5 Baby friendly care

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When you have completed this unit you should be able to:

Introduction to baby friendly care

5-1 What is baby friendly care?

This is the care of newborn infants where the needs of the infant and mother are placed before those of the hospital or clinic staff. Baby friendly care is also an attempt to look after the infant in a way that is as natural and humane as possible. As with mother friendly care, baby friendly care is good, evidence based care. The infant, parents and health workers all benefit from baby friendly care.

Baby friendly care is good for the infant, parents and health workers.

5-2 Why is baby friendly care important?

Because it is believed to be the best method of caring for infants in both poor and industrialised countries. Many routines of observation and management in infant care have been developed for sick or high risk infants and are not necessarily needed for well infants. These routines may even be harmful or dangerous to healthy infants. Each infant should be given the best and most appropriate care.

Baby friendly care is also important because it promotes bonding between parents and their infant.

5-3 What is mother-infant bonding?

This is the special, strong, emotional bond or attachment, which develops between a mother and her newborn infant. A similar bond is developed between the infant and father as well as other close family members. Bonding also occurs between an infant and the clinic or hospital staff, especially when a small infant spends many weeks or months in the nursery. Bonding is essential to ensure the good long term parental caring of a child. Therefore, every effort must be made to encourage and support this bonding process.

Baby friendly care must be promoted at every opportunity.

5-4 Is baby friendly care new?

Although the principles of baby friendly care have been known and practiced in some places for many years, it is only been recently that the importance of baby friendly care has been appreciated and actively promoted. Unfortunately, many hospitals and clinics still do not provide baby friendly care.

5-5 Is baby friendly care expensive?

Almost all aspects of baby friendly care can be introduced at no or very little extra cost. Expensive equipment is not needed to provide baby friendly care. Because infants thrive with baby friendly care, hospital expenses and service costs are often reduced. Baby friendly care is cost effective because it is both good and cheap. All levels of care, from primary to tertiary, can be made baby friendly

5-6 Why has baby friendly care not always been used?

Because of ignorance, selfishness or an inability to change. In the past it was not understood what was the best method of caring for newborn infants. Often staff and parents chose methods that were easiest for them. Even if better methods of caring for infants were known, it is difficult to change old habits and routines. Research studies have helped to identify which methods of care result in the best outcome for infants and their families.

5-7 What are the problems with baby friendly care?

Some old routines and practices have to change if we are to give better care. Any change causes uncertainty, insecurity and resistance with parents, health workers and administrators. Many people do not like change, even if the change is to everyone’s benefit. Therefore, the main problem with the introduction of baby friendly care is to convince and support those who need to change. This is not always easy. Introducing baby friendly care requires vision, time, dedication and a lot of effort.

Introducing baby friendly care is often difficult as health care workers have to change their attitudes, beliefs and practices.

5-8 Should baby friendly care only apply to well infants?

No. Baby friendly care should be given to all infants as the principles of baby friendly care can be used for both well and sick or high risk infants.

5-9 When should baby friendly care be used?

Baby friendly care should be used, at all times. Baby friendly care has changed the way that infants are cared for immediately after delivery, in the nursery and postnatal ward, and after discharge home. All levels of care should be made baby friendly.

5-10 What are examples of baby friendly care?

Whenever possible, the following examples of baby friendly care should be practised:

  1. Keeping the mother and infant together after delivery.
  2. Immediate and exclusive breastfeeding.
  3. Discharging the mother and infant home as soon as possible.
  4. Using kangaroo mother care for low birth weight infants.
  5. Allowing open visiting by parents in the nursery.

Care of the infant immediately after delivery

5-11 Why should infants be given to their mothers straight after delivery?

Because it is kind, sensible, practical and the best way of promoting bonding between a mother and her newborn infant. In the past it was incorrectly believed that the mother was too tired to hold her infant immediately after delivery. The staff also believed it was easier for them and the parents if the infant was moved away to the nursery for a few hours until the delivery was completed and the mother had a chance to sleep. Mothers usually were not asked what they wanted. It seemed more convenient for the staff if the infant was not kept in the labour ward or theatre.

After all the excitement, pain and effort of labour and delivery, the mother has every right to hold her infant. As soon as the infant is delivered, dried well, briefly assessed, and the cord cut, the infant should be given to the mother unless there is a medical indication not to do so. Most mothers want to hold their infants after delivery.

Most mothers want to hold their infant as soon as possible after delivery.

5-12 Should the infant stay with the mother after delivery?

Yes. There is no need for most infants to be moved away for routine observations, measurements or procedures:

  1. An Apgar score at five minutes is not indicated in normal infants who have a normal score at one minute.
  2. Routine identification, weighing, eye care and vitamin K can be given once the mother has had a chance to see and hold her infant.
  3. The artery forceps need not be immediately replaced by a cord clamp.
  4. Bathing the infant is not needed straight after delivery.

Allow the mother to hold and breastfeed her infant before the routine procedures are done.

If the infant has problems and must to be taken directly to the nursery, the mother should visit her infant as soon as possible after delivery. Take a Polaroid photograph of the infant for the mother.

5-13 Should the mother and infant be separated when the mother is moved from the labour ward?

No. Not only should the infant be given to the mother immediately after birth, but they should also be kept together if possible when the mother is moved out of the labour ward. If the mother and her infant have to be separated, because either needs medical care, they must be brought together again as soon as possible. Ideally the parents should be allowed some private time to spend together with their infant once the delivery has been completed. This is a very special time for them.

Whenever possible, the mother and infant should be kept together after delivery.

5-14 Why is it important to breastfeed as soon as possible after birth?

Because it is a very effective method of promoting successful breastfeeding. It also encourages bonding and helps to stimulate uterine contractions and delivery of the placenta. If a woman chooses not to breastfeed, she should still hold her infant after delivery. Many women want to put their infant to the breast immediately after birth. It is not important that most women have very little milk on the first day after delivery. When a delivery is being attended only by a single midwife, giving the infant to the mother allows her to concentrate on the safe delivery of the placenta.

Mothers should be allowed to hold and put their infant to the breast immediately after birth.

The choice of breast or formula feeding must be carefully considered before delivery in women who are known to be HIV positive. If the mother decides to exclusively formula feed, she should be given her infant to hold but not to put to the breast. Baby friendly care can still be practiced if a mother decides to formula feed.

5-15 What are the benefits of exclusive breastfeeding?

  1. For the first six months of life, breast milk meets all the nutrition needs of most infants.
  2. Exclusive breastfeeding is the most effective method of preventing infections in the infant, especially serious gastroenteritis.
  3. It reduces the risk of allergy in infants born into a family with a history of allergies.
  4. It is cheap and does not require bottles or cups.
  5. It reduces the chance of the mother falling pregnant again soon.
  6. It helps the mother lose the normal weight gained during pregnancy. Most of the fat built up during pregnancy is to support months of breastfeeding after delivery.
  7. Exclusive breastfeeding reduces the risk of mother-to-child transmission of HIV (compared to mixed breastfeeding) if the HIV infected mother chooses to breastfeed her infant.

Mothers should be encouraged to exclusively breastfeed for the first six months and then continue to breastfeed for as long as possible after other feeds are introduced.

There are many benefits of exclusive breastfeeding for both mother and infant.

5-16 Should mothers give Kangaroo Mother Care to their infants after delivery?

Yes. Once the infant has been well dried, it should be placed skin-to-skin between the mother’s breasts. She can now keep her infant warm and they can get to know each other. Infants receiving KMC are less stressed than infants placed alone in cribs.

5-17 When should the mother and infant be discharged home?

If both are healthy and normal, they can usually be discharged home after six hours. Most of the serious complications after delivery (e.g. post partum haemorrhage in the mother or respiratory distress in the infant) will have presented before this time.

5-18 What are the advantages of early discharge?

  1. Usually the mother wants to be at home with her family and away from the clinic or hospital.
  2. It allows the mother to relax, sleep and establish breastfeeding at home.
  3. At home she is familiar with the routines and has her family to help and support her.
  4. The mother and infant are less likely to develop infections at home.
  5. It saves staff and expenses and helps to avoid overcrowding in hospital.

Care of the infant in the nursery

5-19 How can care in the nursery be made baby friendly?

Many changes can be made in a newborn nursery to provide better care for infants:

  1. Recognising infants as individuals.
  2. Encouraging mothers and family to spend time with their infant.
  3. Improve communication between parents and staff.
  4. Make the nursery environment as relaxing as possible.
  5. Promote nesting, cluster investigations and handling, and quiet times.

5-20 Why should infants be recognised as individuals?

As with adults and older children, it is important that each infant be recognised as an individual with his or her own personality and needs. This improves both staff and parent bonding with the infant which improves care. Whenever possible, care should be tailored to meet the individual needs of infants.

Every effort must be made to make infants recognisable as individuals.

Many simple steps can be taken to make infants recognised as individuals. One of the most important ways is to give infants names.

5-21 When should infants be given names?

As soon as possible. Parents often decide on a name or short list of possible names during the pregnancy. Most infants can be given a first name within the first week, even if it is only a ‘nick name’. Often an infant is only recognised as an individual when a name is chosen. However, some parents need to consult distant family before a name can be given. Failure to name an infant may be a sign of poor bonding.

In many cultures an infant has no rights and is not accepted as a member of the community until it is formally named.

5-22 How should the infant’s name be displayed?

Usually the mother’s first name and surname are given on the infant’s records and on a card attached to the overhead radiant heater, incubator or cot. The name is also on the identification tag on the infant’s wrist and ankle. As soon as an infant is given a first name, this should be added to the infant record and identification labels. Staff should be encouraged to refer to infants by their names.

5-23 How can name labels easily indicate whether the infant is a boy or a girl?

This is simply done by colour coding with blue labels for boys and pink labels for girls. Either a coloured card can be used or a white card with a coloured stripe added with a crayon or highlighter. Identifying the gender (sex) of the infant helps to give him or her some individuality. It is also very useful when staff speak to parents. At a glance one knows the gender of the infant if the coloured label is clearly displayed. It improves staff communication with parents to know the gender of their infant.

Each infant in the nursery should have a clearly visible label giving the infant’s name and gender.

5-24 How should infants be dressed?

Infants usually wear nappies (diapers), to make nursing easier, and are partially dressed to avoid heat loss. Woollen caps and cotton jackets are worn. However, other clothes can be worn to individualise infants and promote bonding. Mothers should be encouraged to bring their own clothes for the infant. Booties, leggings and ‘baby-grows’ are popular. Different and attractive colours also help to make infants look different from one another. Some parents bring a small cover or even a duvet.

Do not bath all infants in the same place as this increase the risk of spreading infection. Infants are usually bathed in their plastic bassinettes. Dry infants immediately after a bath to prevent hypothermia.

5-25 Should messages and toys be allowed in a nursery?

Parents should be encouraged to bring written or drawn messages and cards for their infants. They can be placed inside or outside a closed incubator. Some parents bring toys, especially a doll or teddy bear. This makes parents feel that the infant is their own and does not simply ‘belong to the hospital’. It is safe to have toys in an incubator. However, toys must not be moved from one infant to another as this can spread infections.

5-26 How can infants be handled more gently?

Infants are often alarmed when handled, especially if they are handled roughly and with cold hands. They get a fright, cry and become jittery. Often they display the startle reflect with outstretched arms and open hands. Rough handling may even precipitate apnoea, vomiting or cyanosis.

Infants must always be handled gently, slowly and with warm hands. Do not suddenly turn the infant over. Infants must always be handled with respect. Simply because an infant cannot always express pain, fear and anxiety, does not give careers the right to ignore an infant’s feelings.

5-27 How can stressful procedures be best managed?

Some stress is unavoidable such as needle sticks. Gentle handling helps. The procedure should be done quickly and expertly. Holding, touching and talking soothingly after the procedure reduces the duration of crying. Putting the infant to the breast is very helpful in reducing the stress. A small feed of milk or glucose water also helps. Only do procedures that are necessary and not simply because they have been done routinely for years, e.g. blood glucose or serum bilirubin measurements on all newborn infants.

Often parents are asked to leave the room when stressful procedures are performed. However, some parents prefer to remain with their infant so that they know what is being done. They will also be there to comfort the infant during and after the procedure. Parents should be given the option.

5-28 What is cluster care?

Whenever possible, investigations and handling of infants should be clustered together so that they can be done at the same time. This is preferable to repeatedly disturbing the infant. For example, the routine observations, nappy change and blood sampling for glucose measurement can all be done together rather than each at a different time. As a result the infant is disturbed once and not many times. This requires planning and organisation. Cluster care is not always easy with a shortage of staff but every effort should be made.

5-29 What is the importance of quiet times?

It is important that both well and sick infants be allowed quiet times when they can rest and sleep. This is important for growth and recovery. Being continually stimulated and disturbed is very stressful. During sleep the oxygen and energy needs of infants fall.

Infants should be allowed time to sleep.

5-30 Should the nursery always be brightly lit?

Remember that infants can see well. Sometimes a good, bright light is needed to examine an infant or perform a difficult procedure. However, at most times the lighting in the nursery does not have to be bright. Curtains or blinds can also be used to prevent direct sunlight reaching infants. With the wider use of electronic monitoring, bright lighting in the nursery at all times is not necessary. Many nurseries now reduce the lighting at night.

Under phototherapy, the infant’s eyes should be covered. This is done for comfort. Their eyes can be uncovered during feeding times. A screen may be needed to shield other infants from being disturbed by phototherapy lights.

5-31 Can noise be a problem in the nursery?

The nursery must not be a noisy place as infants have good hearing and are easily disturbed. Like bright lights, noise is stressful to infants, parents and staff. Frequently sounding, loud alarms are particularly stressful. Incubator motors can also be very loud, especially if they are not routinely serviced. Telephones can also be too loud. Staff should not speak loudly, shout or laugh loudly in the nursery. It is not appropriate to have a television set in a nursery as it distracts the staff and parents.

5-32 Should both the mother and her partner be allowed to visit an infant in the nursery?

It is essential that both parents visit their infant in the nursery as soon as possible after birth. Not only is this very important for bonding but it is the parents right to see their infant. Strict visiting hours should not be kept in the nursery. Parents are encouraged to visit their infant whenever possible and to spend as much time as they can with their infant. Often working fathers can only visit in the evening.

In some nurseries, parents are asked to wait outside during ward rounds. This may be needed to keep the diagnosis of infants confidential. They may also be asked to leave if an infant needs resuscitation or if an infant has died.

Parents should be encouraged to spend as much time as possible with their infant in the nursery.

5-33 Should parents be allowed to touch their infants?

Yes. Parents must be encouraged to touch their infant, as this is a very important part of bonding. Many parents are afraid of touching and possibly hurting a very small or sick infant. However, even very ill infants in intensive care can be gently touched.

Usually parents touch the infant’s hands and feet first before they touch the head and trunk. This is often very reassuring for the parents. A mother will often sit for a long time, beside the incubator, touching and talking to her infant. Unmarried fathers should also be allowed to visit their infants if the mother agrees. Everyone, including patents, must always wash their hand with soap, or spray them with a disinfectant (e.g. chlorhexidine in alcohol), before touching an infant.

It is important that parents touch their infant.

5-34 Should siblings be allowed into the nursery?

Yes. It is important for the siblings to also visit and touch their newly born brother or sister. The siblings are always interested in the new addition to the family and need to bond with the infant. Visiting children in the nursery must always be accompanied by a parent, they must be closely supervised and well behaved and must always wash their hands before touching the infant. Siblings who are sick (e.g. a common cold) must not be allowed into the nursery. The risk of siblings infecting an infant is no greater than that of the parents or staff. Anyone who has an infectious illness, especially a viral illness, should not be in contact with small infants.

Siblings should be allowed to visit an infant in the nursery.

5-35 Should other family members be allowed to visit the infant?

Usually grandparents are also allowed to visit an infant in the nursery. This is very important if the mother does not have a partner or if the grandparents are going to help look after the infant. Bonding between grandparents and the infant is especially important when the mother is very young and still living at home. Unless under exceptional circumstances, other family members and friends are not usually allowed into the nursery. The nursery cannot be filled with visiting family members. Only one or two people are allowed to visit an infant at one time.

5-36 How should the nursery be decorated?

The appearance of the nursery affects the mood and behavior of all that work or visit there. The nursery and intensive care unit should not look like a stark hospital ward with white walls and no decorations. A light colour, such as blue or pink, makes the nursery appear gentler and less threatening. It also makes the work environment less stressful to the staff. Curtains should have restful colours and patterns. Pictures or posters can be hung on the walls. Breastfeeding mothers and young animals are favourite topics.

5-37 What clothes should staff wear in the nursery?

Not only does light, attractive, comfortable clothing make the working conditions more enjoyable for the staff but improves the environment for everyone. Formal uniforms are often threatening to parents. All staff must wear name tags so that they can be identified by parents. Doctors need not wear white coats. Long sleeves should always be rolled up to avoid spreading infection. Clothing should be practical and clean but not provocative. Usually wedding or engagement rings can be worn.

5-38 Should music be allowed in the nursery?

Soft, gentle background music is soothing to staff and parents and makes the atmosphere in the nursery more relaxed and less stressful. If a radio is to be used, loud music or the spoken voice should be avoided. Recorded classical music is best. The volume of the music should be turned down during quiet times.

A view to the outside world reduces working stress. Efforts must be made, however, to reduce excessive heat loss or gain through windows by using curtains or blinds or by double-glazing the windows. Avoid direct sunlight in the nursery. Curtains may become dusty but do not collect bacteria. They should be washed regularly.

5-40 What is nesting?

The unborn infant is ‘nested’ safely in a warm, dark and quiet intra-uterine environment where the infant is enclosed in a small space. The infant can touch the uterine walls. Newborn infants also need to feel secure in a closed space. The ideal closed space is provided by kangaroo mother care. A similar environment can be created in a closed incubator or overhead radiant heater by ‘nesting’. A towel or small cotton blanket is rolled up and placed on the mattress around the infant to form a circle or horse-shoe. Infants are often nested on their side which helps to keep their back flexed. It is important that the infant’s head does not lie on the towel as this will flex the neck, which can obstruct breathing. Infants are usually nursed on their back or side as this reduces the risk of ‘cot death’. However, infants with respiratory distress or reflux are often nursed on their abdomen.

5-41 How can communication with parents be improved?

Every effort must be made to improve communication between health workers and parents. Parents should feel able to ask questions and be given clear, honest and easy-to-understand answers. Although both doctors and nurses must speak to parents, the nurses are often better at communicating. Nurses spend more time with the infants and get to know them well. Good communication is baby friendly as it promotes parent-infants bonding.

5-42 How can parents be given information about their infants?

Information is best given directly to parents by the staff. A simple, honest explanation of the problems, risks and management of the infant is needed. However information pamphlets (e.g. on low birth weight infants or infants being ventilated) are very useful as parents can read them again and again. Often what is told to parents is not remembered because of the stressful situation. Booklets, videos, CDs, notices and photographs (even the internet) can help provide specific information. The names and uses of different pieces of equipment used in the nursery can be explained by means of pictures.

Care of infants in an intensive care unit

5-43 Do newborn infants feel pain?

In the past it was often incorrectly believed that newborn infants do not feel pain. Infants show all the stress responses seen by children and adults who are in pain. They cry, frown, actively move their arms and legs, increase their heart rate, blood pressure and blood glucose concentration, and have raised levels of stress hormones in their blood (adrenaline and noradrenaline).

Every effort must be made to reduce the pain experienced by infants during medical procedures such as taking a sample of blood or starting an intravenous infusion. Effective local or generalised analgesia must always be used for major procedures such as inserting a chest drain. Special scoring systems (pain assessment scores) are available to measure an infant’s stress response to pain and discomfort. The score helps to monitor pain and guide pain management. In order to reduce stress, infants being ventilated are often sedated, e.g. with morphine or midazolam (Dormicum).

After repeated painful procedures an infant learns what to expect and starts crying before the procedure is started. This is commonly seen when repeated arterial punctures are necessary. The possible long-term emotional effects are not known.

5-44 What can be done to reduce pain in newborn infants?

  1. Avoid unnecessary investigations.
  2. Be aware of painful complications such as fractures.
  3. Handle infants gently, especially if they are in pain.
  4. Allow the infant to suckle at the breast during painful procedures such as a heel prick.
  5. Use local anaesthetic (e.g. lignocaine) when indicated, e.g. if a chest drain is inserted.
  6. A general analgesic, e.g. morphine, should be used in infants with severe pain, e.g. postoperatively. Paracetamol can be used for lesser pain.
  7. Gentle touch can be used to reduce pain.

Pain and discomfort in newborn infants should be actively managed.

5-45 What causes stress to newborn infants?

Factors other than pain can cause stress in newborn infants:

  1. Separation from the mother. Every effort must be made to keep mothers and their infants together.
  2. Excessive handling and stimulation. Do not handle small, ill infants unless it is necessary. It is best to cluster handling, e.g. change nappy and take heel prick blood sample for glucose measurement at the same time rather than at different times.
  3. Lack of sleep. It is important that infants are allowed time to sleep.
  4. Excessive light and noise. Intensive care units are usually noisy and brightly lit. Reduce the noise of loud voices and alarms and ringing telephones when possible. Soft background music is preferable. Reduce lighting when infants are asleep.

5-46 How can the parent’s anxiety and stress be lessened?

Part of good infant care includes thinking about the needs of the parents. It is very stressful to have your infant in an intensive care unit. Open and honest communication is the best way to reduce parental stress. Bereavement counselling is particularly important when infants are dying or have died, or are born with severe congenital abnormalities. A follow-up phone call to bereaved parents is greatly appreciated by the family. Photographs of the infant, a lock of hair, foot print or name tag are helpful for bereaved parents as keep-sakes.

The concept of mother friendly care is also important as kinder, gentler, more considerate care of parents visiting a neonatal ICU must be promoted. A special, private room for counselling parents is very useful. This space can also be used by parents who want to spend private time with their dying or dead infant.

5-47 Can the developmental outcome of infants receiving intensive care be improved?

There is good evidence that gentler, more ‘humane’, baby friendly care can improve the mental development and behaviour of small infants who are managed in an intensive care unit. Modern, scientific care of newborn infants (which improves survival) should, therefore, be modified to ensure the best outcome of survivors.

NIDCAP (Newborn Individualised Developmental Care and Assessment Program) is a method of caring for very small infants where the optimum environment is provided for normal brain development. It is based on the theory that sensory input influences the function and structure of the developing brain. Research shows a better developmental outcome after using NIDCAP in neonatal ICUs.

Care of infants in the postnatal ward

5-48 How can the postnatal ward be made more ‘baby friendly’?

Almost all the changes that can be made in the nursery can also be made in the postnatal ward:

  1. Each mother and her infant should be kept together.
  2. The ward should be comfortably warm.
  3. It should be painted in pleasing colours.
  4. The lighting must not be too bright. Avoid direct sunlight.
  5. Loud noises must be avoided.
  6. It should have a homely feel rather than a hospital appearance.
  7. Comfortable chairs for feeding are important.
  8. Some privacy is essential.
  9. Staff must be gentle, supportive, kind and friendly.
  10. Visitors should be allowed in a controlled fashion.
  11. Mothers in the postnatal ward, who still have small or sick infants in the nursery, should be given every assistance to visit their infants whenever they want to. If they are too ill to visit their infant, or have their infant with them, they should be given a Polaroid photograph of the infant. This helps bonding.

5-49 What care should be given to infants in a postnatal ward?

Most infants in a postnatal ward are normal, health and born at term. Therefore, care should be aimed at promoting bonding, encouraging and supporting exclusive breastfeeding, and the routine management such as cord care and recording weight gain. The infant may be nursed in bed with the mother, carried around in the KMC position or allowed to sleep beside her bed in a crib (bassinet). Sharing a bed is not dangerous and does not increase the risk of cot death. The fear of the mother rolling onto the infant is unfounded. The infant should be bathed in the plastic crib and not at a common site where cross infection may occur. This is a good opportunity to help the mother learn about caring for her newborn infant. Mothers often help, and learn from, each other.

If the infant requires phototherapy, this can usually be given in the postnatal ward. As soon as possible, the mother and her infant should be discharged home together.

5-50 Should the infant be kept with the mother all the time?

If possible the mother and her infant should be kept together. Infants should not be routinely moved to the nursery at night so that they do not disturb the mothers’ sleep. Mothers should be encouraged to demand feed both day and night. If an individual infant cries a lot or if the mother is not well, the infant may be moved out of the ward for a few hours. However, the infant must be brought back for feeds.

What is no longer acceptable is for the mother to watch television, entertain her friends and rest most of the day while her infant is taken to the nursery to be bottle fed.

Care of the infant at home

5-51 How can the home be made more ‘baby friendly’?

As with the nursery and postnatal ward, many small but important changes can be made at home to improve the care and well being of the newborn infant. The question of the infant sleeping in the same bed as the parents remains controversial. However, there are many benefits to this practice for the first few months after delivery, especially with poor, cold housing.

Looking after a newborn infant at home is very demanding and mothers often feel exhausted. Every assistance should, therefore, be given to the mother, especially during the first few weeks when the infant is till being breastfed frequently. Help with routine household tasks, such as cleaning and cooking, are needed most. The father should support the mother when she arrives home with her infant. Grandmothers are particularly important with young, inexperienced mothers.

5-52 Should neighbours and distant family visit the infant?

Once the mother and infant are at home, visits by neighbours, friends and family are common. However, anyone who has an infectious illness, especially an upper respiratory tract infection, should be kept away from the infant. Young parents often need a lot of help and support from family and friends. Isolation and a lack of support is a main factor in the neglect and battering of infants.

5-53 Is it safe to kiss infants?

It is normal for a mother to want to hug and kiss her infant. However, some serious infections, such as herpes, can be spread to infants by kissing. Anyone with fever blisters (recurrent herpes infection) must never kiss an infant, as herpes infection in a young infant can be fatal. It is best if other family and friends do not kiss the infant, especially on the mouth.

5-54 Should all infants be taken to the well baby clinic?

Regular visits to the local well baby clinic are an important part of good primary health care. Weight gain and feeding should be monitored, routine immunisations given, minor problems managed and education and support given to the mother. When the weather is cold, KMC can be used to keep the infant warm on the way to and from the clinic. Every effort should be made to ensure that the well baby clinic is baby friendly.

Baby Friendly Hospital Initiative

5-55 What is the Baby Friendly Hospital Initiative?

The Baby Friendly Hospital Initiative (BFHI) is an international programme of the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) that was introduced in 1991. The BFHI is based on the Ten Steps to Successful Breastfeeding and aims to promote, introduce, protect and support breastfeeding. The BFHI recognises hospitals which have taken steps to create the best possible conditions for breastfeeding. These hospitals, after a detailed inspection, are awarded Baby Friendly status if they meet all the criteria. More and more state and private hospitals and delivery centres in South Africa are being given this award. All hospitals with maternity facilities should be encouraged to achieve Baby Friendly status.

The Baby Friendly Hospital Initiative aims to promote, introduce, protect and support breastfeeding.

5-56 What are the ten steps to successful breastfeeding?

  1. Have a written breastfeeding policy that is frequently communicated to all the health care staff.
  2. Train all the health care staff in the skills needed to implement successful breastfeeding.
  3. Inform all pregnant women about the benefits and management of breastfeeding.
  4. Help mothers to start breastfeeding within an hour of delivery.
  5. Show mothers how to breastfeed and teach them how to maintain lactation even if they are separated from their infants.
  6. Do not give newborn infants formula, water or other food unless this is indicated for medical reasons.
  7. Allow mothers and their infants to remain together all the time from delivery to discharge.
  8. Encourage breastfeeding on demand.
  9. Discourage the use of dummies, teats and nipple shields.
  10. Promote the formation of breastfeeding support groups and refer mothers to these groups on discharge from hospital or clinic.

The Baby Friendly Initiative also includes HIV infected mothers who choose to formula feed their infants as this is a medical indication.

Touch therapy

5-57 What is touch therapy?

Touch is one of the five important senses. By touching we communicate with others. Touching is one of the most important ways a mother and infant bond with each other. Touch therapy teaches mothers to use touch as a way of getting to know their infant better. Physical contact is one of the basic needs of infants (and adults) and is essential for normal emotional and interpersonal development. Infants like being touched. Many young, inexperienced mothers are reluctant to have a lot of physical contact with their infant, especially if they were not touched a lot by their own parents. They may also not have a close physical relationship with their partner. Touching one another is often not encouraged in some cultures.

Clarissa Estes in her book Women who run with wolves states that ‘hands laid upon another can sooth, comfort, remove pain and heal’.

5-58 What are the advantages of touch therapy for infants?

  1. Touch therapy (or massage therapy) helps many mothers bond more closely with their infant.
  2. Touch therapy has been shown in a number of studies to decrease crying and increase the weight gain of preterm infants.

Touch therapy is very useful in helping some mothers bond with their infant.

5-59 How is touch therapy given?

Most mothers will naturally touch, stroke and gently rub their infants without formal guidance or instructions. However, some mothers need encouragement, support and help to develop meaningful physical contact with their infant. Mothers often use oil or talcum powder for massaging. At the same time they usually also talk, sing or make ‘baby sounds’. Eye contact is important. Slow, gentle stroking is a way of expressing love and care.

Touch or massage therapy is a method of systematically stroking an infant, usually starting with the face and then moving to the chest, arms, stomach, legs and back. Mothers are best taught how to give massage therapy by a touch therapist. Massage should be firm, slow and rhythmical. Fathers can also benefit from learning how to give touch therapy. Many cultural practices include some form of infant massage. It is best to use a commercial ‘baby oil’ or simple carrier oils only as additives can be absorbed through the infant’s thin skin.

5-60 How does touch therapy work?

Touching and stroking induces relaxation, reduces stress behaviour and promotes a feeling of wellbeing. Numerous studies on both humans and animals have demonstrated the many benefits of touch. It is a powerful way of improving mother-infant bonding. Massage may reduce the pain of infant colic.

Touch therapy is being used more and more in children and adults with severe or chronic illnesses, such as AIDS. Simply being touched makes people feel better.

Touch therapy is being used in some neonatal intensive care units as part of the management of small or sick infants, especially infants in pain or receiving painful or stressful procedures. Touch plays an important part in the skin-to-skin care of KMC.

Research into the ‘biology of touch’ shows that massage therapy reduces the level of stress hormones (cortisol, adrenaline and noradrenaline) and promotes vagal stimulation. This helps digestion and absorption, immune responses and sleep patterns. Touching or rubbing an area of skin helps to reduce pain originating from the same dermatome (the gate theory of pain). Mothers intuitively ‘rub the pain better’.

Case study 1

A young woman delivers her first born infant at a rural hospital. The infant appears well and healthy when assessed immediately after birth. She is not given her infant to hold as the labour ward is cold. It is routine practice to move all infants to the nursery straight after delivery so that their mothers can rest. The staff find it easier if infants are weighed, given vitamin K and prophylactic eye care in the nursery. Only after 6 hours is the infant brought to the postnatal ward so that the mother can breastfeed.

1. What is the problem with the management of this infant?

The mother and her infant should not be separated after delivery. No medical reason has been given to move the infant to the nursery.

2. How should this infant have been kept warm?

The labour ward should not be cold. This infant should have been given to the mother so that she could keep the infant warm by giving kangaroo mother care. Both the mother and infant could be covered with a blanket to keep them warm if the room was cold.

3. Why should mothers not be allowed time alone after delivery, without their infant, so that they can rest?

The time immediately after delivery is very important to start both the bonding process and to begin breastfeeding. Most mothers want to hold their infant as soon as possible after delivery. Placing the infant on the breast after birth is the best way of ensuring that the mother establishes successful breastfeeding. Separating mother and infant is stressful to them both.

4. Is it not important that the infant is weighed and given vitamin K and prophylactic eye care as soon as possible after birth?

These routine procedures can be postponed until the mother has had a chance to hold her infant and place the infant on the breast. Early breastfeeding may even speed up the third stage of labour. The routine procedures can best be done once the placenta has safely been delivered.

5. Is it not easier for the staff to care for the infant in the nursery than keep the infant with the mother?

With baby friendly care, it is important to do what is best for the mother and infant rather than what is easier for the staff. The mother can hold and care for her infant while the midwife or doctor manages the delivery of the placenta.

6. If an infant has to be taken to the nursery, when should the infant be brought back to the mother?

Sometimes either the mother or infant are ill and the infant cannot stay with the mother. The mother should then visit the infant in the nursery, or the infant should be taken to the mother in the ward, as soon as possible. There is no medical reason for all healthy infants to be taken to the nursery for ‘observations’ for the first 6 hours after birth. Most infants delivered by Caesarean section can also stay with their mother. Photographs of the infant can promote bonding if the mother and her infant have to be separated.

Case study 2

When a new nursery was opening in a regional hospital, it was decided to write protocols for routine care in order to establish high standards of management. The mother’s name was clearly displayed on each crib or incubator to help identify infants. Both parents were allowed to visit during strictly controlled visiting hours but only the mother was allowed to touch her infant. Siblings had to remain in the waiting room outside the nursery. The walls were painted white and curtains, pictures and posters were not allowed. Radios and television sets were strictly prohibited. All nurses wore uniforms and infants wore regulation hospital clothing. Toys were banned.

1. Is it helpful to have the mother’s name on each infant crib or incubator?

Yes, as it is important to identify infants. However, it is also helpful to add the infant’s own name as this allows infants to be recognised as individuals, which promotes bonding. Colour coding labels, pink for girls and blue for boys, should be used.

2. Who should be able to visit infants in a nursery?

Both parents and siblings. Usually grandparents are also allowed to visit. However, some control over visiting is important as the nursery cannot be filled with visitors. The visitors may have to take turns. It is important that siblings are not excluded from this important family occasion.

3. Is it important that parents only visit during fixed visiting hours?

Parents should be able to visit at any time and stay as long as they want. Often working fathers cannot visit during formal visiting hours. . They may only be able to visit in the evenings. Parents of small infants should be encouraged to spend time giving KMC to their infants.

4. How should a nursery be decorated?

Every effort must be made to make the nursery look as less stressful as possible. White walls with no decorations are cold and threatening. Light coloured walls with attractive curtains and pictures or posters make the nursery appear more like a home and creates a restful mood. A nursery should not look like a typical, traditional hospital ward.

5. Should radios and television sets be allowed in a nursery?

Television is a distraction and should not be allowed. A radio playing soft, relaxing music helps to reduce stress, especially among the nursing staff.

6. What clothing is best for staff and infants in the nursery?

Nurses clothing should be comfortable, attractive and not threatening. Formal nursing uniforms are not recommended. All staff must wear name tags for easy identification by parents. Infants in incubators should always have warm caps and nappies. They may also have coloured cotton or woollen tops. Families often bring clothes for their infants which help to give the infants an identity of their own. Soft toys are safe as long as they are not shared with other infants.

Case study 3

In a large hospital, attempts are being made to make a neonatal intensive care unit more ‘humane’ and baby friendly. As there are only a few windows it is suggested that better, brighter lights should be installed. One of the nurses has read about nesting and cluster care and is keen to introduce these new practices. The senior doctors want to improve communication with patients and give them easier access to information. The question of correct pain management is also discussed at a staff meeting.

1. Should a neonatal intensive care unit have good lighting?

Lighting is important and this is best achieved with windows. They allow natural light in and also reduce stress if the staff can look out. However, bright lighting disturbs infants and can prevent them sleeping. Bright lights are only needed during specific procedures. Ideally there should be quiet times with dim lighting.

2. What is ‘nesting’?

With nesting, a towel or small cotton blanket is rolled up and placed on the mattress around the infant to form a circle or horse-shoe. Infants are often nested on their side. In this way the infants can feel the limit of their immediate environment rather than move around the incubator until they can lie against the side wall.

3. What are the advantages of ‘cluster care’?

When using cluster care, investigations (e.g. taking blood for glucose measurement) and handling (e.g. nappy changes or feeds) of infants are clustered together so that they can be done at the same time. This reduces the frequency that an infant is disturbed and allows for longer periods of rest and sleep.

4. How can parents be given easier access to information about their infant’s health problems?

It is important that parents understand what is wrong with their infant, the risks and the management. Careful, simple and repeated explanation is most important. However, giving parents written information in the form of pamphlets is also useful as they can read and reread the information at home. In addition, booklets, videos, notices and photographs can be used.

5. What are the principles of pain management in newborn infants?

  1. Infants do feel and express signs of pain.
  2. Unnecessary painful procedures must be avoided, e.g. routine blood glucose measurements when there is not a good indication.
  3. Always handle infants gently.
  4. If possible, allow infants to suckle at the breast during painful procedures.
  5. Use a local anaesthetic (e.g. lignocaine) or a general analgesic (e.g. morphine) when a painful procedure is done (e.g. inserting a chest drain).
  6. Touching and stroking an infant may help to relieve stress.

Case study 4

In a postnatal ward all infants are nursed in cribs next to their mother’s beds. Sharing a bed is not allowed because of the fear of the mother rolling onto the infant in her sleep. When infants are discharged home, mothers are advised to get the infant used to sleeping alone in a cot in a separate room. A newly appointed nurse suggests that the hospital should become ‘baby friendly’. The older members of staff are unhappy to change routines which ‘have worked well for many years’. They get angry when touch therapy is suggested.

1. Is it safe to allow mothers and infants to share beds in hospital and at home?

For many years mothers have shared beds with their infants at home without any side effects. In poor communities it may be the most practical way of keeping infants warm at night. The risk of cot death is not increased. The risk of mothers rolling onto and smothering their infants is also very small. In many baby friendly hospitals infants sleep with their mothers.

2. What is a baby friendly hospital?

This is a hospital (or clinic) which places the care of the mother and her infant ahead of the needs of the hospital and staff. Baby friendly care is good, evidenced based care which promotes bonding and breastfeeding.

3. What is the Baby Friendly Hospital initiative?

This is an international programme supported by the World Health Organisation and based on the ‘Ten steps to successful breastfeeding’. Hospitals and clinics are formally inspected and, if successful, awarded BFI status.

4. What are the ten steps to successful breastfeeding?

These are practical steps that can be implemented in order to promote, support and manage successful breastfeeding in a maternity service.

5. Why is there sometimes resistance to hospitals or clinics becoming baby friendly?

Any change in managing mothers and infants causes uncertainty, insecurity and resistance with parents, health workers and administrators. Many people do not like change, even if the change is to everyone’s benefit. With the introduction of baby friendly care it is important to convince and support those who need to change from previous ideas and habits.

6. What is touch therapy?

It is a method of teaching mothers to touch and gently stroke their infant. It builds confidence in anxious, inexperienced mothers and promotes bonding. Touch therapy soothes crying infants and can increase weight gain.

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