2 Care of normal infants

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Contents

• Objectives
• Caring for normal infants
• Feeding the normal infant
• The baby-friendly approach
• Discharging a normal infant
• Case studies

Objectives

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

• Manage normal newborn infants
• Diagnose and treat common minor problems
• Manage breastfeeding
• Promote baby-friendly care
• Discharge a normal infant

Caring for normal infants

2-1 What is a normal infant?

A normal infant has the following characteristics:

1. The infant is born at term (37 to 42 weeks gestation).
2. The 1 minute Apgar score is 7 or more and no resuscitation is needed after birth.
3. The infant weighs between 2500 g and 4000 g at birth.
4. On physical examination the infant appears healthy with no congenital abnormalities or abnormal clinical signs.
5. The infant feeds well.
6. There have been no problems with the infant since delivery.

Normal infants are at low risk of developing problems in the newborn period and, therefore, require primary care only. About 80% of all newborn infants are normal.

Normal newborn infants are at low risk of developing problems and require only primary care.

2-2 Should all normal infants be kept with their mothers?

Yes, all normal infants should stay with their mothers and not get cared for in the nursery. This is called rooming-in. The infant is either 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 infants staying with their mothers are:

1. The mother remains close to her infant all the time and gets used to caring for her infant. This strengthens bonding.
2. It encourages breastfeeding.
3. It builds up the mother’s confidence in her ability to handle her infant.
4. It prevents the infant being exposed to the infections commonly present in a nursery.
5. It reduces the number of staff needed to care for infants.

Mothers and infants should stay together.

2-3 When should the infant receive the first bath?

There is no need to routinely bath all infants after delivery to remove the vernix. Vernix will not harm the infant and disappears spontaneously after a day or two. Vernix protects the skin and kills bacteria. Many infants also get cold if they are bathed soon after delivery. The only indication for an infant to be washed or bathed soon after birth is severe meconium staining or contamination with maternal stool.

It is, however, important that all primiparous mothers learn how to bath their infants before they go home. If these infants have to be bathed on the first day of life, it is preferable that this be delayed until they are a few hours old.

2-4 What is the appearance of a newborn infant’s stool?

For the first few days the infant will pass meconium, which is dark green and sticky. By day 5 the stools should change from green to yellow, and by the end of the first week the stools should have the appearance of scrambled egg. The stools of breastfed infants may also be soft and yellow-green but should not smell offensive.

Some infants will pass a stool after every feed while others may not pass a stool for a number of days. As long as the stool is not hard, the frequency of stools is not important.

2-5 How many wet nappies should an infant have a day?

A normal infant should have at least 6 wet nappies a day. If the infant has fewer than 6 wet nappies a day, you should suspect that the infant is not getting enough milk. However, during the first 5 days, infants may have fewer wet nappies as infants normally pass little urine in the first few days. This protects them from dehydration at a time when many mothers produce only small amounts of milk.

2-6 What routine cord care is needed?

The umbilical cord stump is soft and wet after delivery and this dead tissue is an ideal site for bacteria to grow. The cord should therefore be kept clean. It should also be dried out as soon as possible by applications of surgical spirits (alcohol) or chlorhexidine solution after each nappy change. It is important to apply enough spirits or chlorhexidine to run into all the folds around the base of the cord. There is no need to use antibiotic powders. If the cord remains soft after 24 hours, or becomes wet and smells offensively, then the cord should be treated with surgical spirits or chlorhexidine every 3 hours. Do not cover the cord with a bandage. Usually the cord will come off between 1 and 2 weeks after delivery.

Good cord care with surgical spirits or chlorhexidine solution is important.

2-7 Can a vaginal discharge be normal in an infant?

Yes. Many female infants have a white, mucoid vaginal discharge at birth, which may continue for a few weeks. Less commonly the discharge may be bloody. Both are normal and caused by the secretion of oestrogen by the infant before and after delivery.

2-8 May normal infants have enlarged breasts?

Yes. Many infants, both male and female, have enlarged breasts at birth due to the secretion of oestrogen. The breasts may enlarge further after birth. Breast enlargement is normal and the breasts may remain enlarged for a few months after delivery. Some enlarged breasts may secrete milk. It is very important that these breasts are not squeezed as this may introduce infection resulting in mastitis or a breast abscess.

2-9 Which birth marks are normal?

1. A blue patch over the sacrum is very common and used to be called a ‘mongolian spot’. It is seen in normal infants and is due to the delayed migration of pigment cells into other areas of the skin. It is not a sign of Down syndrome (mongolism). Sometimes similar patches are seen over the back, arms and legs and may look like bruises. They need no treatment and disappear during the first few years of life.
2. It is common for an infant to have a few small pink or brown marks on the skin at birth. These are normal and disappear in a few weeks.
3. Many infants also have pink areas on the upper eyelid, the bridge of the nose and back of the neck that become more obvious when the infant cries. These marks are called ‘angel’s kisses’ and ‘stork bites’ by mothers. They are also normal and usually disappear within a few years.
4. Some infants develop one or more raised red lumps on their skin during the first few weeks. These ‘strawberry patches’ grow for a few months and take a few years to disappear. They are best left alone and not treated.

2-10 Are cysts on the gum or palate normal?

Small cysts on the infant’s gum or palate are common and almost always normal. They do not need treatment and disappear with time. They must not be opened with a pin or needle as this may introduce infection.

2-11 Can infants be born with teeth?

Yes, some infants are born with teeth. These are either primary teeth or extra teeth. Primary teeth are firmly attached and should not be removed. Extra teeth are very small and usually very loose. A tooth that is very loose, and is only attached by a thread of tissue, can be pulled out. It will be replaced later by a primary tooth.

2-12 Should ‘tongue tie’ be treated?

Many infants have a web of mucous membrane under the tongue that continues to the tip. As a result the infant is not able to stick the tongue out fully and, therefore, is said to have ‘tongue tie’. This does not interfere with sucking and usually corrects itself with time. Do not cut the membrane as this may cause severe bleeding. Refer the child to a surgeon if the tongue does not appear normal by 2 years.

2-13 Does an umbilical hernia need treatment?

Infants commonly develop a small umbilical hernia after the cord has separated. This does not cause problems and usually disappears without treatment when the infant starts to walk. If the hernia is still present at 5 years the child should be referred for possible surgical correction.

2-14 Do normal infants commonly have a blocked nose?

Yes, a blocked nose is common due to the small size of the nose in a newborn infant. Normal infants also sneeze. Usually a blocked nose does not need treatment. However, some infants may develop breathing difficulties or apnoea if both nostrils are completely blocked. Nose drops containing drugs can be dangerous as they are absorbed into the blood stream and can cause a rapid heart rate. Sodium bicarbonate 2% or saline nose drops can be used. The blocked nose is usually not caused by a cold.

2-15 Are wide fontanelles and sutures common?

Many normal infants have wide fontanelles and sutures. This is particularly common in low-birth-weight infants. The anterior fontanelle may also pulsate. If the anterior fontanelle bulges and the infant’s head appears too big, the infant must be referred to a level 2 or 3 hospital as hydrocephaly is probably present. If you are uncertain, repeat the head circumference measurement in 2 weeks. It should not increase by more than 0.5 cm per week.

2-16 Are extra fingers or toes normal?

Extra fingers that are attached by a thread of skin are common and occur in normal infants. There is often a family history of extra digits. Extra fingers or toes should be tied off as close to the hand or foot as possible with a piece of surgical silk. If the extra digit contains cartilage or bone and is well attached with a broad base, it must not be tied off. These infants have a high risk of other abnormalities and, therefore, should be referred to a level 2 or 3 hospital.

2-17 Should an infant’s nails be cut?

If an infant’s fingernails become long they may scratch the face. Long nails should, therefore, be cut straight across with a sharp pair of scissors. Do not cut the nails too short. Never bite or tear the nails. Nail clippers are dangerous.

2-18 Should the foreskin of an infant’s penis be pulled back?

No. The foreskin is usually attached to the underlying skin in an infant and, therefore, should not be pulled back to clean the glans. All newborn male infants have erections of the penis. They also have larger testes than older infants. These signs usually disappear within a few months and are due to the secretion of male hormones.

2-19 When should the normal infant be fully examined?

Weighing and examining all newborn infants are important parts of primary care. A full examination should be done after the mother and infant have recovered from the delivery, which usually takes about 2 hours. The infant must be examined in front of the mother so that she is reassured that the infant is normal. It also gives her a chance to ask questions about her infant. The infant is also briefly examined immediately after birth to identify any gross abnormalities. The head circumference should also be carefully measured. Both weight and head circumference should be plotted on the growth charts in the Road-to-Health booklet.

All newborn infants should be weighed and examined.

2-20 How should the infant be dressed?

It is important that the infant does not get too hot or too cold. Usually an infant wears a cotton vest and a gown that ties at the back or a ‘baby grow’. A disposable or washable nappy is worn. If the room is cold, a woollen cap should be worn. Woollen booties are sometimes also worn. It is important that the clothing is not too tight. Infants should be dressed so that they are comfortable and warm. Usually a single woollen blanket is adequate.

2-21 Must the birth be notified?

The birth of every infant must be notified by the hospital, clinic or midwife. The parents later must register the infant’s name with the local authority.

2-22 Should all infants receive a Road-to-Health booklet?

Yes. All newborn infants must be given a Road-to-Health booklet, as this is one of the most important advances in improving the healthcare of children. The relevant information must be entered at birth. Mothers should be told the importance of the booklet. Explain the idea of the Road-to-Health booklet to her. She must present the booklet every time the infant is seen by a healthcare worker. It is essential that all immunisations be entered in the booklet. A record of the infant’s weight gain is also very important as poor weight gain or weight loss indicates that a child is not thriving.

All newborn infants must be given a Road-to-Health booklet.

2-23 Should newborn infants be immunised?

The schedule of immunisations varies slightly in different areas but most newborn infants are given BCG and polio drops within 5 days of delivery. It is safe to give BCG and polio drops to infants of HIV-positive mothers. Sick and preterm infants are usually given BCG and polio drops when they are ready to be discharged home.

Feeding the normal infant

2-24 What milk can be given to a normal infant?

• Breast milk. Human breast milk meets all the nutritional needs of a healthy term infant.
• Formula feeds. These powdered feeds are made from cow’s milk or soya bean and are modified to have similar constituents to breast milk.

If possible mothers should exclusively breastfeed their infants for the first six months.

Whenever possible mothers should exclusively breastfeed their infants.

2-25 What are the benefits of breastfeeding?

Breastfeeding, especially exclusive breastfeeding, provides many benefits to both the infant and mother. The main benefits are:

Benefits to the infant

1. Breast milk is the ideal feed for term infants as it provides all the nutrients in the correct amount and proportion for normal growth and development.
2. Breast milk is easily digested and absorbed.
3. Breast milk is clean and warm, and avoids the dangers of a contaminated water supply, inadequately sterilised bottles and teats, and lack of refrigeration facilities.
4. Breast milk avoids the danger of diluted or concentrated formula.
5. Breast milk contains many anti-infective factors and decreases the risk of infections, especially gastroenteritis, a major cause of death of infants in poor communities.
6. Breast milk decreases the risk of allergy in the infant, especially if there is a strong family history of allergy.

Breastfeeding decreases the incidence of gastroenteritis and lowers the infant mortality rate in poor communities.

Benefits to the mother

1. Breastfeeding is much cheaper than buying formula feeds.
2. Breast milk is instantly available at all times. No sterilising of bottles and teats, and preparation of formula is needed.
3. It is emotionally satisfying for the mother to successfully breastfeed her infant and helps to form a strong bond between mother and infant.
4. Breastfeeding helps the involution of the uterus and reduces the amount of bleeding during the puerperium.
5. Breastfeeding helps the mother to lose excessive weight gained during pregnancy. Pregnancy, not breastfeeding, alters the breast shape of a primiparous woman.

Breastfeeding is cheap and ensures an adequate, safe supply of food. It therefore decreases the incidence of malnutrition.

With the correct use of antiretroviral prophylaxis the risk of HIV transmission in breast milk is small.

2-26 Why do some mothers not breastfeed successfully?

Breastfeeding is not always easy, as the ‘natural art of breastfeeding’ has to be learned. Some mothers do not breastfeed or fail to breastfeed successfully because:

1. They believe that they do not have enough milk because it takes a number of days before the supply of milk increases.
2. They do not know the advantages of breastfeeding.
3. They think that their milk is too thin, or their breasts too large or too small.
4. They develop cracked nipples or engorged breasts due to an incorrect method of feeding.
5. They want to return to work and do not realise that many working mothers can continue to breastfeed successfully.
6. They are afraid of breastfeeding.
7. Lack of support at home and in health facilities.
8. They have flat or inverted nipples.
9. Traditional beliefs may result in unsuccessful breastfeeding, e.g. incorrect beliefs that colostrum is not good for the infant, intercourse spoils the milk, and delayed feeding causes the milk to become sour in the breast.
10. Poor sleeping or excessive crying by the infant is blamed on the quality or supply of the breast milk.
11. They are HIV positive and elect not to breastfeed.

2-27 How can breastfeeding be promoted?

Breastfeeding should be promoted as the normal, natural method of feeding an infant. This can be achieved by:

1. Encouraging a positive attitude towards breastfeeding in the home during childhood and adolescence by seeing other infants being breastfed.
2. Teaching the advantages of breastfeeding in schools.
3. Promoting breastfeeding in the media (radio, TV, books).
4. Teaching the advantages and method of breastfeeding in all antenatal clinics.
5. Starting breastfeeding groups run by mothers who have themselves breastfed.
6. Encouraging breastfeeding and practising kangaroo mother care in hospitals and clinics.
7. Discouraging bottle feeding in hospital. Rather use cups for expressed breast milk or formula feeding.

Further information on breastfeeding in South Africa can be obtained from a local breastfeeding support group or local branches of the Breastfeeding Association, La Leche League, and National Childbirth Education and Parenting Association.

Breast is best.

2-28 How can breastfeeding be encouraged in hospitals and clinics?

Staff should be convinced that breastfeeding has many benefits for the mother and infant, they should feel comfortable and not embarrassed when speaking to patients about breastfeeding, and they must have the knowledge and skills to teach mothers how to breastfeed. Mothers must be helped individually with kindness and patience.

Facilities for rooming-in must be provided, and the mother allowed unlimited access to her infant to demand feed. The national baby-friendly hospital initiative encourages breastfeeding.

2-29 What is the value of a local breastfeeding support group?

Often the best person to advise and help a breastfeeding mother is someone who has successfully breastfed herself. A number of mothers who have breastfed and are interested in helping others to breastfeed can form a local support group. With help and training by midwives and doctors they can provide a very helpful service.

2-30 What preparation does a mother need for breastfeeding?

1. The decision to breastfeed should be taken before her infant is born. If she is still undecided at delivery, she should be encouraged to breastfeed.
2. No routine preparation of breasts and nipples before delivery is necessary.
3. A good, supportive bra should be worn. Breast size is no indication of a woman’s ability to breastfeed.

2-31 How can you treat flat or inverted nipples?

If a woman’s nipples appear flat or inverted during pregnancy, they can be corrected by the infant breastfeeding.

2-32 Should the infant be put to the breast immediately after delivery?

Yes, the mother should breastfeed her infant as soon as possible after delivery as the infant’s drive to breastfeed is usually strongest in the first hour after birth. Early suckling promotes bonding between the mother and infant. It also stimulates milk production and encourages successful breastfeeding. The small amount of colostrum in the first few days satisfies the infant and is very rich in antibodies.

2-33 Should clear feeds be given during the first few days?

Sterile water or dextrose water should not be given before starting breast or formula feeds on day 1. A breastfed infant does not need additional clear feeds. If the mother wants to breastfeed, no bottle feeds should be given to the infant as a teat can confuse the infant and cause it to reject the nipple.

Unlike a bottle-fed infant that sucks the milk out of the teat, a breastfed infant holds the nipple against the hard palate and compresses the milk ducts in the areola with the gums in a chewing movement (suckling).

Routine clear feeds are not needed on day 1.

2-34 What is the best position to hold an infant while feeding?

The correct position of the infant while feeding is important. The mother should be warm and comfortable. Usually she sits up and holds her infant across her body in front of her. The infant is held in one arm, and should lie on its side with its mouth facing the nipple. The breast is held in the other hand to offer the nipple to the infant.

Mothers should be encouraged to try different feeding positions in order to find which is most comfortable. Some mothers prefer to lie down while they feed. Other mothers prefer to tuck the infant under an arm like a rugby ball.

2-35 How should an infant fix at the breast?

One of the commonest mistakes made when breastfeeding is that the infant is not held and fixed correctly (latched) at the breast. The infant must take the whole nipple and most of the pigmented areola into the mouth. Sucking or chewing on the nipple causes pain and damages the nipple. The mother should let her nipple touch the infant’s cheek, so that the infant will turn towards the breast with an open mouth to take the nipple. Make sure that the infant’s nose is not covered by the breast.

The infant must take the whole nipple and most of the areola into the mouth when fixing at the mother’s breast.

2-36 Should infants be demand fed?

Yes. Whenever possible infants should be demand fed. This means that the infant is put to the breast whenever hungry. A normal breastfed infant will usually feed every 2 to 4 hours during the day for the first few weeks. Demand feeding prevents engorged breasts.

2-37 What is the let-down reflex?

When an infant is put to the breast, the pituitary gland in the mother’s brain responds by producing the hormones prolactin and oxytocin. Prolactin stimulates the breast to secrete milk while oxytocin produces the ‘let-down reflex’. This reflex produces a tingling feeling in the breast, and results in milk being pumped into the infant’s mouth by the contraction of muscle cells that surround the milk ducts under the areola. Milk may leak from the other nipple during feeds. The release of oxytocin helps the uterus to involute by causing the uterus to contract. It may also produce abdominal pain during feeding for the first few days after delivery. Tension, anxiety and a lack of sleep may inhibit the let-down reflex.

2-38 How do you manage leaking breasts?

Milk leaking from the breasts is common in the first few weeks of feeding. Leaking of the opposite breast during feeding can be stopped by pressing on that nipple. Cotton handkerchiefs or pads can be used for leaking between feeds. They should be changed frequently as dampness may cause sore nipples.

2-39 Can a mother’s milk be too strong or too weak?

No, but the appearance of breast milk varies. There are 3 different types of breast milk:

1. Colostrum. This is a milky fluid produced in small quantities for the first few days after delivery. However, it contains a lot of protein and provides all the infant’s nutritional needs. After 3 to 5 days the milk supply suddenly increases and the breasts feel full. This is due to the production of mature milk, which consists of foremilk and hind milk.
2. Foremilk. This is produced at the start of each feed. It appears very weak and thin as it consists mainly of water with little fat. On a hot day a thirsty infant will take frequent, small feeds of foremilk.
3. Hindmilk. This is only produced towards the end of a feed. It looks thick and rich, and contains a lot of fat. A hungry infant will empty the breast to obtain the hindmilk.

2-40 Do all mothers produce enough breast milk?

Most mothers produce enough milk for their infant if breastfeeding is encouraged and managed correctly. Unfortunately many mothers stop breastfeeding during the first 5 days because they are incorrectly advised that they do not have enough milk or because the infant is losing weight. Milk supply is normally best in the morning and poorest in the late afternoon and early evening.

The mother is probably not producing enough milk if:

1. Her breasts do not feel full before feeds after day 5.
2. The infant continues to lose weight after day 5.
3. The infant loses more than 10% of its birth weight.
4. The infant is not gaining weight by 2 weeks.
5. The infant does not wet 6 or more nappies in 24 hours (after day 5), is very restless and appears hungry.

If you are worried that an infant is not getting enough milk, then the infant can be test weighed before and after a feed. After the first week of life, most term infants will gain about 25 g per day. Weight gain is best determined over a few days.

2-41 Is it normal for an infant to lose weight after birth?

Yes. Most breastfed infants will lose weight for the first few days after birth due to the small volume of breast milk being produced. Colostrum, however, will meet the infant’s nutritional needs. Once the milk ‘comes in’, between days 3 and 5, the infant will start to gain weight. Most breastfed infants regain their birth weight by day 7. This weight loss is normal and does not cause the infant any harm. The normal infant does not usually lose more than 10% of the birth weight. Marked weight loss suggests that the infant is ill or not getting enough milk.

2-42 Is it necessary to weigh a normal infant every day?

No. The normal infant should be weighed at delivery and again on days 3 and 5 if still in hospital. Weight at discharge must be recorded. At every clinic visit the infant’s weight should be measured and recorded. Ill infants should be weighed every day until well.

2-43 How can you improve a mother’s milk supply?

1. Reassurance, support and encouragement that she will be able to breastfeed. Also ensure that she is getting enough sleep and is not under too much stress, as anxiety is a major cause of poor milk production. Anxiety also inhibits the let-down reflex. Many mothers are more relaxed in their own homes.
2. Make sure that she is fixing the infant correctly to the breast and that the infant is sucking correctly.
3. Put the infant to the breast frequently during the day until a good milk supply is established. If the infant is not demand feeding 3- to 4-hourly, it should be woken for feeds. The best stimulus to milk production is the infant sucking frequently and for prolonged periods.
4. The mother should rest for a while in the afternoon and drink adequate fluids.
5. Stop any bottle feeds.

The best stimulus for milk production is frequent feeding.

2-44 Should infants be routinely test weighed?

No, there is no need to test weigh all infants. The amount of milk an infant takes varies widely between feeds. A small feed, which is common in the afternoon or when the mother is tired, may cause maternal anxiety. Test weighing may be useful to assess a mother’s milk production if the infant does not gain weight.

2-45 Should the infant always feed on both breasts?

It is best to empty one breast first before putting the infant to the opposite breast. This ensures that the infant gets the rich hind milk. Start each feed on alternate breasts. However, for the first few days it is useful to allow the infant to feed on both breasts to stimulate the milk production.

2-46 What should you do if an infant refuses the breast?

Some infants may reject the breast and refuse to fix on the nipple and suckle. Common causes are a sore mouth due to thrush, the infant being ill or upset, or the milk flow being too fast. These problems should be looked for and treated.

Do not hold the infant’s head too tightly or push the face towards the breast, as the infant will turn towards your hand instead of the nipple. It may help to squeeze a little breast milk onto the nipple before placing it in the infant’s mouth.

2-47 What may cause an infant to choke while feeding?

During the first few weeks the mother may have a lot of milk and the milk may flow too 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 may help for the mother to lie back at the start of the feed with the infant across her chest so that the milk has to flow upwards against gravity. The mother may have to express a bit before starting the feed, or feed the infant more frequently. Too much milk and milk that flows too quickly settles with time.

2-48 How should you manage swollen or painful breasts?

A normal, full breast feels tense and heavy, but is not painful and any discomfort is relieved by feeding. Breasts that are swollen, tender, hard, lumpy and painful are caused by either engorgement or mastitis.

Both engorgement and mastitis result from an obstruction in milk flow:

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 common if the infant does not room-in and if the mother does not demand feed.

   Treatment consists of emptying the breast by expressing or allowing the infant to suckle. The infant should be fed on the most painful breast first. Sponging the breasts with warm water or standing under a warm shower relieves the discomfort, while a mild analgesic like paracetamol (Panado) is helpful. Often the infant is not able to fix correctly if the breast is engorged as the nipples become flattened by the swelling. If some milk is first expressed from the breast, the infant will usually fix well. Breast engorgement should be prevented by frequent feeds.

2. Mastitis (milk fever)

   Mastitis is an inflammation of the breast due to infection in blocked milk ducts. It causes a swollen, painful red area of one breast. The mother feels ill and may have a high temperature.

   Treat with rest, warm compresses and a mild analgesic. It is most important that the infant continues to suckle frequently on the affected breast, as this will help the milk to flow. Altering the feeding position often helps to drain the affected area. Mastitis is not dangerous for the infant. If the signs and symptoms do not improve within 24 hours an antibiotic (e.g. cloxacillin) should be prescribed for 5 days. If a fluctuant mass develops then a breast abscess has formed. This should be surgically drained. Due to the pain of a breast abscess, feeding may have to be stopped on that breast for a few days. However, feeding can be continued if possible.

2-49 How do you prevent painful nipples?

The nipples should be kept dry between feeds. Instead of protecting the nipples with lanolin cream, petroleum jelly (Vaseline) or masse cream, it is suggested that a little colostrum or hind milk be left to dry on the nipples after each feed. The milk has anti-infective properties and the fat protects the nipples. Do not use alcohol on the nipples. Avoid vigorous washing or soap on the nipples.

It is important that the infant is correctly fixed at the breast so that the nipple is not chewed. When removing the infant from the breast, the mother should insert her little finger into the corner of the infant’s mouth to break the suction.

Correct fixing of the infant at the breast will help to prevent painful nipples.

2-50 How should you treat painful nipples?

Nipples are often painful during the first few days of breastfeeding, especially if the infant is very hungry or is not fixing on the breast correctly. Do not let the infant sleep at the nipple until the nipples have toughened.

Cracked nipples are very painful and should be prevented by correctly fixing the infant to the breast and avoiding engorged breasts. Treat cracked nipples with colostrum or hind milk and mild analgesics. Alter the position of the infant on the nipple so that it does not suck on the tender area. It may be necessary to stop feeding on that side for 24 hours and express the breast instead. Frequent short feeds when the infant is not hungry are preferable. Reassure the mother that painful nipples heal very quickly. Mothers with painful nipples need a lot of support if they are to continue breastfeeding.

2-51 Do breastfed infants need complementary feeds?

Most breastfed infants do not need complementary (additional) feeds of formula. Complementary feeds may decrease the production of breast milk and the teat may confuse the infant. Only if an infant fails to gain weight, after management to improve the mother’s milk supply has been tried, should complementary feeds be used. If possible give these by cup rather than bottle.

Some mothers will give complementary feeds if they have to leave their infant for more than a few hours. However, expressing breast milk into a cup for the missed feed would be preferable. Expressed breast milk can be safely stored up to 6 hours in a cool place or for 48 hours in a fridge. Breast milk can be safely frozen and stored for 2 weeks in a fridge freezer or 6 months in a deep freezer. Frozen milk should be thawed slowly by placing the container in warm (not hot) water.

2-52 Can working mothers continue to breastfeed?

Yes. Mothers can continue to breastfeed for many months while working. Breast milk can be expressed at work and this or formula is given to the infant during the day. When at home the mother breastfeeds frequently. Ideally it should be possible to take the infant to work or leave the infant in a creche at or near the place of work.

2-53 Do drugs cross into the breast milk?

Almost all drugs that the mother takes by mouth will cross into the breast milk in very small quantities that will not affect the infant. Breastfeeding mothers should only take medication that is necessary.

2-54 When should an infant not be breastfed?

1. If, after counselling, the mother has decided that she definitely does not want to breastfeed, then the infant should be fed formula.
2. If a mother is unable to breastfeed because she is separated from her infant, she should express her milk, manually or with a breast pump, for the infant to be cup fed.
3. If the mother has an inadequate milk supply despite advice and support, and if the infant is not gaining weight by 2 weeks, then complementary feeds should be started to ensure normal growth.
4. If the mother is very ill.
5. If the mother is HIV positive and decides, after counselling, to formula feed her infant.

2-55 What formula feed should be used for a term infant?

A number of formula feeds are available for term infants (NAN 1, S26, Similac, Lactogen 1, SMA). They are very similar and, therefore, the milk available at the local clinic or the cheapest milk should be bought. Unaltered cows’ milk, evaporated milk and skimmed milk are not suitable for infants under 6 months of age. Milk creamers must never be used to feed infants.

Bottle-fed infants should be fed on demand. If fed according to a schedule, most infants will need to be fed 6 times a day, at 06:00, 10:00, 14:00, 18:00, 22:00 and 02:00. After the first few weeks the 02:00 feed can be missed. Most term infants will take about 100 ml per feed after the first week.

2-56 How is formula made up?

If a mother decides to formula feed her infant, it is very important that she knows how to mix formula correctly. She must also have a source of clean water and know how to clean a cup or bottle and teat.

A level scoop of milk powder (scraped level with a knife and not packed down) is added to 25 ml of clean water in a feeding bottle. The water should have been boiled beforehand and allowed to cool. The bottle and teat must have been cleaned and sterilised by boiling or standing in a disinfecting agent (Milton or half-diluted Jik). Shake the bottle well to mix the feed. Bottles should not be used if they cannot be cleaned properly.

One of the great dangers of formula feeds is to make the mixture too strong or too weak. If too much milk powder is added, the infant may receive too much salt which can be dangerous. If too little milk powder is added, the infant may become malnourished. Another danger is gastroenteritis caused by infected water or dirty bottles and teats. These and other problems of formula feeds can be avoided by breastfeeding.

Formula-fed infants should be offered a few clear feeds daily if the weather is very hot. Bottle-fed infants must be held while feeding. The bottle should not be propped.

Many of the dangers of infection when using bottles and teats can be avoided if cup feeds are used instead.

2-57 What are the advantages of cup feeding over bottle feeding?

If an infant cannot be breastfed it is better to cup feed than to bottle feed. The greatest advantage of cup feeding is that a cup can be easily cleaned with soap and water. A cup also dries easily, especially if placed in the sun, which helps to sterilise the cup. This is most important when clean or boiling water is not available for washing bottles. A cup feed usually takes less time than a bottle feed. It is also easier to wean a preterm infant from tube feeds onto cup feeds than onto bottle feeds as many infants can swallow well before being able to suck. Any small plastic cup or dish can be used to feed an infant. Breast milk can be expressed directly into the cup before a feed is given to a preterm infant. Mothers who do not breastfeed should be shown how to cup feed before they are discharged home after delivery.

In some infants bottle feeding may cause problems with breastfeeding as the mechanism of sucking from a bottle is different from feeding at a breast. This is often called ‘nipple confusion’.

2-58 Are iron and vitamin supplements needed?

A normal term infant born to a healthy mother on a good, mixed diet and regularly exposed to sunlight does not need supplements. Additional iron and vitamin supplements may be of benefit in poor communities, where iron drops 0.3 ml (or syrup 5 ml) and multivitamin drops 0.3 ml (or syrup 5 ml) can be given daily. Supplements given to well term infants are not harmful. Remember that all preterm infants need a higher dosage of supplements (0.6 ml).

2-59 When should solids be introduced?

Normally breast milk or formula feeds will meet all the infant’s nutritional needs until 6 months of age. Thereafter, milk alone is not enough and solids should be introduced. If possible, an infant should be exclusively breastfed for 6 months. Even if the mother can only breastfeed for a few weeks or months, this will be of benefit to both her and her infant. Introducing solids reduces the anti-infectious properties of breast milk.

Some mothers continue to partially breastfeed up to 2 years. It is best to continue breastfeeding after solids have been introduced. This practice is particularly important in poor communities as breast milk provides the infant with a good source of protein. Weaning from formula should be done over a few weeks by dropping one feed per week.

Whenever possible infants should be exclusively breastfed for 6 months.

The baby-friendly approach

2-60 What is a baby-friendly hospital?

The idea of a ‘baby-friendly’ hospital or clinic was introduced by the World Health Organisation to promote the advantages of breastfeeding. An agency is available to register hospitals as baby friendly. To become registered as a baby-friendly hospital all ten steps to successful breastfeeding have to be implemented.

2-61 What are the ten steps to successful breastfeeding?

1. Have a written breastfeeding policy that is frequently communicated to all the healthcare staff.
2. Train all the healthcare staff in the skills needed to implement successful breastfeeding.
3. Inform all pregnant women about the benefits of breastfeeding.
4. Help mothers to start breastfeeding within 30 minutes 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 or water feeds 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 demand feeding.
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 the hospital or clinic.

2-62 What are the advantages of the baby-friendly approach to the care of infants?

It promotes exclusive breastfeeding and bonding between mother and infant. This is particularly important in communities where malnutrition, gastroenteritis and child abuse are common. The baby-friendly way of infant care is also kinder, gentler, cheaper and better. Every effort must be made to make all hospitals and clinics baby friendly.

If HIV-positive mothers decide to breastfeed, then exclusive breastfeeding will reduce the risk of mother-to-child transmission of HIV. If they decide to formula feed, many of the practices which encourage bonding can still be practised.

Discharging a normal infant

2-63 When can an infant be discharged from the hospital or clinic?

Most normal newborn infants can be discharged 6 hours after delivery. Before discharging an infant from either a hospital or clinic, you should ask yourself the following questions:

1. Does the infant appear normal, active and healthy?
2. Does the infant feed well?
3. Can the mother feed and care for her infant?
4. Does the infant weigh 1800 g or more?

If the answer to any of these questions is ‘No’ the infant should not be discharged.

2-64 What advice should the mother be given about her infant at discharge?

Before discharge all mothers must be advised about:

1. Feeding the infant
2. Bathing and dressing the infant
3. Follow-up appointments and arrangements
4. Reporting immediately if the infant appears ill or behaves abnormally
5. The importance of the Road-to-Health booklet

2-65 Should normal infants be followed up after discharge?

If the infant is discharged before 7 days of age, the infant should be seen at home or at a clinic on days 2 and 5 to assess whether:

1. The infant appears healthy or sick
2. The infant is feeding well and receiving enough milk
3. The mother is managing to care for her infant
4. The cord is clean and dry
5. The infant is jaundiced
6. The mother has any problems with her infant

After the age of one week, the normal infant should be followed at the local well-baby clinic to assess the infant’s weight gain and general development, and to receive the required immunisations. These details must be noted on the Road-to-Health booklet.

Case study 1

An infant is delivered by spontaneous vertex delivery at term. Three minutes after birth the cord is clamped and cut and the infant is dried. The infant cries well and appears normal. The infant has a lot of vernix and a blue mark is noticed over the lower back. The infant passes urine after delivery but does not pass urine again for 24 hours.

1. When should the infant be given to the mother?

As soon as the infant is dried, the cord cut, the Apgar score determined, cord cut and a brief examination indicates that the infant is a normal, healthy term infant. The father should also be present to share this exciting moment.

2. What is the blue mark over the infant’s back?

A ‘mongolian spot’, which is normal. It is important to explain to the mother that it is not a bruise. It disappears over a few years.

3. Should the vernix be washed off immediately after delivery?

Infants should not be bathed straight after delivery, as they often get cold, while vernix should not be removed as it helps protect the infant’s skin from infection. It would be better to bath the infant the following day, in the mother’s presence, when most of the vernix will have cleared.

4. Should the infant stay with the mother after delivery?

Yes, if possible the mother and her infant should not be separated after delivery.

5. Does it matter if the infant only passes urine once in the first 24 hours?

No. During the first few days a normal infant often does not pass urine frequently. However, after day 5, an infant should have at least 6 wet nappies a day.

Case study 2

Starch powder is sprinkled onto the umbilical cord of a newborn infant twice a day to hasten drying. The cord is then covered with a linen binder. The mother is worried that the infant has enlarged breasts. As the ward is cold at night, she puts the infant into her bed.

1. What do you think of the method of cord care in this infant?

The cord should be dried with surgical spirits or chlorhexidine solution and not covered with starch powder. Covering the umbilical cord with a binder is incorrect as it prevents the cord from drying out.

2. What treatment is needed for the infant’s enlarged breasts?

No treatment is needed and the mother must not squeeze the breasts. The mother must be reassured that breast enlargement is normal and resolves spontaneously in a few months.

3. What would you advise the mother about sleeping with her infant?

If the ward is cold and there is no simple way of keeping the infant warm, then the infant should sleep with the mother. It is important that infants do not get cold. Kangaroo mother care is a very effective method of keeping the infant warm.

Case study 3

A normal infant weighs 3000 g at birth. By day 4 the infant appears well but the weight has dropped to 2850 g and it is suggested that formula be started. The next day the mother has painful, engorged breasts. The policy in the hospital is to keep all normal infants in the nursery where the mothers can visit at feeding time.

1. Is the weight loss of 150 g normal for this infant?

Yes. An infant may normally lose up to 10% of the birth weight in the first 5 days after delivery.

2. Should formula feeds be started?

No. Within a day or two the mother should have enough milk and the infant will start to gain weight.

3. How should the mother’s engorged breasts be managed?

Stop formula feeds and allow the infant to breastfeed frequently.

4. What do you think of normal infants being kept in the nursery?

Normal infants should room-in with their mothers.

Case study 4

A well newborn infant is given clear feeds of 5% dextrose for the first day. As the mother is tired after the delivery, the infant is immediately sent to the nursery. On day 3 the mother is advised to bottle feed as her milk appears to be too weak. She is a poor woman who plans to return to a rural district. It is suggested that the infant starts solids at 1 month.

1. Should clear feeds be used in a healthy newborn infant?

No. Feeds should be started with breast milk or full-strength formula.

2. Why should the infant not be sent immediately to the nursery?

It is important for the mother to hold her infant after the delivery. This promotes breastfeeding and bonding. It is best if the mother and infant are kept together.

3. Why is it incorrect to advise formula feeds if the breast milk appears to be weak?

Both foremilk and colostrum often appear weak. This is normal and never an indication for formula feeds.

4. What are the dangers of a poor rural woman giving bottle feeds?

She may not be able to clean the bottle and teat correctly. Cup feeds would be safer if formula is used as a cup is easier to clean. This mother should be encouraged to breastfeed.

5. Why is it important that this woman breastfeed her infant?

She will not be able to buy formula as she is poor and probably does not live close to a shop. As a result the infant is at high risk of gastroenteritis and malnutrition. These problems can usually be prevented by breastfeeding.

6. When should the infant be given solids?

This mother should breastfeed for as long as possible. It would probably be best if solids were only started at 6 months.