Newborn Sleeping

How many hours a day should my newborn be sleeping?

Newborns sleep for the vast majority of the day, usually in the range of 18 to 20 hours a day.

What is the proper position for a newborn to sleep in? Are sleep positioners necessary?

The proper position for a newborn to sleep is on his or her back. Although during your hospitalization, some nurses may place the baby on his or her side, this is not recommended when you bring the baby home. Placing a baby on his or her back for sleep is one of the few methods you have to protect your baby against Sudden Infant Death Syndrome, or “crib-death.” Since the American Academy of Pediatrics instituted the “Back to Sleep” campaign, the incidence of SIDS has dramatically decreased. Recently the AAP issued a warning about sleep positioners as they have been found to place babies at higher risk of su ocation. Therefore, we recommend against the use of them.

How do I reduce the risk of Sudden Infant Death Syndrome?

Sudden Infant Death Syndrome (also known as SIDS or crib-death) is a rare syndrome that causes unexplained death in an otherwise healthy child in the first year of life. The most reliable method to protect your baby against SIDS is placing the baby to sleep on his or her back, as above. Other ways to protect an infant against SIDS include: eliminating any second hand smoke, avoiding over bundling and overly heated bedrooms, and removing extra blankets and stu ed animals from the crib or bassinet. Some research has shown that having a fan in the room has also can decrease the incidence of SIDS.

Do you recommend swaddling?

Swaddling can be a great way to comfort a crying child, and many of our patients respond very well to it. That being said, there are some babies who do not like being swaddled and even in the newborn period will find a way to kick themselves out of the tight wrapped blanket.
Is it okay for our family to co-sleep in the same bed?

The American Academy of Pediatrics recommends no co-sleeping with parents because of the increased incidence of Sudden Infant Death Syndrome. That being said, many cultures and other countries embrace co-sleeping as an important part of family life. It is important for you to analyze the risks and the benefits of co-sleeping before you make your decision. If you decide to co- sleep, it is very important to ensure that there are not excess blankets that could cover the baby’s face.

When is it okay to let my baby cry?

There is no right answer to this question. In the newborn period, you are getting to know your child and his or her needs. Crying can mean many di erent things: hunger, an uncomfortably wet diaper, a desire to be held, or simple irritability. In these first few weeks, it is best to assume that your baby is trying to tell you something and only “let the baby cry” if all of the above possible causes of distress have been ruled out. If you feel like your baby is in pain or discomfort, it is best to call your physician to rule out any other reasons your baby may be crying. 

Newborn Feeding/Weight Gain

How often should I breastfeed?

The frequency of breastfeeding is di erent for every newborn and your baby will determine his/her own feeding schedule. Most newborns end up feeding about every 2-3 hours (and it can be more frequent than that!). In the first two weeks of life, the baby should not go any more than 4 hours without feeding (at least until the baby regains his or her birthweight), and should feed at least 8-12 times in 24 hours. If your baby is sleepy, you may have to undress him or her, tickle the feet or rub the back to wake him or her for feeds. With time, you will find that your baby will fall into his or her own schedule during the day and night. Babies may have periods in the day when they cluster their feeds, feeding every hour, and this is normal.

How long will it take for my milk to come in? Is there anything I can do to make my milk come in faster?

Mature human breastmilk usually comes in about 72 hours after delivery. The breasts swell and become engorged with milk. With second and third pregnancies, milk can come in slightly earlier. Until the mature milk comes in, mothers produce an early milk called “colostrum” which provides for all of the baby’s nutritional needs. The best thing for you to do to “help” the mature milk come in is to allow your baby to suckle on the breast. The sensation of suckling at the breast produces release of a hormone in the brain which tells the glands in the breast to initiate milk production. Although there are a number of other remedies, such as Fenugreek and Mother’s Milk Tea, these are typically used to stimulate breastmilk production once the milk has already come in, not to hasten its arrival.

Is it okay to supplement with formula or sugar water until my milk comes in? What do you recommend?

It is not necessary to supplement with formula or sugar water from a nutritional standpoint. However, some parents find that their babies are more fussy and irritable until the mature milk comes in and are soothed by a few ounces of formula to “tide them over.” We would recommend not introducing formula until breastfeeding has become well established, but we support parents who decide to supplement while in the hospital. We would recommend that if the baby is going to be receiving significant amounts of supplementation (more than 2 ounces per day), that this should be formula and not sugar water. It is also important to remember to always put the baby to the breast first in order to stimulate milk production before supplementing with formula. If you give your baby formula, always follow package directions when preparing it. You do not need to boil water before preparing formula.

My baby has lost 10 ounces since he/she was born. Is this okay?

Babies normally lose up to 10 percent of their birth weight in the first week of life and regain it in the second. We will be monitoring the baby’s weight both in the hospital and in our o ce. Our goal is for your baby to have regained his/ her birth weight by the 2 week o ce visit.

How much spit up is normal?

Many babies spit up when they feed, and it is usually normal. If your baby spits up often, keep his or her head raised for at least 30 minutes after feeding. Spitting up small amounts is harmless as long as your baby is gaining weight and is not in pain. Spitting up usually ends by age six to nine months. If the spit up becomes projectile and is associated with every feed, that would be abnormal and might require some tests to work up the problem. Other symptoms that may indicate that your baby has reflux are: irritability after feeding and arching of the back. Make sure you are burping with each feed as this will help to expel some of the air the baby may have swallowed. After feeds, gently burp the baby by holding the baby on your chest, upright and gently patting or stroking the back. Do this for 2 to 5 minutes. Your baby may not burp after every feeding.

Who should I contact if I am having a difficult time with breastfeeding?

During your hospital stay, you should take advantage of the nurses and the lactation consultants provided by the hospital. Once you are home, you are always free to bring breastfeeding questions to our o ce, but for issues that require more time and expertise, we wholeheartedly recommend the lactation consultants at the Pump Station. Our patients with difficult breastfeeding issues have had an incredible response to the assistance given by their consultants and the various services provided by the Pump Station: pumpstation.com. We also have names of lactation consultants that make house calls. Please call our o ce for more information.

What are the advantages to breastfeeding over formula feeding?

Breastfeeding has many distinct advantages over formula feeding for the baby, including but not limited to enhanced immune system, decreased incidence of food allergies and eczema, lower obesity rates, and fewer ear infections. The American Academy of Pediatrics recommends breastfeeding for the first year of life. This being said, we understand that breastfeeding is not the best decision for every family and we support parents that decide to opt for formula instead.

Are there any contraindications to breastfeeding?

There are very few contraindications to breastfeeding. If you are taking a medication, please let us know before breastfeeding, so that we can verify that is safe for lactation. Of note, Tylenol and Advil (which is not recommended during pregnancy) are both safe medications to take while breastfeeding. Real contraindications to breastfeeding include: active herpes lesions on the breast, mother positive for HIV, and certain antibiotics.

Are there any foods that I need to avoid while breastfeeding?

A breastfeeding mother has a great deal more freedom than a pregnant woman. Many of the foods that are o -limits in pregnancy are okay while breastfeeding, if eaten in moderation: alcohol, ca eine, and mercury-containing fish included. If a large amount is consumed, it may be wise to “pump and dump” the expressed breast milk from when the next feed is due, and give the baby some stored breastmilk for that particular feed. A breastfeeding woman should focus on eating a well balanced diet, drinking lots of fluids, and remaining on her prenatal vitamins. We are currently recommending that breastfeeding mothers take a DHA/ARA containing fatty acid supplement, which has shown thus far to have a positive benefit on neurologic development.

If I decide not to breastfeed, what formula is best?

Choosing a formula can be overwhelming for a new mom as there are literally hundreds to choose from. Most babies will do just fine with the basic, modified cow’s milk formulas: Enfamil, Similac, or Good Start. The AAP recommends that any formula you use be iron-fortified. If your baby develops symptoms of a dairy protein allergy, your pediatrician may recommend a hypoallergenic formula such as Nutramigen or Alimentum. These formulas should also be given to newborns when there is a family history of significant allergies in the parents or siblings. Some babies may show signs of gassiness, and it may be recommended to try a sensitive formula, such as Similac Sensitive, Enfamil Gentlease, or Good Start Soothe. Again, it is best to speak with your pediatrician prior to switching formulas as they can help guide you in your decision. 

Newborn Hospital Protocol

How long can we expect to stay in the hospital?

The typical hospital stay is the same at St. John’s, Santa Monica/UCLA and Cedars-Sinai Medical Centers. After a vaginal delivery, new mothers stay in the hospital for 2 days after delivering their baby. Following a cesarean delivery, a 4 day hospital stay is recommended by obstetricians.

How often will we see a pediatrician while in the hospital?

Your baby’s first exam will take place within 24 hours after you deliver, usually between the hours of 6am and 9am. The first exam is a thorough exam in which the doctor will examine the baby’s eyes, heart, lungs, extremities, and reflexes. For the remainder of your hospital stay, the pediatrician will visit daily (typically in the mornings before o ce hours) and monitor the baby’s feeding, weight loss, and physical exam. If you have any questions for the doctor, please write them down and we would be happy to answer them when we stop by.

What is the reason for the Vitamin K shot after birth?

Some babies are born with low levels of vitamin K, which is a very important factor for blood clotting. Babies who are born with low levels of vitamin K can develop what is known as “hemorrhagic disease of the newborn,” a dangerous life-threatening condition in which babies have uncontrollable bleeding. A single shot of Vitamin K prevents this disease, and is given to all babies born in the United States. Oral vitamin K is not a viable alternative, because it takes too long to reach sufficient levels in the baby’s body to protect them against the disease.

Why is the erythromycin ointment applied to my baby’s eyes?

Erythromycin is an antibiotic ointment that is applied to the eyes of all newborns to prevent chlamydia and gonorrheal eye infections. Although the vast majority of women are screened for these diseases during their pregnancies, these sexually transmitted diseases have a tendency to be “silent” and women can carry them without knowing it. For this reason, all babies are treated and protected in the United States, especially because the consequences of leaving these eye infections untreated are so terrible: blindness and permanent visual damage.

What is the newborn screen and what diseases does it test for? When do we get the results?

The newborn screen is a mandatory blood test that is performed on every baby in the United States prior to discharge from the hospital. It screens for a number of di erent genetic (inheritable) diseases which require early intervention, including: phenylketonuria, sickle cell anemia, hypothyroidism, and a group of rare disorders that are known as “inborn errors of metabolism.” The results will be mailed to our o ce and we should have them by your baby’s 2 week well child visit. If you are following up with a di erent o ce, be sure to have them call us so we can fax over the results to your pediatrician.

Will my baby get a hearing screen?

Every baby gets a hearing screen before leaving the hospital. Both ears will be tested and the results will either be “pass” or “referred.” If the results show the baby is “referred” in one or both ears, it does not mean that your baby has a hearing deficit. The test performed in the hospital is a screening test and will pick up some “false positives,” babies with normal hearing that falsely test positive for a hearing deficit. If your baby is referred, we will refer you for a more accurate hearing test after your first visit to our o ce. 

Water Safety

Rule #1: Children should never be left alone near water.
Rule #2: Flotation devices DO NOT take the place of adult supervision.
Rule #3: Even shallow water (a few inches deep) is enough for children to drown.

Water and children are dangerous partners. ALWAYS BE WATER SAFE. It is also important, living in the Southern California area, to introduce your children to swimming classes at a young age. 

Vomiting

Vomiting is a common symptom in childhood and is usually caused by a viral infection of the stomach. This is known as ‘viral gastroenteritis’. Symptoms may last up to one week and often include diarrhea, crampy abdominal pain and fever. The vomiting is often the greatest in the first 24 hours of illness. There is no treatment for viral gastroenteritis other than adequate rehydration to replete lost fluids.

The replacement of fluids is important in the vomiting child, but parents should wait at least 30 minutes after a vomiting episode to begin fluid introduction. This gives your child’s belly a chance to rest. Offering your child small amounts of clear liquids is the key to treatment success. One teaspoon every five to ten minutes will ensure adequate hydration.

If your child is able to tolerate these small amounts, the volume can be gradually increased. If your child does not eat any solids for several days, don’t worry! They will be ‘okay’. It is common to lose up to 5 – 10 % of body weight during a period of gastroenteritis.

Important signs of dehydration:
*No urine output for over 8 hours *No tear formation during crying *Dry lips and mouth

Call our office if your child:
*Shows any signs of dehydration (see above)
*Unable to keep fluids down after several attempts of feeding *If you see any blood in your child’s vomit or diarrhea
*Fever that persists for more than 72 hours
*Severe localized abdominal pain 

Teething

Infants begin teething between four and six months of age. The first teeth to come in are often the bottom two middle teeth, followed by the two upper central teeth.

Symptoms associated with teething are increased drooling, swollen gums, increased fussiness and general discomfort. A slight temperature is frequently associated with teething, but a temperature over 100.4 is atypical and your pediatrician should be called.

Treatment for teething consists of applying a cool wash cloth to your child’s gums, applying teething gels like Nums‐it or Orajel, allowing your child to gnaw on a cooled soft toy like a “teething ring” and finally giving Tylenol or Motrin (if older than six months) if your child has significant discomfort. 

Sun Safety

All children should be protected from sunburn with protective clothing like hats and fine‐meshed shirts as well as a sunblock.

Our recommendation is to apply a PABA‐free, UVB/UVA sunscreen that is waterproof and has a sun protection factor (SPF) of 30 or greater. Sunscreens should be applied 30 minutes before outdoor activity and should be reapplied several times throughout the day, especially after coming out of water, to insure proper protection.

For children less than 6 months of age, the best approach is to avoid direct sun exposure and to use protective clothing. If direct sun is unavoidable, sunscreen application is ‘ok’ to utilize.

The Environmental Working Group has a website that gives a list of the most environmentally safe and friendly products. The link to this site is: www.cosmeticsdatabase.com. 

Introducing Solids

Most babies are ready to eat solid foods between four and six months of age. Before beginning solids, your infant should have good head control. Children with a family history of allergies should consider introducing food at six months of age.

FOUR TO SIX MONTHS: Generally, we recommend starting with two tablespoons of rice cereal twice a day for the first two weeks. (This simple grain cereal is generally well‐tolerated by infants and allows the child the opportunity to “learn” what it is like to take solid foods.)

After two weeks of rice cereal, white fruits (such as apple sauce, pears and bananas) and yellow vegetables (such as squash, carrots and sweet potatoes) may be introduced on a one‐ at‐a‐time basis every 4 to 5 days. A third meal can be added at this time as well.

This slow introduction process allows parents to assess for food allergies or intolerance, which can manifest as rashes, diarrhea or vomiting of the food. Any food that causes these symptoms in your child should be stopped immediately and your pediatrician should be notified.

Later on, after these blander foods are introduced, green vegetables (such as spinach and broccoli) and colored fruits (such as apricots and peaches) can be introduced. White meats, (such as chicken, fish and lamb) can be introduced around six months of age. Red meat, rich in zinc and iron, is typically introduced around eight to nine months of age.

EIGHT TO TEN MONTHS: This is a good time to introduce finger foods into the diet. Make sure that the pieces are cut up into small pieces (Cheerio‐sized) and that the food is soft enough to chew. You can also introduce egg yolks and dairy products like yogurt and soft cheeses at this time. If there is a family history of dairy allergy, however, we recommend that you speak with your pediatrician before starting these foods.

When a larger variety of solid foods is introduced, mothers will notice a decrease in the number of breastfeeding episodes to 4 to 5 times per day or a decrease in the amount of formula to about 20 to 14 ounces per day.

TEN TO TWELVE MONTHS: By this age, your baby’s diet should include nearly all table foods except those listed below:

**Do not give your child any honey, whole milk, citrus, peanut butter, nuts or shellfish prior to one year of age.

**Avoid nuts, popcorn, hotdogs, chewing gum, whole grapes, uncooked carrots and hard candy prior to three years of age due to the risk of choking.

Head Injuries

Head injuries are common among young children. Fortunately, serious consequences are rare, especially if there has NOT been a loss of consciousness after the injury.

The best way to avoid a head injury is to prevent it. Car seats or booster seats from birth through six years OR 60 pounds are not only the law, they are a good idea! Always buckle up your child.

Once your child becomes mobile, safety proofing your home is important. Be wary of sharp edges, tabletops and fireplaces.

Children like to climb on furniture, so be sure that wall units and bookcases are fixed to the wall.

Finally, children should wear a protective head gear while doing any activity that could result in head injury. Bicycle riding, skiing and skateboarding are three good examples.

IF YOUR CHILD DOES SUSTAIN A SIGNIFICANT HEAD INJURY, we recommend that you call us immediately. Having your child evaluated by a physician is also critical.

IN THE FIRST 24 HOURS AFTER INJURY, your child should be monitored for the following symptoms:

‐ Increased fatigue
‐ Vomiting and nausea ‐ Headache complaints

‐ Double or blurred vision ‐ Unsteady gait
‐ Personality changes
‐ Confusion

‐ Excess irritability

**If your child displays any of the above symptoms, please call us for an evaluation. 

First Aid Kit - What to Include

We recommend having the following products at home so that when they are needed, you are well prepared.

1. Infant/Children’s Tylenol (Acetaminophen)

2. Infant/Motrin (Ibuprofen) ***Not to be given to children under 6 months 

3. Desitin or other diaper rash cream with Zinc Oxide

4. Sunblock: PABA free with both UVA and UVB coverage

5. Children’s Benadryl suspension

6. Hydrocortisone 1% ointment

7. Lotrimin (clotrimazole) ointment

8. Aquaphor or other hypoallergenic skin moisturizer

9. Nasal saline drops and bulb suction (We like the Nasal Aspirator) 

10.Thermometer and KY jelly for rectal digital thermometers

11. Neosporin ointment

12. Cold packs

13. Band‐Aids

14. EpiPen if your child has ever had a severe allergic reaction to foods or environmental stimuli (i.e. Bees). 

Ear Pain

Ear pain is one of the most common complaints in children. As there are many possible causes of ear pain, it is important to have your child evaluated by a physician. It is difficult to assess a child’s ear pain over the phone and cannot be diagnosed appropriately. There are three main causes of ear pain, and we will discuss each one briefly.

1. Inner Ear Infection: Inner ear infections may be caused by either a viral or bacterial infection and therefore not all infections require antibiotics. A recent cold or nasal congestion or fluid in the inner ear places your child at greater risk of an ear infection.

   a. Symptoms include: ear pain, fever, irritability and nasal congestion.

b . Treatment for inner ear infections is typically antibiotics, but in some circumstances, it is okay to watch for 48 hours to see if this will resolve without intervention. Tylenol and Motrin and numbing ear drops will help with pain symptoms.

1. Outer Ear Infection (Swimmer’s Ear) is an infection in the ear canal. Children who swim or have frequent contact with water are at greater risk. Water in the canal can cause irritation and can allow for bacterial infection.

   1. Symptoms: outer ear pain, especially when pulling on ear; discharge from the ear canal. Some children will also develop a fever.

   2. Treatment: antibiotic ear drops

   3. Prevention: if your child develops recurrent outer ear infections, thorough drying of the ears after swimming and bathing may decrease incidence. Over the counter ear drops such as Swimmer’s Ear work well.

2. Teething: Even though it is the gums that are painful and swelling, a child may feel the pain in the ear and this is what is called “referred pain.” The molars are the ones that particularly cause referred pain.

   1. Symptoms: drooling, low‐grade fever, pulling or gnawing on toys

   2. Treatment: see teething section for more details: massaging gums with finger or a cool wash cloth, Tylenol or Motrin for severe symptoms. 

Diarrhea

Diarrhea is defined as a sudden increase in watery stools. It is most often caused by a viral infection of the intestines called gastroenteritis. Diarrhea may present alone or with other symptoms including vomiting, fever and abdominal cramping. It can last for up to a week but typically the symptoms are the most severe in the first 24‐48 hours. Because it is a virus, treatment is supportive care and ensuring adequate hydration. If the diarrhea is persistent, then it is best to speak to your pediatrician, as there are other causes of diarrhea as well.

For children with diarrhea, the most important aspect of treatment is hydration.

Fruit juices may exacerbate the loose stools and it is best to avoid them. For a majority of children, dairy is okay and we encourage continuing to breastfeed, but in a minority of children it may cause increased bloating or cramping. If this is the case, then it is best to avoid dairy until the diarrhea resolves. If you child feels like eating, you can offer foods like bread, rice, applesauce and toast.

Probiotics have also been shown to help decrease diarrheal symptoms and we do recommend giving it daily during this illness.

Please call the office if:

• Signs of dehydration: no urine for more than 8 hours, no tears when

  crying, dry mouth, listlessness, weight loss and sunken eyes.

• Any blood in the stool

• Fever for more than 72 hours

• Localized abdominal pain

• Persisted diarrhea for more than 48 hours 

Croup

Croup is a viral illness that causes fever and inflammation of the upper airway. This inflammation causes the “barky” or seal‐like cough. The swelling can also make the airway so narrow that they have noisy breathing even without coughing and this is called stridor. The cough is usually worse at nighttime and can be very scary for the family.

Children are more likely to get croup between 6 months and 3 years of age. After 3 years of age, the airway is larger, so the swelling typically does not cause any significant trouble. Like other viral respiratory illnesses, it can last for a week but typically there are just 2‐3 nights of significant coughing and the fever usually does not last for more than 72 hours.

Croup can be scary, but it is important to stay calm because the more calm your child is, the more comfortable he will be able to breath. Warm moist air can help with the stridor. Run a hot shower in the bathroom with the door closed and sit with your child for at least 10 minutes. A humidifier in the room while sleeping will also help as well. If your child does not improve and has stridor at rest (as opposed to when he is crying, agitated, or coughing), then he needs to be evaluated and may need steroids to decrease the swelling. Like other viruses, antibiotics will not make this illness better.

Please call the office immediately if your child is having any difficulty breathing. 

Bee Stings

Summertime brings out the bees and sometimes, no matter how careful we try to be with our children, they get STUNG! When this happens, scrape out the stinger gently at the level of the skin. (Grabbing the stinger with your fingers can actually result in more venom being injected into your child.)

Immediately after a sting, your child will experience pain and some swelling.
These symptoms usually resolve within a couple of hours. Some children have swelling and redness that persists for a few days. If this does occur, please contact one of our physicians.

For mild reactions, apply a cold compress to the area. This will help decrease symptoms. Home remedies such as meat tenderizer (that helps to denature the venom proteins) and toothpaste do work. Finally, oral Benadryl is helpful in reducing the allergic response associated with beestings.

Call 911 if your child displays any of the following symptoms:
*Sudden onset of a hoarse voice, shortness of breath or difficulty breathing *Lightheadedness, dizziness or loss of consciousness
*Nausea, diarrhea or vomiting 

Cough and Cold

Children are notorious for having many colds throughout their early years and most will have at least 8‐10 colds in the first two years of life. Since these symptoms can last for up to three weeks, it may feel like they have a constant runny nose!

Colds are caused from viruses and typically peak during the fall and winter months. They are spread directly through contact with the virus such as sneezing or coughing. Cold symptoms are coughing, sneezing, fever, nasal congestion and runny nose. Most children do not need any treatment for viruses and antibiotics are used to treat bacterial infections, NOT viral infections. The best treatment is supportive care. There are many cough and cold medications that are available but these preparations are no longer recommended for children under 4 years of age.

Young infants are susceptible to colds and because they are nasal breathers, may become fussy during feeding or have some difficulty sleeping. In this case, you may need to let your child take several breaks during feeding to catch their breath. To help their breathing, you can place a few drops of nasal saline in each nostril and then suction with a nasal aspirator. The saline helps to break up the mucous and this will help their breathing. We recommend doing this prior to feeding and sleeping. Furthermore, a cool mist vaporizer in the room may help loosen nasal secretions and ensure a more comfortable sleep.

When to call the office:
• Fever that persists for more than 72 hours
•Any difficulty breathing
• Infant less than 2 months old with a fever
• If your child is lethargic or refuses to eat
• Fever that does not respond to Tylenol or Motrin