them from dehydration at a time when many M...
CARE OF NORMAL INFANTS        31   It is seen in normal infants and is due to          the tongue out fully and, therefore...
32    PRIMAR Y NEWBORN CAREThere is often a family history of extra digits.       cotton vest and a gown that ties at the ...
CARE OF NORMAL INFANTS       33FEEDING THE NORMAL                                    Benefits to the motherINFANT         ...
34    PRIMAR Y NEWBORN CARE7. They have flat or inverted nipples.             2-28 How can breast feeding be8. Traditional...
CARE OF NORMAL INFANTS        352-32 Should the infant be put to the breast          2-35 How should an infant fix at the ...
36   PRIMAR Y NEWBORN CARE2-38 How do you manage leaking breasts?           1. Her breasts do not feel full before feeds  ...
CARE OF NORMAL INFANTS      37     is not under too much stress, as anxiety         2-46 What should you do if an infant  ...
38    PRIMAR Y NEWBORN CAREcommon if the infant does not room-in and if         It is important that the infant is correct...
CARE OF NORMAL INFANTS      39in a cool place or for 48 hours in a fridge.        1, SMA). They are very similar and, ther...
40    PRIMAR Y NEWBORN CAREMany of the dangers of infection when using         months of age. Thereafter, milk alone is no...
CARE OF NORMAL INFANTS       414. Help mothers to start breast feeding within     1. Does the infant appear normal, active...
42    PRIMAR Y NEWBORN CAREthe cord is clamped and cut and the infant          CASE STUDY 2is dried. The infant cries well...
CARE OF NORMAL INFANTS      431. Is the weight loss of 150 g normal for this         2. Why should the infant not be senti...
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Primary Newborn Care: Care of normal infants

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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker – Miriam Adhikari, South African Journal of Child Health, Primary Newborn Care was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: the care of infants at birth, the care of normal infants, the care of low-birth-weight infants, emergency management of infants, the management of important problems.

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Transcript of "Primary Newborn Care: Care of normal infants"

  1. 1. 2 Care of normal infants Normal infants are at low risk of developing Objectives problems in the newborn period and, therefore, require primary care only. About When you have completed this unit you 80% of all newborn infants are normal. should be able to: • Manage normal newborn infants. Normal newborn infants are at low risk of develop- • Diagnose and treat common minor ing problems and require only primary care. problems. • Manage breast feeding. • Promote baby friendly care. 2-2 Should all normal infants be kept with • Discharge a normal infant. their mothers? Yes, all normal infants should stay with their mothers and not get cared for in the nursery.CARING FOR NORMAL This is called rooming-in. The infant is eitherINFANTS nursed in a cot next to the mother’s bed or is given skin-to-skin care (Kangaroo Mother Care or KMC). The advantages of infants2-1 What is a normal infant? staying with their mothers are:A normal infant has the following 1. The mother remains close to her infant allcharacteristics: the times and gets used to caring for her infant. This strengthens bonding.1. The infant is born at term (37 to 42 weeks 2. It encourages breast feeding. gestation). 3. It builds up the mother’s confidence in her2. The 1 minute Apgar score is 7 or more and ability to handle her infant. no resuscitation is needed after birth. 4. It prevents the infant being exposed to the3. The infant weighs between 2500 g and infections commonly present in a nursery. 4000 g at birth. 5. It reduces the number of staff needed to4. On physical examination the infant care for infants. appears healthy with no congenital abnormalities or abnormal clinical signs. The father should be present at the delivery to5. The infant feeds well. share this exciting moment.6. There have been no problems with the infant since delivery.
  2. 2. 30 PRIMAR Y NEWBORN CARE them from dehydration at a time when many Mothers and infants should stay together. mothers produce only small amounts of milk.2-3 When should the infant receive the first 2-6 What routine cord care is needed?bath? The umbilical cord stump is soft and wet afterThere is no need to routinely bath all infants delivery and this dead tissue is an ideal site forafter delivery to remove the vernix. Vernix bacteria to grow. The cord should, therefore, bewill not harm the infant and disappears kept clean. It should also be dried out as soonspontaneously after a day or two. Vernix as possible by 6 hourly applications of surgicalprotects the skin and kills bacteria. Many spirits (alcohol). It is important to apply enoughinfants also get cold if they are bathed soon spirits to run into all the folds around the baseafter delivery. The only indication for an infant of the cord. There is no need to use antibioticto be washed or bathed soon after birth is powders. If the cord remains soft after 24severe meconium staining or contamination hours, or becomes wet and smells offensively,with maternal blood or stool. then the cord should be treated with surgical spirits every 3 hours. Do not cover the cordIt is, however, important that all primiparous with a bandage. Usually the cord will come offmothers learn how to bath their infants between 1 and 2 weeks after delivery.before they go home. If these infants haveto be bathed on the first day of life, it ispreferable that this be delayed until they are a Good cord care with surgical spirits is important.few hours old.2-4 What is the appearance of a newborn 2-7 Can a vaginal discharge be normal ininfant’s stool? an infant?For the first few days the infant will pass Yes. Many female infants have a white, mucoidmeconium, which is dark green and sticky. vaginal discharge at birth, which may continueBy day 5 the stools should change from green for a few weeks. Less commonly the dischargeto yellow, and by the end of the first week may be bloody. Both are normal and caused bythe stools should have the appearance of the secretion of oestrogen by the infant beforescrambled egg. The stools of breast fed infants and after delivery.may also be soft and yellow-green but shouldnot smell offensive. 2-8 May normal infants have enlarged breasts?Some infants will pass a stool after every feedwhile others may not pass a stool for a number Yes. Many infants, both male and female, haveof days. As long as the stool is not hard, the enlarged breasts at birth due to the secretionfrequency of stools is not important. of oestrogen. The breasts may enlarge further after birth. Breast enlargement is normal and2-5 How many wet nappies should an the breasts may remain enlarged for a fewinfant have a day? months after delivery. Some enlarged breasts may secrete milk. It is very important thatA normal infant should have at least 6 wet these breasts are not squeezed as this maynappies a day. If the infant has fewer than 6 introduce infection resulting in mastitis or awet nappies a day, you should suspect that the breast abscess.infant is not getting enough milk. However,during the first 5 days, infants may have 2-9 Which birth marks are normal?fewer wet nappies as infants normally passlittle urine in the first few days. This protects 1. A blue patch over the sacrum is very common and is called a ‘mongolian spot’.
  3. 3. CARE OF NORMAL INFANTS 31 It is seen in normal infants and is due to the tongue out fully and, therefore, is said to the delayed migration of pigment cells into have ‘tongue tie’. This does not interfere with other areas of the skin. It is not a sign of sucking and usually corrects itself with time. Down syndrome (mongolism). Sometimes Do not cut the membrane as this may cause similar patches are seen over the back, severe bleeding. Refer the child to a surgeon if arms and legs and may look like bruises. the tongue does not appear normal by 2 years. They need no treatment and disappear during the first few years of life. 2-13 Does an umbilical hernia need2. It is common for an infant to have a few treatment? small pink or brown marks on the skin at birth. These are normal and disappear in a Infants commonly develop a small umbilical few weeks. hernia after the cord has separated. This does3. Many infants also have pink areas on the not cause problems and usually disappears upper eyelid, the bridge of the nose and without treatment when the infant starts to back of the neck that become more obvious walk. If the hernia is still present at 5 years the when the infant cries. These marks are child should be referred for possible surgical called ‘angel’s kisses’ and ‘stork bites’. They correction. are also normal and usually disappear within a few years. 2-14 Do normal infants commonly have a4. Some infants develop one or more raised blocked nose? red lumps on their skin during the first Yes, a blocked nose is common due to the small few weeks. These ‘strawberry patches’ size of the nose in a newborn infant. Normal grow for a few months and take a few infants also sneeze. Usually a blocked nose does years to disappear. They are best left alone not need treatment. However, some infants may and not treated. develop breathing difficulties or apnoea if both nostrils are completely blocked. Nose drops2-10 Are cysts on the gum or palate containing drugs can be dangerous as they arenormal? absorbed into the blood stream and can causeSmall cysts on the infant’s gum or palate are a rapid heart rate. Sodium bicarbonate 2% orcommon and almost always normal. They do saline nose drops can be used. The blocked nosenot need treatment and disappear with time. is usually not caused by a cold.They must not be opened with a pin or needleas this may introduce infection. 2-15 Are wide fontanelles and sutures common?2-11 Can infants be born with teeth? Many normal infants have wide fontanelles andYes, some infants are born with teeth. These sutures. This is particularly common in loware either primary teeth or extra teeth. birth weight infants. The anterior fontanellePrimary teeth are firmly attached and should may also pulsate. If the anterior fontanellenot be removed. Extra teeth are very small and bulges and the infant’s head appears too big, theusually very loose. A tooth that is very loose, infant must be referred to a level 2 or 3 hospitaland is only attached by a thread of tissue, can as hydrocephaly is probably present. If yoube pulled out. It will be replaced later by a are uncertain, repeat the head circumferenceprimary tooth. measurement in 2 weeks. It should not increase by more than 0.5 cm per week.2-12 Should ‘tongue tie’ be treated? 2-16 Are extra fingers or toes normal?Many infants have a web of mucousmembrane under the tongue that continues to Extra fingers that are attached by a thread ofthe tip. As a result the infant is not able to stick skin are common and occur in normal infants.
  4. 4. 32 PRIMAR Y NEWBORN CAREThere is often a family history of extra digits. cotton vest and a gown that ties at the back or aExtra fingers or toes should be tied off as close ‘baby grow’. A disposable or washable nappy isto the hand or foot as possible with a piece of worn. If the room is cold, a woollen cap shouldsurgical silk. If the extra digit contains cartilage be worn. Woollen booties are sometimes alsoor bone and is well attached with a broad base, worn. It is important that the clothing is not tooit must not be tired off. These infants have a tight. Infants should be dressed so that they arehigh risk of other abnormalities and, therefore, comfortable and warm. Usually a single woollenshould be referred to a level 2 or 3 hospital. blanket is adequate.2-17 Should an infant’s nails be cut? 2-21 Must the birth be notified?If an infant’s fingernails become long they may The birth of every infant must be notified byscratch the face. Long nails should, therefore, be the hospital, clinic or midwife. The parentscut straight across with a sharp pair of scissors. later must register the infant’s name with theDo not cut the nails too short. Never bite or tear local authority.the nails. Nail clippers are dangerous. 2-22 Should all infants receive a Road-to-2-18 Should the foreskin of an infant’s Health Card?penis be pulled back? Yes. All newborn infants must be given aNo. The foreskin is usually attached to the Road-to-Health Card (preschool card), asunderlying skin and, therefore, should not be this is one of the most important advancespulled back to clean the glans. All newborn, in improving the health care of children. Themale infants have erections of the penis. They relevant information must be entered at birth.also have larger testes than older infants. These Mothers should be told the importance of thesigns usually disappear within a few months card. Explain the idea of the Road-to-Healthand are due to the secretion of male hormones. Card to her. She must present the card every time the infant is seen by a health care worker.2-19 When should the normal infant be It is essential that all immunisations be enteredfully examined? on the card. A record of the infant’s weight gain is also very important as poor weight gain orWeighing and examining all newborn infants weight loss indicates that a child is not thriving.are important parts of primary care. A fullexamination should be done after the motherand infant have recovered from the delivery, All newborn infants must be given a Road-to-which usually takes about 2 hours. The infant Health Card.must be examined in front of the mother sothat she is reassured that the infant is normal.It also gives her a chance to ask questions 2-23 Should newborn infants beabout her infant. The infant is also briefly immunized?examined immediately after birth to identify The schedule of immunisations varies slightlyany gross abnormalities. in different areas but most newborn infants are given B.C.G. and polio drops within 5 days of All newborn infants should be weighed and delivery. It is safe to give polio drops to infants examined. of HIV positive mothers. However, their B.G.G. immunisation is often delayed until it can be established that they are not HIV2-20 How should the infant be dressed? infected. Sick and preterm infants are usuallyIt is important that the infant does not get given B.C.G. and polio drops when they aretoo hot or too cold. Usually an infant wears a ready to be discharged home.
  5. 5. CARE OF NORMAL INFANTS 33FEEDING THE NORMAL Benefits to the motherINFANT 1. Breast feeding is much cheaper than buying formula feeds. 2. Breast milk is instantly available at all2-24 What milk can be given to a normal times. No sterilising of bottles and teats,infant? and preparation of formula is needed. 3. It is emotionally satisfying for the mother• Breast milk. Human breast milk meets to successfully breast feed her infant and all the nutritional needs of a healthy term helps to form a strong bond between infant. mother and infant.• Formula feeds. These powdered feeds are 4. Breast feeding helps the involution of the made from cow’s milk or soya bean and are uterus and reduces the amount of bleeding modified to have similar constituents to during the puerperium. breast milk. 5. Breast feeding helps the mother to lose excessive weight gained during pregnancy. Whenever possible mothers should breast feed Pregnancy, not breast feeding, alters the their infants. breast shape of a primiparous woman. Breast feeding is cheap and ensures an adequate,2-25 What are the benefits of breast safe supply of food. It, therefore, decreases thefeeding? incidence of malnutrition.Breast feeding provides many benefits to boththe infant and mother. The main benefits are: Breast feeding may increase the risk of HIV transmission from mother to infant. This mustBenefits to the infant be taken into account when discussing breast1. Breast milk is the ideal feed for term feeding with a mother. infants as it provides all the nutrients in the correct amount and proportion for normal 2-26 Why do some mothers not breast feed growth and development. successfully?2. Breast milk is easily digested and absorbed. Breast feeding is not always easy, as the3. Breast milk is clean and warm, and avoids ‘natural art of breast feeding’ has to be learned. the dangers of a contaminated water Some mothers do not breast feed or fail to supply, inadequately sterilised bottles and breast feed successfully because: teats, and lack of refrigeration facilities.4. Breast milk avoids the danger of diluted or 1. They believe that they do not have enough concentrated formula. milk because it takes a number of days5. Breast milk contains many anti-infective before the supply of milk increases. factors and decreases the risk of infections, 2. They do not know the advantages of breast especially gastroenteritis, a major cause of feeding. death of infants in poor communities. 3. They think that their milk is too thin, or6. Breast milk decreases the risk of allergy their breasts too large or too small. in the infant, especially if there is a strong 4. They develop cracked nipples or engorged family history of allergy. breasts due to an incorrect method of feeding. 5. They want to return to work and do not Breast feeding decreases the incidence of realise that many working mothers can gastroenteritis and lowers the infant mortality continue to breast feed successfully. rate in poor communities. 6. They are afraid of breast feeding.
  6. 6. 34 PRIMAR Y NEWBORN CARE7. They have flat or inverted nipples. 2-28 How can breast feeding be8. Traditional beliefs may result in encouraged in hospitals and clinics? unsuccessful breast feeding, e.g. incorrect Staff should be convinced that breast feeding beliefs that colostrum is not good for the has many benefits for the mother and infant, intercourse spoils the milk, and infant, they should feel comfortable and delayed feeding causes the milk to become not embarrassed when speaking to patients sour in the breast. about breast feeding, and they must have9. Poor sleeping or excessive crying by the the knowledge and skills to teach mothers infant is blamed on the quality or supply of how to breast feed. Mothers must be helped the breast milk. individually with kindness and patience.10. They are HIV positive and elect not to breast feed. Facilities for rooming-in must be provided, and the mother allowed unlimited access to2-27 How can breast feeding be promoted? her infant to demand feed. The national baby friendly hospital initiative encourages breastBreast feeding should be promoted as the feeding.normal, natural method of feeding an infant.This can be achieved by: 2-29 What is the value of a local breast1. Encouraging a positive attitude towards feeding support group? breast feeding in the home during Often the best person to advise and help a childhood and adolescence by seeing other breast feeding mother is someone who has infants being breast fed. successfully breast fed herself. A number of2. Teaching the advantages of breast feeding mothers who have breast fed and are interested in schools. in helping others to breast feed can form a3. Promoting breast feeding in the media local support group. With help and training by (radio, TV, books). midwives and doctors they can provide a very4. Teaching the advantages and method of helpful service. breast feeding in all antenatal clinics.5. Starting breast feeding groups run by mothers who have themselves breast fed. 2-30 What preparation does a mother need6. Encouraging breast feeding and practice for breast feeding? kangaroo mother care in hospitals and 1. The decision to breast feed should be clinics. taken before her infant is born. If she is7. Discouraging bottle feeding in hospital. still undecided at delivery, she should be Rather use cups for expressed breast milk encouraged to breast feed. or formula feeding. 2. No routine preparation of breasts andFurther information on breast feeding in nipples before delivery is necessary.South Africa can be obtained from a local 3. A good, supportive bra should be worn.breast feeding support group or local branches Breast size is no indication of a woman’sof the Breastfeeding Association, La Leche ability to breast feed.League, and National Childbirth Educationand Parenting Association. 2-31 How can you treat flat or inverted nipples? Breast is best. If a woman’s’ nipples appear flat or inverted during pregnancy, they can be corrected by the infant sucking after delivery.
  7. 7. CARE OF NORMAL INFANTS 352-32 Should the infant be put to the breast 2-35 How should an infant fix at the breast?immediately after delivery? One of the commonest mistakes made whenYes, the mother should breast feed her infant breast feeding is that the infant is not heldas soon as possible after delivery as the infant’s and fixed correctly (latched) at the breast.sucking drive is usually strongest in the first The infant must take the whole nipple andhour after birth. Early suckling promotes most of the pigmented areola into the mouth.bonding between the mother and infant. It also Sucking or chewing on the nipple causes painstimulates milk production and encourages and damages the nipple. The mother shouldsuccessful breast feeding. The small amount let her nipple touch the infant’s cheek, so thatof colostrum in the first few days satisfies the the infant will turn towards the breast with aninfant and is very rich in antibodies. open mouth to take the nipple. Make sure that the infant’s nose is not covered by the breast.2-33 Should clear feeds be given during thefirst few days? The infant must take the whole nipple and mostSterile water or dextrose water should not be of the areola into the mouth when fixing at thegiven before starting breast or formula feeds mother’s breast.on day 1. A breast fed infant does not needadditional clear feeds. If the mother wants tobreast feed, no bottle feeds should be given to 2-36 Should infants be demand fed?the infant as a teat can confuse the infant and Yes. Whenever possible infants should because it to reject the nipple. demand fed. This means that the infant isUnlike a bottle fed infant, that sucks the milk put to the breast whenever hungry. A normalout of the teat, a breast fed infant holds the breast fed infant will usually feed every 2 to 4nipple against the hard palate and compresses hours during the day for the first few weeks.the milk ducts in the areola with the gums. Demand feeding prevents engorged breasts.The breast fed infant, therefore, makes achewing movement while feeding (suckling). 2-37 What is the let down reflex? When an infant is put to the breast, the Routine clear feeds are not needed on day 1. pituitary gland in the mother’s brain responds by producing the hormones prolactin and oxytocin. Prolactin stimulates the breast to2-34 What is the best position to hold an secrete milk while oxytocin produces the ‘letinfant while feeding? down reflex’. This reflex produces a tinglingThe correct position of the infant while feeling in the breast, and results in milkfeeding is important. The mother should be being pumped into the infant’s mouth by thewarm and comfortable. Usually she sits up and contraction of muscle cells that surroundholds her infant across her body in front of the milk ducts under the areola. Milk mayher. The infant is held in one arm, and should leak from the other nipple during feeds. Thelie on its side with its mouth facing the nipple. release of oxytocin helps the uterus to involuteThe breast is held in the other hand to offer the by causing the uterus to contract. It maynipple to the infant. also produce abdominal pain during feeding for the first few days after delivery. Tension,Mothers should be encouraged to try different anxiety and a lack of sleep may inhibit the letfeeding positions in order to find which is down reflex.most comfortable. Some mothers prefer to liedown while they feed. Other mothers prefer totuck the infant under an arm like a rugby ball.
  8. 8. 36 PRIMAR Y NEWBORN CARE2-38 How do you manage leaking breasts? 1. Her breasts do not feel full before feeds after day 5.Milk leaking from the breasts is common 2. The infant continues to lose weight afterin the first few weeks of feeding. Leaking of day 5.the opposite breast during feeding can be 3. The infant loses more than 10% of its birthstopped by pressing on that nipple. Cotton weight.handkerchiefs or pads can be used for leaking 4. The infant is not gaining weight by 2 weeks.between feeds. They should be changed 5. The infant does not wet 6 or more nappiesfrequently as dampness may cause sore nipples. in 24 hours (after day 5), is very restless and appears hungry.2-39 Can a mother’s milk be too strong ortoo weak? If you are worried that an infant is not getting enough milk, then the infant can be testNo, but the appearance of breast milk varies. weighed before and after a feed. After the firstThere are 3 different types of breast milk: week of life, most term infants will gain about1. Colostrum. This is a milky fluid produced 25 g per day. Weight gain is best determined in small quantities for the first few days over a few days. after delivery. However, it contains a lot of protein and provides all the infant’s 2-41 Is it normal for an infant to lose weight nutritional needs. After 3 to 5 days the after birth? milk supply suddenly increases and Yes. Most breast fed infants will lose weight the breasts feel full. This is due to the for the first few days after birth due to the production of mature milk, which consists small volume of breast milk being produced. of foremilk and hind milk. Colostrum, however, will meet the infant’s2. Foremilk. This is produced at the start of nutritional needs. Once the milk ‘comes in’, each feed. It appears very weak and thin between days 3 and 5, the infant will start to as it consists mainly of water with little gain weight. Most breast fed infants regain fat. On a hot day a thirsty infant will take their birth weight by day 7. This weight loss frequent, small feeds of foremilk. is normal and does not cause the infant any3. Hindmilk. This is only produced towards harm. The normal infant does not usually lose the end of a feed. It looks thick and more than 10% of the birth weight. Marked rich, and contains a lot of fat. A hungry weight loss suggests that the infant is ill or not infant will empty the breast to obtain the getting enough milk. hindmilk. 2-42 Is it necessary to weigh a normal2-40 Do all mothers produce enough infant every day?breast milk? No. The normal infant should be weighedMost mothers produce enough milk for their at delivery and again on days 3 and 5 if stillinfant if breast feeding is managed correctly. in hospital. Weight at discharge must beUnfortunately many mothers stop breast recorded. At every clinic visit the infant’sfeeding during the first 5 days because they weight should be measured and recorded. Illare incorrectly advised that they do not have infants should be weighed every day until well.enough milk or because the infant is losingweight. Milk supply is normally best in themorning and poorest in the late afternoon and 2-43 How can you improve a mother’s milkearly evening. supply?The mother is probably not producing enough 1. Reassurance, support and encouragementmilk if: that she will be able to breast feed. Also ensure that she is getting enough sleep and
  9. 9. CARE OF NORMAL INFANTS 37 is not under too much stress, as anxiety 2-46 What should you do if an infant is a major cause of poor milk production. refuses the breast? Anxiety also inhibits the let down reflex. Some infants may reject the breast and refuse Many mothers are more relaxed in their to fix on the nipple and suck. Common causes own homes. are a sore mouth due to thrush, the infant2. Make sure that she is fixing the infant being ill or upset, or the milk flow being too correctly to the breast and that the infant is fast. These problems should be looked for and sucking correctly. treated.3. Put the infant to the breast frequently during the day until a good milk supply Do not hold the infant’s head too tightly or is established. If the infant is not demand push the face towards the breast, as the infant feeding 3 to 4 hourly, it should be woken will turn towards your hand instead of the for feeds. The best stimulus to milk nipple. It may help to squeeze a little breast production is the infant sucking frequently milk onto the nipple before placing it in the and for prolonged periods. infant’s mouth.4. The mother should rest for a while in the afternoon and drink adequate fluids. 2-47 What may causes an infant to choke5. Stop any bottle feeds. while feeding? During the first few weeks the mother may The best stimulus for milk production is frequent have a lot of milk and the milk may flow too feeding. fast causing the infant to choke or gag when feeding. As a result the infant may refuse to feed or overfeed and become restless. It may2-44 Should infants be routinely test help for the mother to lie back at the start ofweighed? the feed with the infant across her chest so that the milk has to flow upwards against gravity.No, there is no need to test weigh all infants. The mother may have to express a bit beforeThe amount of milk an infant takes varies starting the feed, or feed the infant morewidely between feeds. A small feed, which frequently. Too much milk and milk that flowsis common in the afternoon or when the too quickly settles with time.mother is tired, may cause maternal anxiety.Test weighing may be useful to assess amother’s milk production if the infant does 2-48 How should you manage swollen ornot gain weight. painful breasts? A normal, full breast feels tense and heavy, but2-45 Should the infant always feed on both is not painful and any discomfort is relievedbreasts? by feeding. Breasts that are swollen, tender, hard, lumpy and painful are caused by eitherIt is best to empty one breast first before engorgement or mastitis.putting the infant to the opposite breast. Thisensures that the infant gets the rich hind milk. Both engorgement and mastitis result from anStart each feed on alternate breasts. However, obstruction in milk flow:for the first few days it is useful to allow theinfant to feed on both breasts to stimulate themilk production. 1. Engorged breasts Both breasts are swollen, hard and painful but the mother does not feel ill. The milk does not flow freely. Engorged breasts usually occur between days 3 and 5 when the mother’s milk suddenly ‘comes in’. Engorged breasts are
  10. 10. 38 PRIMAR Y NEWBORN CAREcommon if the infant does not room-in and if It is important that the infant is correctlythe mother does not demand feed. fixed at the breast so that the nipple is not chewed. When removing the infant from theTreatment consists of emptying the breast by breast, the mother should insert her littleexpressing or allowing the infant to suck. The finger into the corner of the infant’s mouth toinfant should be fed on the most painful breast break the suction.first. Sponging the breasts with warm wateror standing under a warm shower relievesthe discomfort, while a mild analgesic like Correct fixing of the infant at the breast will helpparacetamol (Panado) is helpful. Often the to prevent painful nipples.infant is not able to fix correctly if the breastis engorged as the nipples become flattenedby the swelling. If some milk is first expressed 2-50 How should you treat painful nipples?from the breast, the infant will usually fix well. Nipples are often painful during the first fewBreast engorgement should be prevented by days of breast feeding, especially if the infantfrequent feeds. is very hungry or is not fixing on the breast2. Mastitis (milk fever) correctly. Do not let the infant sleep at the nipple until the nipples have toughened.Mastitis is an inflammation of the breast dueto infection in blocked milk ducts. It causes Cracked nipples are very painful and shoulda swollen, painful, red area of one breast. The be prevented by correctly fixing the infant tomother feels ill and may have a temperature. the breast and avoiding engorged breasts. Treat cracked nipples with colostrum or hind milkTreat with rest, warm compresses and a and mild analgesics. Alter the position of themild analgesic. It is most important that infant on the nipple so that it does not suckthe infant continues to suck frequently on on the tender area. It may be necessary to stopthe affected breast, as this will help the milk feeding on that side for 24 hours and expressto flow. Altering the feeding position often the breast instead. Frequent short feedshelps to drain the affected area. Mastitis is when the infant is not hungry are preferable.not dangerous for the infant. If the signs and Reassure the mother that painful nipples healsymptoms do not improve within 24 hours very quickly. Mothers with painful nipplesan antibiotic (penicillin or cloxacillin) should need a lot of support if they are to continuebe prescribed for 5 days. If a fluctuant mass breast feeding.develops then a breast abscess has formed.This should be surgically drained. Due to the 2-51 Do breast fed infants needpain of a breast abscess, feeding may have to complementary feeds?be stopped on that breast for a few days. Ifpossible, feeding can be continued however. Most breast fed infants do not need complementary (additional) feeds of formula.2-49 How do you prevent painful nipples? Complementary feeds may decrease the production of breast milk and the teat mayThe nipples should be kept dry between feeds. confuse the infant. Only if an infant fails toInstead of protecting the nipples with lanolin gain weight, after management to improve thecream, petroleum jelly (Vaseline) or masse mother’s milk supply has been tried, shouldcream, it is suggested that a little colostrum complementary feeds be used. Some mothersor hind milk be left to dry on the nipples will give complementary feeds if they have toafter each feed. The milk has anti-infective leave their infant for more than a few hours.properties and the fat protects the nipples. Do However, expressing milk into a bottle for thenot use alcohol on the nipples. Avoid vigorous missed feed would be preferable. Expressedwashing or soap on the nipples. breast milk can be safely stored up to 6 hours
  11. 11. CARE OF NORMAL INFANTS 39in a cool place or for 48 hours in a fridge. 1, SMA). They are very similar and, therefore,Breast milk can be safely frozen and stored the milk available at the local clinic or thefor 2 weeks in a fridge freezer or 6 months in cheapest milk should be bought. Unaltereda deep freeze. Frozen milk should be thawed cows milk, evaporated milk and skimmedslowly by placing the container in warm (not milk are not suitable for infants under 6hot) water. months of age. Milk creamers must never be used to feed infants.2-52 Can working mothers continue to Bottle fed infants should be fed on demand. Ifbreast feed? fed according to a schedule, most infants willYes. Mothers can continue to breast feed for need to be fed 6 times a day, at 06:00, 10:00,many months while working. Breast milk 14:00, 18:00, 22:00 and 02:00. After the firstcan be expressed at work and this or formula few weeks the 02:00 feed can be missed. Mostis given to the infant during the day. When term infants will take about 100 ml per feedat home the mother breast feeds frequently. after the first week.Ideally it should be possible to take the infantto work or leave the infant in a creche at or 2-56 How is formula made up?near the place of work. If a mother decides to formula feed her infant, it is very important that she knows how to mix2-53 Do drugs cross into the breast milk? formula correctly. She must also have a sourceAlmost all drugs that the mother takes by of clean water and know how to clean a cup ormouth will cross into the breast milk in very bottle and teat.small quantities that will not affect the infant. A level scoop of milk powder (scraped levelBreast feeding mothers should only take with a knife and not packed down) is addedmedication that is necessary. to 25 ml of clean water in a feeding bottle. The water should have been boiled beforehand2-54 When should an infant not be breast and allowed to cool. The bottle and teat mustfed? have been cleaned and sterilised by boiling1. If, after counselling, the mother has decided or standing in a disinfecting agent (Milton or that she definitely does not want to breast half-diluted Jik). Shake the bottle well to mix feed, then the infant should be fed formula. the feed. Bottles should not be used if they2. If a mother is unable to breast feed because cannot be cleaned properly. she is separated from her infant, she should One of the great dangers of formula feeds express her milk, manually or with a breast is to make the mixture too strong or too pump, for the infant to be cup fed. weak. If too much milk powder is added,3. If the mother has an inadequate milk the infant may receive too much salt which supply despite advice and support, and if can be dangerous. If too little milk powder is the infant is not gaining wait by 2 weeks, added, the infant may become malnourished. then complementary feeds should be Another danger is gastroenteritis caused by started to ensure normal growth. infected water or dirty bottles and teats. These4. If the mother is very ill. and other problems of formula feeds can be5. If the mother is HIV positive and decides, avoided by breast feeding. after counselling, to formula feed her infant. Formula fed infants should be offered a few clear feeds daily if the weather is very hot.2-55 What formula feed should be used for Bottle fed infants must be held while feeding.a term infant? The bottle should not be propped.A number of formula feeds are available forterm infants (NAN 1, S26, Similac, Lactogen
  12. 12. 40 PRIMAR Y NEWBORN CAREMany of the dangers of infection when using months of age. Thereafter, milk alone is notbottles and teats can be avoided if cup feeds enough and solids should be introduced. Ifare used instead. possible, an infant should be entirely breast fed for 6 months. Even if the mother can only2-57 What are the advantages of cup breast feed for a few weeks or months, thisfeeding over bottle feeding? will be of benefit to both her and her infant. Introducing solids reduces the anti-infectiousIf an infant cannot be breast fed it is better properties of breast milk.to cup feed than to bottle feed. The greatestadvantage of cup feeding is that a cup can Some mothers continue to partially breastbe easily cleaned with soap and water. A cup feed up to 2 years. It is best to continue breastalso dries easily, especially if placed in the feeding after solids have been introduced.sun, which helps to sterilise the cup. This is This practice is particularly important in poormost important when clean or boiling water is communities as breast milk provides the infantnot available for washing bottles. A cup feed with a good source of protein and helps reduceusually takes less time than a bottle feed. It is the risk of pregnancy in the mother. Weaningalso easier to wean a preterm infant from tube should be done over a few weeks by droppingfeeds onto cup feeds than onto bottle feeds as one feed per week.many infants can swallow well before beingable to suck. Any small plastic cup or dish can Whenever possible infants should be entirelybe used to feed an infant. Breast milk can be breast fed for 6 months.expressed directly into the cup before a feed isgiven to a preterm infant. Mothers who do notbreast feed should be shown how to cup feedbefore they are discharged home after delivery. THE BABY FRIENDLYIn some infants bottle feeding may cause APPROACHproblems with breast feeding as themechanism of sucking from a bottle isdifferent from feeding at a breast. This is often 2-60 What is a baby friendly hospital?called ‘nipple confusion’. The idea of a ‘Baby Friendly Hospital’ or clinic was introduced by the World Health2-58 Iron and vitamin supplements Organisation to promote the advantagesneeded? of breast feeding. An agency is available toA normal term infant born to a healthy mother registers hospitals as baby friendly. To becomeon a good, mixed diet and regularly exposed to registered as a Baby Friendly Hospital all thesunlight does not need supplements in the first ‘Ten steps to successful breast feeding’ have to6 months of life. Additional iron and vitamin be implemented.supplements may, however, be of benefit inpoor communities when iron drops 0.3 ml (or 2-61 What are the ten steps to successfulsyrup 5 ml) and multivitamin drops 0.3 ml (or breast feeding?syrup 5 ml) can be given daily. Supplementsgiven to well term infants are not harmful. 1. Have a written breast feeding policy that isRemember that all preterm infants need more frequently communicated to all the healthsupplements (0.6 ml). care staff. 2. Train all the health care staff in the skills needed to implement successful breast2-59 When should solids be introduced? feeding.Normally breast milk or formula feeds will 3. Inform all pregnant women about themeet all the infant’s nutritional needs until 6 benefits of breast feeding.
  13. 13. CARE OF NORMAL INFANTS 414. Help mothers to start breast feeding within 1. Does the infant appear normal, active and 30 minutes of delivery. healthy?5. Show mothers how to breast feed and teach 2. Does the infant feed well? them how to maintain lactation even if 3. Can the mother feed and care for her infant? they are separated from their infants. 4. Does the infant weigh 1800 g or more?6. Do not give newborn infants formula or If the answer to any of these questions is ‘No’ water feeds unless this is indicated for the infant should not be discharged. medical reasons.7. Allow mothers and their infants to remain together all the time from delivery to 2-64 What advice should the mother be discharge. given about an infant at discharge?8. Encourage demand feeding. Before discharge all mothers must be advised9. Discourage the use of dummies, teats and about: nipple shields.10. Promote the formation of breast feeding 1. Feeding their infant. support groups and refer mothers to these 2. Bathing and dressing their infant. groups on discharge from hospital or clinic. 3. Follow-up appointments and arrangements. 4. Reporting immediately if the infant appears ill or behaves abnormally.2-62 What are the advantages of the baby 5. The importance of the Road-to-Healthfriendly approach to the care of infants? Card (preschool card).It promotes exclusive breast feeding andbonding between mother and infant. This 2-65 Should normal infants be followed upis particularly important in communities after discharge?where malnutrition, gastroenteritis and childabuse are common. The baby friendly way of If the infant is discharged before 7 days of age,infant care is also kinder, gentler, cheaper and the infant should be seen at home or at a clinicbetter. Every effort must be made to make all on days 2 and 5 to assess whether:hospitals and clinics baby friendly. 1. The infant appears healthy or sick.If HIV positive mothers decide to breast feed, 2. The infant is feeding well and receivingthen exclusive breast feeding may reduce the enough milk.risk of mother to child transmission of HIV. 3. The mother is managing to care for herIf they decide to formula feed, many of the infant.practices which encourage bonding can still be 4. The cord is clean and dry.practised. 5. The infant is jaundiced. 6. The mother has any problems with her infant.DISCHARGING A NORMAL After the age of one week, the normal infant should be followed at the local ‘well baby’INFANT clinic to assess the infant’s weight gain and general development, and to receive the required immunisations. These details must be2-63 When can an infant be discharged noted on the Road-to-Health Card.from the hospital or clinic?Most normal newborn infants can bedischarged 6 hours after delivery. Before CASE STUDY 1discharging an infant from either a hospital orclinic, you should ask yourself the following An infant is delivered by spontaneous vertexquestions: delivery at term. Immediately after birth
  14. 14. 42 PRIMAR Y NEWBORN CAREthe cord is clamped and cut and the infant CASE STUDY 2is dried. The infant cries well and appearsnormal. The infant has a lot of vernix and a Starch powder is sprinkled onto the umbilicalblue mark is noticed over the lower back. The cord of a newborn infant twice a day to hasteninfant passes urine after delivery but does not drying. The cord is then covered with a linenpass urine again for 24 hours. binder. The mother is worried that the infant has enlarged breasts. As the ward is cold at1. When should the infant be given to the night, she puts the infant into her bed.mother?As soon as the infant is dried, the cord cut, 1. What do you think of the method of cordthe Apgar score determined and a brief care in this infant?examination indicates that the infant is a The cord should be dried with surgical spiritsnormal, healthy term infant. The father should and not covered with starch powder. Coveringalso be present to share this exciting moment. the umbilical cord with a binder is incorrect as it prevents the cord drying out.2. What is the blue mark over the infant’sback? 2. What treatment is needed for the infant’sA ‘mongolian spot’, which is normal. It is enlarged breasts?important to explain to the mother that it is No treatment is needed and the mother mustnot a bruise. It disappears over a few years. not squeeze the breasts. The mother must be reassured that breast enlargement resolves3. Should the vernix be washed off spontaneously in a few months.immediately after delivery?Infants should not be bathed straight after 3. What would you advise the motherdelivery, as they often get cold, while vernix about sleeping with her infant?should not be removed as it helps protect the If the ward is cold and there is no simple wayinfant’s skin from infection. It would be better of keeping the infant warm, then the infantto bath the infant the following day, in the should sleep with the mother. It is importantmother’s presence, when most of the vernix that infants do not get cold. Kangaroo motherwill have cleared. care is a very effective method of keeping the infant warm.4. Should the infant stay with the motherafter delivery?Yes, if possible the mother and her infant CASE STUDY 3should not be separated after delivery. A normal infant weighs 3000 g at birth. By5. Does it matter if the infant only passes day 4 the infant appears well but the weighturine once in the first 24 hours? has dropped to 2850 and it is suggested that formula be started. The next day the motherNo. During the first few days a normal infant has painful, engorged breasts. The policy inoften does not pass urine frequently. However, the hospital is to keep all normal infants inafter day 5, an infant should have at least 6 wet the nursery where the mothers can visit atnappies a day. feeding time.
  15. 15. CARE OF NORMAL INFANTS 431. Is the weight loss of 150 g normal for this 2. Why should the infant not be sentinfant? immediately to the nursery?Yes. An infant may normally lose up to 10% of It is important for the mother to hold herthe birth weight in the first 5 days after delivery. infant after the delivery. This promotes breast feeding and bonding. It is best if mother and2. Should formula feeds be started? infant be kept together.No. Within a day or two the mother should 3. Why is it incorrect to advise formulahave enough milk and the infant will start to feeds if the breast milk appears to begain weight. weak?3. How should the mother’s engorged Both foremilk and colostrum often appearbreasts be managed? weak. This is normal and never an indication for formula feeds.Stop formula feeds and allow the infant tobreast feed frequently. 4. What are the dangers of a poor rural woman giving bottle feeds?4. What do you think of normal infantsbeing kept in the nursery? She may not be able to clean the bottle and teat correctly. Cup feeds would be safer if formulaNormal infants should room-in with their is used as a cup is easier to clean. This mothermothers. should be encouraged to breast feed. 5. Why is it important that this womanCASE STUDY 4 breast feed her infant?A well newborn infant is given clear feeds of 5% She will not be able to buy formula as shedextrose for the first day. As the mother is tired is poor and probably does not live close toafter the delivery, the infant is immediately sent a shop. As a result the infant is at high riskto the nursery. On day 3 the mother is advised of gastroenteritis and malnutrition. Theseto bottle feed as her milk appears to be too problems can usually be prevented by breastweak. She is a poor women who plans to return feeding.to a rural district. It is suggested that the infantstarts solids at 1 month. 6. When should the infant be given solids? This mother should breast feed for as long as1. Should clear feeds be used in a healthy possible. It would probably be best if solidsnewborn infant? were only started at 6 months.No. Feeds should be started with breast milkor full strength formula.

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