Primary Newborn Care: Care of normal infants

2
Care of normal
infants

Normal infants are at low risk of developing
Objectives problems in the newborn period and,
therefore, require primary care only. About
When you have completed this unit you 80% of all newborn infants are normal.
should be able to:
• Manage normal newborn infants. Normal newborn infants are at low risk of develop-
• Diagnose and treat common minor ing problems and require only primary care.
problems.
• Manage breast feeding.
• Promote baby friendly care. 2-2 Should all normal infants be kept with
• Discharge a normal infant. their mothers?
Yes, all normal infants should stay with their
mothers and not get cared for in the nursery.
CARING FOR NORMAL This is called rooming-in. The infant is either
INFANTS 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
2-1 What is a normal infant? staying with their mothers are:

A normal infant has the following 1. The mother remains close to her infant all
characteristics: the times and gets used to caring for her
infant. This strengthens bonding.
1. The infant is born at term (37 to 42 weeks 2. It encourages breast feeding.
gestation). 3. It builds up the mother’s confidence in her
2. The 1 minute Apgar score is 7 or more and ability to handle her infant.
no resuscitation is needed after birth. 4. It prevents the infant being exposed to the
3. The infant weighs between 2500 g and infections commonly present in a nursery.
4000 g at birth. 5. It reduces the number of staff needed to
4. On physical examination the infant care for infants.
appears healthy with no congenital
abnormalities or abnormal clinical signs. The father should be present at the delivery to
5. The infant feeds well. share this exciting moment.
6. There have been no problems with the
infant since delivery.

30 PRIMAR Y NEWBORN CARE

them from dehydration at a time when many
Mothers and infants should stay together.
mothers produce only small amounts of milk.

2-3 When should the infant receive the first 2-6 What routine cord care is needed?
bath? The umbilical cord stump is soft and wet after
There is no need to routinely bath all infants delivery and this dead tissue is an ideal site for
after delivery to remove the vernix. Vernix bacteria to grow. The cord should, therefore, be
will not harm the infant and disappears kept clean. It should also be dried out as soon
spontaneously after a day or two. Vernix as possible by 6 hourly applications of surgical
protects the skin and kills bacteria. Many spirits (alcohol). It is important to apply enough
infants also get cold if they are bathed soon spirits to run into all the folds around the base
after delivery. The only indication for an infant of the cord. There is no need to use antibiotic
to be washed or bathed soon after birth is powders. If the cord remains soft after 24
severe meconium staining or contamination hours, or becomes wet and smells offensively,
with maternal blood or stool. then the cord should be treated with surgical
spirits every 3 hours. Do not cover the cord
It is, however, important that all primiparous with a bandage. Usually the cord will come off
mothers learn how to bath their infants between 1 and 2 weeks after delivery.
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 Good cord care with surgical spirits is important.
few hours old.

2-4 What is the appearance of a newborn 2-7 Can a vaginal discharge be normal in
infant’s stool? an infant?

For the first few days the infant will pass Yes. Many female infants have a white, mucoid
meconium, which is dark green and sticky. vaginal discharge at birth, which may continue
By day 5 the stools should change from green for a few weeks. Less commonly the discharge
to yellow, and by the end of the first week may be bloody. Both are normal and caused by
the stools should have the appearance of the secretion of oestrogen by the infant before
scrambled egg. The stools of breast fed infants and after delivery.
may also be soft and yellow-green but should
not smell offensive. 2-8 May normal infants have enlarged
breasts?
Some infants will pass a stool after every feed
while others may not pass a stool for a number Yes. Many infants, both male and female, have
of days. As long as the stool is not hard, the enlarged breasts at birth due to the secretion
frequency of stools is not important. of oestrogen. The breasts may enlarge further
after birth. Breast enlargement is normal and
2-5 How many wet nappies should an the breasts may remain enlarged for a few
infant have a day? months after delivery. Some enlarged breasts
may secrete milk. It is very important that
A normal infant should have at least 6 wet these breasts are not squeezed as this may
nappies a day. If the infant has fewer than 6 introduce infection resulting in mastitis or a
wet nappies a day, you should suspect that the breast abscess.
infant is not getting enough milk. However,
during the first 5 days, infants may have 2-9 Which birth marks are normal?
fewer wet nappies as infants normally pass
little urine in the first few days. This protects 1. A blue patch over the sacrum is very
common and is called a ‘mongolian spot’.

CARE OF NORMAL INFANTS 31

It is seen in normal infants and is due to the tongue out fully and, therefore, is said to
the delayed migration of pigment cells into have ‘tongue tie’. This does not interfere with
other areas of the skin. It is not a sign of sucking and usually corrects itself with time.
Down syndrome (mongolism). Sometimes Do not cut the membrane as this may cause
similar patches are seen over the back, severe bleeding. Refer the child to a surgeon if
arms and legs and may look like bruises. the tongue does not appear normal by 2 years.
They need no treatment and disappear
during the first few years of life. 2-13 Does an umbilical hernia need
2. It is common for an infant to have a few treatment?
small pink or brown marks on the skin at
birth. These are normal and disappear in a Infants commonly develop a small umbilical
few weeks. hernia after the cord has separated. This does
3. Many infants also have pink areas on the not cause problems and usually disappears
upper eyelid, the bridge of the nose and without treatment when the infant starts to
back of the neck that become more obvious walk. If the hernia is still present at 5 years the
when the infant cries. These marks are child should be referred for possible surgical
called ‘angel’s kisses’ and ‘stork bites’. They correction.
are also normal and usually disappear
within a few years. 2-14 Do normal infants commonly have a
4. Some infants develop one or more raised blocked nose?
red lumps on their skin during the first Yes, a blocked nose is common due to the small
few weeks. These ‘strawberry patches’ size of the nose in a newborn infant. Normal
grow for a few months and take a few infants also sneeze. Usually a blocked nose does
years to disappear. They are best left alone not need treatment. However, some infants may
and not treated. develop breathing difficulties or apnoea if both
nostrils are completely blocked. Nose drops
2-10 Are cysts on the gum or palate containing drugs can be dangerous as they are
normal? absorbed into the blood stream and can cause
Small cysts on the infant’s gum or palate are a rapid heart rate. Sodium bicarbonate 2% or
common and almost always normal. They do saline nose drops can be used. The blocked nose
not need treatment and disappear with time. is usually not caused by a cold.
They must not be opened with a pin or needle
as this may introduce infection. 2-15 Are wide fontanelles and sutures
common?
2-11 Can infants be born with teeth? Many normal infants have wide fontanelles and
Yes, some infants are born with teeth. These sutures. This is particularly common in low
are either primary teeth or extra teeth. birth weight infants. The anterior fontanelle
Primary teeth are firmly attached and should may also pulsate. If the anterior fontanelle
not be removed. Extra teeth are very small and bulges and the infant’s head appears too big, the
usually very loose. A tooth that is very loose, infant must be referred to a level 2 or 3 hospital
and is only attached by a thread of tissue, can as hydrocephaly is probably present. If you
be pulled out. It will be replaced later by a are uncertain, repeat the head circumference
primary tooth. measurement in 2 weeks. It should not increase
by more than 0.5 cm per week.
2-12 Should ‘tongue tie’ be treated?
2-16 Are extra fingers or toes normal?
Many infants have a web of mucous
membrane under the tongue that continues to Extra fingers that are attached by a thread of
the tip. As a result the infant is not able to stick skin are common and occur in normal infants.


There is often a family history of extra digits. cotton vest and a gown that ties at the back or a
Extra fingers or toes should be tied off as close ‘baby grow’. A disposable or washable nappy is
to the hand or foot as possible with a piece of worn. If the room is cold, a woollen cap should
surgical silk. If the extra digit contains cartilage be worn. Woollen booties are sometimes also
or bone and is well attached with a broad base, worn. It is important that the clothing is not too
it must not be tired off. These infants have a tight. Infants should be dressed so that they are
high risk of other abnormalities and, therefore, comfortable and warm. Usually a single woollen
should be referred to a level 2 or 3 hospital. blanket is adequate.

2-17 Should an infant’s nails be cut? 2-21 Must the birth be notified?
If an infant’s fingernails become long they may The birth of every infant must be notified by
scratch the face. Long nails should, therefore, be the hospital, clinic or midwife. The parents
cut straight across with a sharp pair of scissors. later must register the infant’s name with the
Do not cut the nails too short. Never bite or tear local authority.
the nails. Nail clippers are dangerous.
2-22 Should all infants receive a Road-to-
2-18 Should the foreskin of an infant’s Health Card?
penis be pulled back?
Yes. All newborn infants must be given a
No. The foreskin is usually attached to the Road-to-Health Card (preschool card), as
underlying skin and, therefore, should not be this is one of the most important advances
pulled back to clean the glans. All newborn, in improving the health care of children. The
male infants have erections of the penis. They relevant information must be entered at birth.
also have larger testes than older infants. These Mothers should be told the importance of the
signs usually disappear within a few months card. Explain the idea of the Road-to-Health
and are due to the secretion of male hormones. Card to her. She must present the card every
time the infant is seen by a health care worker.
2-19 When should the normal infant be It is essential that all immunisations be entered
fully examined? on the card. A record of the infant’s weight gain
is also very important as poor weight gain or
Weighing and examining all newborn infants weight loss indicates that a child is not thriving.
are important parts of primary care. A full
examination should be done after the mother
and infant have recovered from the delivery, All newborn infants must be given a Road-to-
which usually takes about 2 hours. The infant Health Card.
must be examined in front of the mother so
that she is reassured that the infant is normal.
It also gives her a chance to ask questions 2-23 Should newborn infants be
about her infant. The infant is also briefly immunized?
examined immediately after birth to identify The schedule of immunisations varies slightly
any gross abnormalities. in different areas but most newborn infants are
given B.C.G. and polio drops within 5 days of
All newborn infants should be weighed and delivery. It is safe to give polio drops to infants
examined. of HIV positive mothers. However, their
B.G.G. immunisation is often delayed until
it can be established that they are not HIV
2-20 How should the infant be dressed? infected. Sick and preterm infants are usually
It is important that the infant does not get given B.C.G. and polio drops when they are
too hot or too cold. Usually an infant wears a ready to be discharged home.


FEEDING THE NORMAL Benefits to the mother

INFANT 1. Breast feeding is much cheaper than
buying formula feeds.
2. Breast milk is instantly available at all
2-24 What milk can be given to a normal times. No sterilising of bottles and teats,
infant? and preparation of formula is needed.
3. It is emotionally satisfying for the mother
• Breast milk. Human breast milk meets to successfully breast feed her infant and
all the nutritional needs of a healthy term helps to form a strong bond between
infant. mother and infant.
• Formula feeds. These powdered feeds are 4. Breast feeding helps the involution of the
made from cow’s milk or soya bean and are uterus and reduces the amount of bleeding
modified to have similar constituents to during the puerperium.
breast milk. 5. Breast feeding helps the mother to lose
excessive weight gained during pregnancy.
Whenever possible mothers should breast feed Pregnancy, not breast feeding, alters the
their infants. breast shape of a primiparous woman.

Breast feeding is cheap and ensures an adequate,
2-25 What are the benefits of breast
safe supply of food. It, therefore, decreases the
feeding?
incidence of malnutrition.
Breast feeding provides many benefits to both
the infant and mother. The main benefits are: Breast feeding may increase the risk of HIV
transmission from mother to infant. This must
Benefits to the infant be taken into account when discussing breast
1. Breast milk is the ideal feed for term feeding with a mother.
infants as it provides all the nutrients in the
correct amount and proportion for normal 2-26 Why do some mothers not breast feed
growth and development. successfully?
2. Breast milk is easily digested and absorbed.
Breast feeding is not always easy, as the
3. Breast milk is clean and warm, and avoids
‘natural art of breast feeding’ has to be learned.
the dangers of a contaminated water
Some mothers do not breast feed or fail to
supply, inadequately sterilised bottles and
breast feed successfully because:
teats, and lack of refrigeration facilities.
4. Breast milk avoids the danger of diluted or 1. They believe that they do not have enough
concentrated formula. milk because it takes a number of days
5. Breast milk contains many anti-infective before the supply of milk increases.
factors and decreases the risk of infections, 2. They do not know the advantages of breast
especially gastroenteritis, a major cause of feeding.
death of infants in poor communities. 3. They think that their milk is too thin, or
6. Breast milk decreases the risk of allergy their breasts too large or too small.
in the infant, especially if there is a strong 4. They develop cracked nipples or engorged
family history of allergy. breasts due to an incorrect method of
feeding.
5. They want to return to work and do not
Breast feeding decreases the incidence of realise that many working mothers can
gastroenteritis and lowers the infant mortality continue to breast feed successfully.
rate in poor communities. 6. They are afraid of breast feeding.


7. They have flat or inverted nipples. 2-28 How can breast feeding be
8. Traditional beliefs may result in encouraged in hospitals and clinics?
unsuccessful breast feeding, e.g. incorrect
Staff should be convinced that breast feeding
beliefs that colostrum is not good for the
has many benefits for the mother and
infant, intercourse spoils the milk, and
infant, they should feel comfortable and
delayed feeding causes the milk to become
not embarrassed when speaking to patients
sour in the breast.
about breast feeding, and they must have
9. Poor sleeping or excessive crying by the
the knowledge and skills to teach mothers
infant is blamed on the quality or supply of
how to breast feed. Mothers must be helped
the breast milk.
individually with kindness and patience.
10. They are HIV positive and elect not to
breast feed. Facilities for rooming-in must be provided,
and the mother allowed unlimited access to
2-27 How can breast feeding be promoted? her infant to demand feed. The national baby
friendly hospital initiative encourages breast
Breast feeding should be promoted as the feeding.
normal, natural method of feeding an infant.
This can be achieved by:
2-29 What is the value of a local breast
1. Encouraging a positive attitude towards feeding support group?
breast feeding in the home during
Often the best person to advise and help a
childhood and adolescence by seeing other
breast feeding mother is someone who has
infants being breast fed.
successfully breast fed herself. A number of
2. Teaching the advantages of breast feeding
mothers who have breast fed and are interested
in schools.
in helping others to breast feed can form a
3. Promoting breast feeding in the media
local support group. With help and training by
(radio, TV, books).
midwives and doctors they can provide a very
4. Teaching the advantages and method of
helpful service.
breast feeding in all antenatal clinics.
5. Starting breast feeding groups run by
mothers who have themselves breast fed. 2-30 What preparation does a mother need
6. Encouraging breast feeding and practice for breast feeding?
kangaroo mother care in hospitals and 1. The decision to breast feed should be
clinics. taken before her infant is born. If she is
7. Discouraging bottle feeding in hospital. still undecided at delivery, she should be
Rather use cups for expressed breast milk encouraged to breast feed.
or formula feeding. 2. No routine preparation of breasts and
Further information on breast feeding in nipples before delivery is necessary.
South Africa can be obtained from a local 3. A good, supportive bra should be worn.
breast feeding support group or local branches Breast size is no indication of a woman’s
of the Breastfeeding Association, La Leche ability to breast feed.
League, and National Childbirth Education
and Parenting Association. 2-31 How can you treat flat or inverted
nipples?

Breast is best. If a woman’s’ nipples appear flat or inverted
during pregnancy, they can be corrected by the
infant sucking after delivery.


2-32 Should the infant be put to the breast 2-35 How should an infant fix at the breast?
immediately after delivery?
One of the commonest mistakes made when
Yes, the mother should breast feed her infant breast feeding is that the infant is not held
as soon as possible after delivery as the infant’s and fixed correctly (latched) at the breast.
sucking drive is usually strongest in the first The infant must take the whole nipple and
hour after birth. Early suckling promotes most of the pigmented areola into the mouth.
bonding between the mother and infant. It also Sucking or chewing on the nipple causes pain
stimulates milk production and encourages and damages the nipple. The mother should
successful breast feeding. The small amount let her nipple touch the infant’s cheek, so that
of colostrum in the first few days satisfies the the infant will turn towards the breast with an
infant and is very rich in antibodies. open mouth to take the nipple. Make sure that
the infant’s nose is not covered by the breast.
2-33 Should clear feeds be given during the
first few days? The infant must take the whole nipple and most
Sterile water or dextrose water should not be of the areola into the mouth when fixing at the
given before starting breast or formula feeds mother’s breast.
on day 1. A breast fed infant does not need
additional clear feeds. If the mother wants to
breast feed, no bottle feeds should be given to 2-36 Should infants be demand fed?
the infant as a teat can confuse the infant and
Yes. Whenever possible infants should be
cause it to reject the nipple.
demand fed. This means that the infant is
Unlike a bottle fed infant, that sucks the milk put to the breast whenever hungry. A normal
out of the teat, a breast fed infant holds the breast fed infant will usually feed every 2 to 4
nipple against the hard palate and compresses hours during the day for the first few weeks.
the milk ducts in the areola with the gums. Demand feeding prevents engorged breasts.
The breast fed infant, therefore, makes a
chewing movement while feeding (suckling). 2-37 What is the let down reflex?
When an infant is put to the breast, the
Routine clear feeds are not needed on day 1. pituitary gland in the mother’s brain responds
by producing the hormones prolactin and
oxytocin. Prolactin stimulates the breast to
2-34 What is the best position to hold an secrete milk while oxytocin produces the ‘let
infant while feeding? down reflex’. This reflex produces a tingling
The correct position of the infant while feeling in the breast, and results in milk
feeding is important. The mother should be being pumped into the infant’s mouth by the
warm and comfortable. Usually she sits up and contraction of muscle cells that surround
holds her infant across her body in front of the milk ducts under the areola. Milk may
her. The infant is held in one arm, and should leak from the other nipple during feeds. The
lie on its side with its mouth facing the nipple. release of oxytocin helps the uterus to involute
The breast is held in the other hand to offer the by causing the uterus to contract. It may
nipple to the infant. also produce abdominal pain during feeding
for the first few days after delivery. Tension,
Mothers should be encouraged to try different anxiety and a lack of sleep may inhibit the let
feeding positions in order to find which is down reflex.
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.


2-38 How do you manage leaking breasts? 1. Her breasts do not feel full before feeds
after day 5.
Milk leaking from the breasts is common
2. The infant continues to lose weight after
in the first few weeks of feeding. Leaking of
day 5.
the opposite breast during feeding can be
3. The infant loses more than 10% of its birth
stopped by pressing on that nipple. Cotton
weight.
handkerchiefs or pads can be used for leaking
4. The infant is not gaining weight by 2 weeks.
between feeds. They should be changed
5. The infant does not wet 6 or more nappies
frequently as dampness may cause sore nipples.
in 24 hours (after day 5), is very restless
and appears hungry.
2-39 Can a mother’s milk be too strong or
too weak? If you are worried that an infant is not getting
enough milk, then the infant can be test
No, but the appearance of breast milk varies. weighed before and after a feed. After the first
There are 3 different types of breast milk: week of life, most term infants will gain about
1. Colostrum. This is a milky fluid produced 25 g per day. Weight gain is best determined
in small quantities for the first few days over a few days.
after delivery. However, it contains a lot
of protein and provides all the infant’s 2-41 Is it normal for an infant to lose weight
nutritional needs. After 3 to 5 days the after birth?
milk supply suddenly increases and
Yes. Most breast fed infants will lose weight
the breasts feel full. This is due to the
for the first few days after birth due to the
production of mature milk, which consists
small volume of breast milk being produced.
of foremilk and hind milk.
Colostrum, however, will meet the infant’s
2. Foremilk. This is produced at the start of
nutritional needs. Once the milk ‘comes in’,
each feed. It appears very weak and thin
between days 3 and 5, the infant will start to
as it consists mainly of water with little
gain weight. Most breast fed infants regain
fat. On a hot day a thirsty infant will take
their birth weight by day 7. This weight loss
frequent, small feeds of foremilk.
is normal and does not cause the infant any
3. Hindmilk. This is only produced towards
harm. The normal infant does not usually lose
the end of a feed. It looks thick and
more than 10% of the birth weight. Marked
rich, and contains a lot of fat. A hungry
weight loss suggests that the infant is ill or not
infant will empty the breast to obtain the
getting enough milk.
hindmilk.

2-42 Is it necessary to weigh a normal
2-40 Do all mothers produce enough
infant every day?
breast milk?
No. The normal infant should be weighed
Most mothers produce enough milk for their
at delivery and again on days 3 and 5 if still
infant if breast feeding is managed correctly.
in hospital. Weight at discharge must be
Unfortunately many mothers stop breast
recorded. At every clinic visit the infant’s
feeding during the first 5 days because they
weight should be measured and recorded. Ill
are incorrectly advised that they do not have
infants should be weighed every day until well.
enough milk or because the infant is losing
weight. Milk supply is normally best in the
morning and poorest in the late afternoon and 2-43 How can you improve a mother’s milk
early evening. supply?

The mother is probably not producing enough 1. Reassurance, support and encouragement
milk if: that she will be able to breast feed. Also
ensure that she is getting enough sleep and


is not under too much stress, as anxiety 2-46 What should you do if an infant
is a major cause of poor milk production. refuses the breast?
Anxiety also inhibits the let down reflex.
Some infants may reject the breast and refuse
Many mothers are more relaxed in their
to fix on the nipple and suck. Common causes
own homes.
are a sore mouth due to thrush, the infant
2. Make sure that she is fixing the infant
being ill or upset, or the milk flow being too
correctly to the breast and that the infant is
fast. These problems should be looked for and
sucking correctly.
treated.
3. Put the infant to the breast frequently
during the day until a good milk supply Do not hold the infant’s head too tightly or
is established. If the infant is not demand push the face towards the breast, as the infant
feeding 3 to 4 hourly, it should be woken will turn towards your hand instead of the
for feeds. The best stimulus to milk nipple. It may help to squeeze a little breast
production is the infant sucking frequently milk onto the nipple before placing it in the
and for prolonged periods. infant’s mouth.
4. The mother should rest for a while in the
afternoon and drink adequate fluids. 2-47 What may causes an infant to choke
5. Stop any bottle feeds. while feeding?
During the first few weeks the mother may
The best stimulus for milk production is frequent have a lot of milk and the milk may flow too
feeding. fast causing the infant to choke or gag when
feeding. As a result the infant may refuse to
feed or overfeed and become restless. It may
2-44 Should infants be routinely test help for the mother to lie back at the start of
weighed? the feed with the infant across her chest so that
the milk has to flow upwards against gravity.
No, there is no need to test weigh all infants.
The mother may have to express a bit before
The amount of milk an infant takes varies
starting the feed, or feed the infant more
widely between feeds. A small feed, which
frequently. Too much milk and milk that flows
is common in the afternoon or when the
too quickly settles with time.
mother is tired, may cause maternal anxiety.
Test weighing may be useful to assess a
mother’s milk production if the infant does 2-48 How should you manage swollen or
not gain weight. painful breasts?
A normal, full breast feels tense and heavy, but
2-45 Should the infant always feed on both is not painful and any discomfort is relieved
breasts? by feeding. Breasts that are swollen, tender,
hard, lumpy and painful are caused by either
It is best to empty one breast first before
engorgement or mastitis.
putting the infant to the opposite breast. This
ensures that the infant gets the rich hind milk. Both engorgement and mastitis result from an
Start each feed on alternate breasts. However, obstruction in milk flow:
for the first few days it is useful to allow the
infant to feed on both breasts to stimulate the
milk production. 1. Engorged breasts
Both breasts are swollen, hard and painful but
the mother does not feel ill. The milk does not
flow freely. Engorged breasts usually occur
between days 3 and 5 when the mother’s milk
suddenly ‘comes in’. Engorged breasts are


common if the infant does not room-in and if It is important that the infant is correctly
the mother does not demand feed. fixed at the breast so that the nipple is not
chewed. When removing the infant from the
Treatment consists of emptying the breast by
breast, the mother should insert her little
expressing or allowing the infant to suck. The
finger into the corner of the infant’s mouth to
infant should be fed on the most painful breast
break the suction.
first. Sponging the breasts with warm water
or standing under a warm shower relieves
the discomfort, while a mild analgesic like Correct fixing of the infant at the breast will help
paracetamol (Panado) is helpful. Often the to prevent painful nipples.
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 2-50 How should you treat painful nipples?
from the breast, the infant will usually fix well.
Nipples are often painful during the first few
Breast engorgement should be prevented by
days of breast feeding, especially if the infant
frequent feeds.
is very hungry or is not fixing on the breast
2. Mastitis (milk fever) correctly. Do not let the infant sleep at the
nipple until the nipples have toughened.
Mastitis is an inflammation of the breast due
to infection in blocked milk ducts. It causes Cracked nipples are very painful and should
a swollen, painful, red area of one breast. The be prevented by correctly fixing the infant to
mother feels ill and may have a temperature. the breast and avoiding engorged breasts. Treat
cracked nipples with colostrum or hind milk
Treat with rest, warm compresses and a and mild analgesics. Alter the position of the
mild analgesic. It is most important that infant on the nipple so that it does not suck
the infant continues to suck frequently on on the tender area. It may be necessary to stop
the affected breast, as this will help the milk feeding on that side for 24 hours and express
to flow. Altering the feeding position often the breast instead. Frequent short feeds
helps to drain the affected area. Mastitis is when the infant is not hungry are preferable.
not dangerous for the infant. If the signs and Reassure the mother that painful nipples heal
symptoms do not improve within 24 hours very quickly. Mothers with painful nipples
an antibiotic (penicillin or cloxacillin) should need a lot of support if they are to continue
be prescribed for 5 days. If a fluctuant mass breast feeding.
develops then a breast abscess has formed.
This should be surgically drained. Due to the 2-51 Do breast fed infants need
pain of a breast abscess, feeding may have to complementary feeds?
be stopped on that breast for a few days. If
possible, feeding can be continued however. Most breast fed infants do not need
complementary (additional) feeds of formula.
2-49 How do you prevent painful nipples? Complementary feeds may decrease the
production of breast milk and the teat may
The nipples should be kept dry between feeds. confuse the infant. Only if an infant fails to
Instead of protecting the nipples with lanolin gain weight, after management to improve the
cream, petroleum jelly (Vaseline) or masse mother’s milk supply has been tried, should
cream, it is suggested that a little colostrum complementary feeds be used. Some mothers
or hind milk be left to dry on the nipples will give complementary feeds if they have to
after each feed. The milk has anti-infective leave their infant for more than a few hours.
properties and the fat protects the nipples. Do However, expressing milk into a bottle for the
not use alcohol on the nipples. Avoid vigorous missed feed would be preferable. Expressed
washing or soap on the nipples. breast milk can be safely stored up to 6 hours


in a cool place or for 48 hours in a fridge. 1, SMA). They are very similar and, therefore,
Breast milk can be safely frozen and stored the milk available at the local clinic or the
for 2 weeks in a fridge freezer or 6 months in cheapest milk should be bought. Unaltered
a deep freeze. Frozen milk should be thawed cows milk, evaporated milk and skimmed
slowly by placing the container in warm (not milk are not suitable for infants under 6
hot) water. months of age. Milk creamers must never be
used to feed infants.
2-52 Can working mothers continue to Bottle fed infants should be fed on demand. If
breast feed? fed according to a schedule, most infants will
Yes. Mothers can continue to breast feed for need to be fed 6 times a day, at 06:00, 10:00,
many months while working. Breast milk 14:00, 18:00, 22:00 and 02:00. After the first
can be expressed at work and this or formula few weeks the 02:00 feed can be missed. Most
is given to the infant during the day. When term infants will take about 100 ml per feed
at home the mother breast feeds frequently. after the first week.
Ideally it should be possible to take the infant
to work or leave the infant in a creche at or 2-56 How is formula made up?
near the place of work.
If a mother decides to formula feed her infant,
it is very important that she knows how to mix
2-53 Do drugs cross into the breast milk? formula correctly. She must also have a source
Almost all drugs that the mother takes by of clean water and know how to clean a cup or
mouth will cross into the breast milk in very bottle and teat.
small quantities that will not affect the infant. A level scoop of milk powder (scraped level
Breast feeding mothers should only take with a knife and not packed down) is added
medication that is necessary. to 25 ml of clean water in a feeding bottle. The
water should have been boiled beforehand
2-54 When should an infant not be breast and allowed to cool. The bottle and teat must
fed? have been cleaned and sterilised by boiling
1. If, after counselling, the mother has decided or standing in a disinfecting agent (Milton or
that she definitely does not want to breast half-diluted Jik). Shake the bottle well to mix
feed, then the infant should be fed formula. the feed. Bottles should not be used if they
2. If a mother is unable to breast feed because cannot be cleaned properly.
she is separated from her infant, she should One of the great dangers of formula feeds
express her milk, manually or with a breast is to make the mixture too strong or too
pump, for the infant to be cup fed. weak. If too much milk powder is added,
3. If the mother has an inadequate milk the infant may receive too much salt which
supply despite advice and support, and if can be dangerous. If too little milk powder is
the infant is not gaining wait by 2 weeks, added, the infant may become malnourished.
then complementary feeds should be Another danger is gastroenteritis caused by
started to ensure normal growth. infected water or dirty bottles and teats. These
4. If the mother is very ill. and other problems of formula feeds can be
5. If the mother is HIV positive and decides, avoided by breast feeding.
after counselling, to formula feed her infant.
Formula fed infants should be offered a few
clear feeds daily if the weather is very hot.
2-55 What formula feed should be used for Bottle fed infants must be held while feeding.
a term infant? The bottle should not be propped.
A number of formula feeds are available for
term infants (NAN 1, S26, Similac, Lactogen


Many of the dangers of infection when using months of age. Thereafter, milk alone is not
bottles and teats can be avoided if cup feeds enough and solids should be introduced. If
are used instead. possible, an infant should be entirely breast
fed for 6 months. Even if the mother can only
2-57 What are the advantages of cup breast feed for a few weeks or months, this
feeding over bottle feeding? will be of benefit to both her and her infant.
Introducing solids reduces the anti-infectious
If an infant cannot be breast fed it is better properties of breast milk.
to cup feed than to bottle feed. The greatest
advantage of cup feeding is that a cup can Some mothers continue to partially breast
be easily cleaned with soap and water. A cup feed up to 2 years. It is best to continue breast
also dries easily, especially if placed in the feeding after solids have been introduced.
sun, which helps to sterilise the cup. This is This practice is particularly important in poor
most important when clean or boiling water is communities as breast milk provides the infant
not available for washing bottles. A cup feed with a good source of protein and helps reduce
usually takes less time than a bottle feed. It is the risk of pregnancy in the mother. Weaning
also easier to wean a preterm infant from tube should be done over a few weeks by dropping
feeds onto cup feeds than onto bottle feeds as one feed per week.
many infants can swallow well before being
able to suck. Any small plastic cup or dish can Whenever possible infants should be entirely
be used to feed an infant. Breast milk can be
breast fed for 6 months.
expressed directly into the cup before a feed is
given to a preterm infant. Mothers who do not
breast feed should be shown how to cup feed
before they are discharged home after delivery. THE BABY FRIENDLY
In some infants bottle feeding may cause APPROACH
problems with breast feeding as the
mechanism of sucking from a bottle is
different from feeding at a breast. This is often 2-60 What is a baby friendly hospital?
called ‘nipple confusion’.
The idea of a ‘Baby Friendly Hospital’ or
clinic was introduced by the World Health
2-58 Iron and vitamin supplements
Organisation to promote the advantages
needed?
of breast feeding. An agency is available to
A normal term infant born to a healthy mother registers hospitals as baby friendly. To become
on a good, mixed diet and regularly exposed to registered as a Baby Friendly Hospital all the
sunlight does not need supplements in the first ‘Ten steps to successful breast feeding’ have to
6 months of life. Additional iron and vitamin be implemented.
supplements may, however, be of benefit in
poor communities when iron drops 0.3 ml (or 2-61 What are the ten steps to successful
syrup 5 ml) and multivitamin drops 0.3 ml (or breast feeding?
syrup 5 ml) can be given daily. Supplements
given to well term infants are not harmful. 1. Have a written breast feeding policy that is
Remember that all preterm infants need more frequently communicated to all the health
supplements (0.6 ml). care staff.
2. Train all the health care staff in the skills
needed to implement successful breast
2-59 When should solids be introduced?
feeding.
Normally breast milk or formula feeds will 3. Inform all pregnant women about the
meet all the infant’s nutritional needs until 6 benefits of breast feeding.


4. Help mothers to start breast feeding within 1. Does the infant appear normal, active and
30 minutes of delivery. healthy?
5. Show mothers how to breast feed and teach 2. Does the infant feed well?
them how to maintain lactation even if 3. Can the mother feed and care for her infant?
they are separated from their infants. 4. Does the infant weigh 1800 g or more?
6. Do not give newborn infants formula or
If the answer to any of these questions is ‘No’
water feeds unless this is indicated for
the infant should not be discharged.
medical reasons.
7. Allow mothers and their infants to remain
together all the time from delivery to 2-64 What advice should the mother be
discharge. given about an infant at discharge?
8. Encourage demand feeding. Before discharge all mothers must be advised
9. Discourage the use of dummies, teats and about:
nipple shields.
10. Promote the formation of breast feeding 1. Feeding their infant.
support groups and refer mothers to these 2. Bathing and dressing their infant.
groups on discharge from hospital or clinic. 3. Follow-up appointments and arrangements.
4. Reporting immediately if the infant
appears ill or behaves abnormally.
2-62 What are the advantages of the baby
5. The importance of the Road-to-Health
friendly approach to the care of infants?
Card (preschool card).
It promotes exclusive breast feeding and
bonding between mother and infant. This 2-65 Should normal infants be followed up
is particularly important in communities after discharge?
where malnutrition, gastroenteritis and child
abuse are common. The baby friendly way of If the infant is discharged before 7 days of age,
infant care is also kinder, gentler, cheaper and the infant should be seen at home or at a clinic
better. Every effort must be made to make all on days 2 and 5 to assess whether:
hospitals and clinics baby friendly. 1. The infant appears healthy or sick.
If HIV positive mothers decide to breast feed, 2. The infant is feeding well and receiving
then exclusive breast feeding may reduce the enough milk.
risk of mother to child transmission of HIV. 3. The mother is managing to care for her
If they decide to formula feed, many of the infant.
practices which encourage bonding can still be 4. The cord is clean and dry.
practised. 5. The infant is jaundiced.
6. The mother has any problems with her
infant.
DISCHARGING A NORMAL After the age of one week, the normal infant
should be followed at the local ‘well baby’
INFANT clinic to assess the infant’s weight gain and
general development, and to receive the
required immunisations. These details must be
2-63 When can an infant be discharged
noted on the Road-to-Health Card.
from the hospital or clinic?
Most normal newborn infants can be
discharged 6 hours after delivery. Before CASE STUDY 1
discharging an infant from either a hospital or
clinic, you should ask yourself the following An infant is delivered by spontaneous vertex
questions: delivery at term. Immediately after birth


the cord is clamped and cut and the infant CASE STUDY 2
is dried. The infant cries well and appears
normal. The infant has a lot of vernix and a
Starch powder is sprinkled onto the umbilical
blue mark is noticed over the lower back. The
cord of a newborn infant twice a day to hasten
infant passes urine after delivery but does not
drying. The cord is then covered with a linen
pass urine again for 24 hours.
binder. The mother is worried that the infant
has enlarged breasts. As the ward is cold at
1. When should the infant be given to the night, she puts the infant into her bed.
mother?
As soon as the infant is dried, the cord cut, 1. What do you think of the method of cord
the Apgar score determined and a brief care in this infant?
examination indicates that the infant is a
The cord should be dried with surgical spirits
normal, healthy term infant. The father should
and not covered with starch powder. Covering
also be present to share this exciting moment.
the umbilical cord with a binder is incorrect as
it prevents the cord drying out.
2. What is the blue mark over the infant’s
back?
2. What treatment is needed for the infant’s
A ‘mongolian spot’, which is normal. It is enlarged breasts?
important to explain to the mother that it is
No treatment is needed and the mother must
not a bruise. It disappears over a few years.
not squeeze the breasts. The mother must be
reassured that breast enlargement resolves
3. Should the vernix be washed off spontaneously in a few months.
immediately after delivery?
Infants should not be bathed straight after 3. What would you advise the mother
delivery, as they often get cold, while vernix about sleeping with her infant?
should not be removed as it helps protect the
If the ward is cold and there is no simple way
infant’s skin from infection. It would be better
of keeping the infant warm, then the infant
to bath the infant the following day, in the
should sleep with the mother. It is important
mother’s presence, when most of the vernix
that infants do not get cold. Kangaroo mother
will have cleared.
care is a very effective method of keeping the
infant warm.
4. Should the infant stay with the mother
after delivery?
Yes, if possible the mother and her infant CASE STUDY 3
should not be separated after delivery.
A normal infant weighs 3000 g at birth. By
5. Does it matter if the infant only passes day 4 the infant appears well but the weight
urine once in the first 24 hours? has dropped to 2850 and it is suggested that
formula be started. The next day the mother
No. During the first few days a normal infant
has painful, engorged breasts. The policy in
often does not pass urine frequently. However,
the hospital is to keep all normal infants in
after day 5, an infant should have at least 6 wet
the nursery where the mothers can visit at
nappies a day.
feeding time.


1. Is the weight loss of 150 g normal for this 2. Why should the infant not be sent
infant? immediately to the nursery?
Yes. An infant may normally lose up to 10% of It is important for the mother to hold her
the birth weight in the first 5 days after delivery. infant after the delivery. This promotes breast
feeding and bonding. It is best if mother and
2. Should formula feeds be started? infant be kept together.
No. Within a day or two the mother should
3. Why is it incorrect to advise formula
have enough milk and the infant will start to
feeds if the breast milk appears to be
gain weight.
weak?
3. How should the mother’s engorged Both foremilk and colostrum often appear
breasts be managed? weak. This is normal and never an indication
for formula feeds.
Stop formula feeds and allow the infant to
breast feed frequently.
4. What are the dangers of a poor rural
woman giving bottle feeds?
4. What do you think of normal infants
being kept in the nursery? She may not be able to clean the bottle and teat
correctly. Cup feeds would be safer if formula
Normal infants should room-in with their is used as a cup is easier to clean. This mother
mothers. should be encouraged to breast feed.

5. Why is it important that this woman
CASE STUDY 4 breast feed her infant?

A well newborn infant is given clear feeds of 5% She will not be able to buy formula as she
dextrose for the first day. As the mother is tired is poor and probably does not live close to
after the delivery, the infant is immediately sent a shop. As a result the infant is at high risk
to the nursery. On day 3 the mother is advised of gastroenteritis and malnutrition. These
to bottle feed as her milk appears to be too problems can usually be prevented by breast
weak. She is a poor women who plans to return feeding.
to a rural district. It is suggested that the infant
starts solids at 1 month. 6. When should the infant be given solids?
This mother should breast feed for as long as
1. Should clear feeds be used in a healthy possible. It would probably be best if solids
newborn infant? were only started at 6 months.
No. Feeds should be started with breast milk
or full strength formula.

Primary Newborn Care: Care of normal infants

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Primary Newborn Care: Care of normal infants