Dr. Khushboo +918860018875

Health Education: Babies

Disclaimer: The information given here neither claims to provide complete knowledge of the topic (which is anyway beyond the scope of this website), nor is it substitute of a professional medical advice. Kindly consult your doctor for complete evaluation and assessment of the complaints, and visit nearest healthcare facility in case of any emergency. Kindly do not make diagnosis or initiate/stop any treatment on basis of this information.

Newborn care

Routine care of newborn after delivery

Exclusive breastfeeds: Mother and  attendants are advised to exclusively breastfeed the babies till 6 months of age. Babies generally feel satisfied after feeding and are able to sleep or play well after feeding. Baby generally sleeps 2 to 3 hrs after feeds and passes urine 6 to 8 times pe

No need to apply anything on umbilical cord. Keep the cord dry and clean and avoid contamination with urine and stool. Generally cord dries and falls off in 5-10 days. If there is any redness, discharge or bleeding contact your pediatric

The routine dip baths should be avoided till the baby is in the hospital premises as this increases the risk of hypothermia. The sponging of the baby should be done once a day with clean water and mild soap, as per the requirement. The bathing may be undertaken once the the baby is discharged from the hospital and cord has fallen

Do not to apply anything on umbilical cord.
Do not apply kajal. Do not give water, honey, ghutti, sugar water or tea.
Avoid everybody touching the newborn. Maintain strict hygiene. Avoid bouncing the baby playfully.
It is not advised to make the baby sleep in prone position (sleeping on tummy)

Yes, it is recommended to have a follow up visit 48 to 36 hours after discharge, or as advised by the pediatrician. Baby will have a general checkup, and will be checked for weight, jaundice, feeding and you can discuss any issues you encounter in initial days.

Generally the child needs to be taken the pediatrician at 6 weeks for vaccination, However if there is any danger sign, you must seek consultation immediately
- Difficulty in feeding
- Lethargy (movement only when
stimulated)
- Fast breathing (> 60/min)
- Chest in drawing
- Abdomen distension
- Temperature of more than 37.5 C or
below 35.5 C
- Baby appears yellow or blue.
- Any redness or discharge from umbilicus.
- Convulsions/Fits
- Anything out of ordinary to normal behaviour of baby

NLD Obstruction

(Tear Duct Blockade)

Congenital nasolacrimal duct obstruction (CNLDO) is a common condition causing excessive tearing or mucoid discharge from the eyes, due to blockage of the nasolacrimal duct system. This condition is quite common, affection 20% of the children. So yes, it is fairly common condition

Excessive tearing from one or both eyes in most common complaint that raises suspicion of NLD obstruction. There also can be crusting and thick discharge. Mild NLD obstruction does not usually cause much discomfort to patients. Affected infants often act normally despite the presence of significant overflow tears and mucopurulent discharge.

There also may be accompanying infection due to deposition of cells and bacteria in the tear duct passage. After treatment of infection, infection itself gets cleared but discharge remains. However, severe cases may cause skin excoriation, redness, swelling and severe infection with pus formation.

However there are other conditions which cause same symptoms but require entirely different line of management. So it is essential to have your baby checked by the doctor.

Lacrimal sac massage is considered as the first-line treatment in the management in the first 12 months of life. There is a specific technique of doing massage called Crigler technique. Your doctor will demonstrate how to do it correctly. The goal of massage is to force fluid through the tear duct and cause the obstruction to open through the hydrostatic pressure. Treatment with antibiotics is also advised if your doctor finds associated infection.

A large number of babies improve with this alone. However, the massage has to be done correctly and regularly to be effective. If the symptoms persist beyond 1st year of life, visit to an eye doctor is mandatory.

Jaundice In Newborn

Jaundice is yellow discoloration of skin and eyes. Jaundice occurs because the blood contains an excess of bilirubin, a yellow coloured pigment, which is a product of hemoglobin breakdown. Serum bilirubin level is measured to know the severity of jaundice.

Yes, generally jaundice is a symptom of liver disease. But what happens in newborn babies in first week is of a different kind. Jaundice in first week of life is rarely due to liver disease. However, exceptions to this dictum exist and rarely, we do encounter babies with liver disease. 

There are many detailed and complex explanations for this phenomena. But in simple words we can understand that in older babies and adults, the liver removes bilirubin from blood, which then passes through the intestinal tract into feaces. However, a newborn’s still-developing liver may not be mature enough to remove bilirubin. Also babies have high level of hemoglobin inside the womb, and red cells rapidly breakdown after birth, causing higher bilirubin load on the liver.

In some babies, level of jaundice can go excessively high due to some underlying factors, like baby and mother blood group mismatch, prematurity, low birth weight, infection, thyroid deficiency, G6PD deficiency, to name a few.

Jaundice generally begins 2 to 4 days after birth and typically peak between 5 to 7 days after birth. However this timeline in not same in all babies and is influenced by a number of factors. The good news is that in most cases, newborn jaundice goes away on its own as a baby’s liver develops and as the baby begins to feed, which helps bilirubin pass through the body.

But in some cases, bilirubin level becomes very high. Brain of a newborn is sensitive to high bilirubin level. Immediate danger of very high bilirubin is Bilirubin Encephalopathy, which is a life threatening condition. In long term, it can cause permanent damage to brain, causing diseases called Kernicterus and Biliubin Induced Neurological Damage. All these conditions are very bad and should be avoided by all means.

Till a certain level, jaundice gets better on its own as the liver matures. That level is different depending on day of life, weight, maturity, and other factors. You doctor will know and tell the cut off level for your baby for that day of life. Sometimes it may be necessary to re-check the bilirubin level to know the trend.

Above certain level, it becomes necessary to actively control the jaundice. The established mode of treatment is phototherapy, in which baby is placed in blue light of specific wavelength range and effective intensity. Baby needs to be constantly under the light for it to be effective. Serum bilirubin level is rechecked till it reaches a safe level. Additional tests may be done to look for any background contributing conditions.

However, sometimes when jaundice is detected late, the situations can be critical. Bilirubin level may be very high at the time of initial presentation, or there may be evidence of brain being affected by the jaundice. In such situation, we need to carry out a procedure called exchange transfusion. Early detection and treatment can avoid the need of this high risk procedure.

After delivery, your baby will be visually checked for jaundice while in hospital. If needed, blood test to know serum bilirubin level will be done.

After discharge, your doctor calls you for follow up visit. Before that also, you your find your baby looking yellow at home, contact your doctor. If your doctor feels that jaundice looks more, serum bilirubin level will be tested. Serum bilirubin report will help to decide the line of management. It will ensure that jaundice is detected at manageable levels.

Sunlight exposure with precautions has many health benifits. But once the bilirubin level is high enough to be in phototherapy range, conventional  sun exposure at home is not effective as it does not safely provide sufficient intensity of required wavelength for significant duration.

However, a special version of sunlight treatment is a matter for research in Africa, and it is called Filtered Sunlight Phototherapy. As mentioned, it is just a research tool right now, and the equipment is not available for general use. You can read more about it

Infantile Colic

Excessive unexplained crying of baby

Crying is an essential behavior to communicate the demands of the baby so that it can be fulfilled by the caregiver. As parents we are naturally inclined to attend to a child when it is crying and see if anything is wrong. However, though crying is a good signal that child is in need, but it is a poor signal of what the child needs.

Many times the baby cries even if we have taken care of all the things that we can think of. This is also normal to some extent. All newborns cry and get fussy sometimes, for no apparent reason. During the first 3 months of life, they cry more than at any other time. But when it is excessive, it becomes a matter of concern

Colic affects up to 20% of infants. Colic is not a disease or diagnosis but a combination of baffling behaviors. It's really just a catch-all term for excessive crying in otherwise healthy babies. Mostly, there is a recognisable pattern of crying:
- With no clear reason (such as hunger or a dirty diaper)
- Like they’re in pain
- Along with clenched fists, stiff arms, an arched back, or curled legs
- While turning bright red
Babies might swallow a lot of air while crying. This can give them gas and make their belly tight or swollen.

The classic definition of infant colic was given in 1954 by Wessel, who described colic as a condition occurring in an otherwise healthy, well-fed infant with crying or fussing for more than three hours a day, for more than three days a week and for more than three weeks.
But for clinical purpose, we can't wait for three weeks to manage, so infantile colic is considered in any small baby with recurrent and prolonged crying which causes concern to parents, that occur without obvious cause and cannot be prevented or resolved.

A recent concept introduced by Dr. Ronald Barr is ‘period of PURPLE Crying’. The word PURPLE is an acronym which stands for "Peak of crying, Unexpected, Resists soothing, Pain like faces, Long lasting, Evening

Despite years of research, the aetiology (reasons) of colic remains elusive and there are many proposed theories. We cannot ask babies where they have pain, so certain assumptions are made. The word ‘colic’ implies an abdominal origin.

Postulated gastrointestinal mechanisms have included increased intraluminal gas, gut dysmotility, and visceral pain, but none is proven. There is some research on non abdominal causes of pain, but no strong evidence has emerged.

The first step for managing colic is to exclude organic causes of crying by history and examination. There are red flags that your doctor will look for in initial assessment. The diagnosis of infantile colic is entirely clinical and laboratory investigations are not needed. However, if your doctor finds something suspicious, some tests may be advised.

Then we have to look for various means to soothe the infant. By trial and error it may be possible to find some position or maneuver which calms the baby. One commonly advised strategy to calm a crying baby is called 5S technique which includes Swaddling, Side/ stomach, Shh-sound, Swinging the baby with tiny jiggly movements, Suckling (letting the baby suckle on breast/ clean pacifier). Other techniques of infant calming include use of white noise, minimal handling, and simulating car ride.

A lot of medications including gripe water are traditionally given for management of infantile colic, but how much benefit they actually give is unclear. There is some data in scientific research to suggest that Probiotics, in particular L reuteri, and preparations containing fennel oil appear effective for reducing colic (read more)

Another major problem it that despite its benign nature, infantile colic can act as a significant stressor for parents which leads to self-doubt, premature termination of breast feeding or even child abuse. One such problem is Shaken Baby Syndrome. The stress of calming a crying baby has sometimes prompted parents to shake or otherwise harm their child. Shaking a baby can cause serious damage to the brain and death. The risk of these uncontrolled reactions is greater if parents don't have information about soothing a crying child, education about colic and the support needed for caring for an infant with colic.

The parents should understand that this period will pass with time and generally after 5-6 months of age, child will be more relaxed. in case of any doubt, please contact your doctor.

Vaccination

The necessary pain

A vaccine is a product made from very small amounts of weak or dead germs or their components that can cause diseases — for example, viruses, bacteria, or toxins. It prepares your body to fight the disease faster and more effectively.

Our body has natural ability for fight off the infection. this is known as immunity. On first encounter, there occurs what is known as primary immune response, which is slower and less effective. There is a very important ability of the immune system to learn from one battle against an organism, and memorise the antigen (component of that organism that elicits immune response). On repeat exposure to same organism, a faster and more effective immune response is activated with the help of memory of previous encounter. It is called secondary immune response.

Vaccination capitalises on this ability of immune system. Vaccines expose the immune system to weak or dead organisms or their immunogenic components. This elicits primary immune response without risk of actual infection, and immune memory is created. On real exposure to organism, secondary immune response is activated which is much more effective.
The actual mechanism is much more complex and varies as per the organism. If interested, you can see a simplified mechanism of flu vaccine

Any vaccine is made available for general use only after it has been found to be reasonably safe and effective in the trials. However, the vaccination relies on the immune system of the body to act, and the limitations of immune system come into play. Some antigen elicit a better response than others. For certain organisms like malaria and dengue, we still don't have a very effective vaccine in spite of decades of research. No vaccine can guarantee 100% protection. But it still provides a reasonable degree of protection against the disease if we follow the recommended schedule.

As far as side effects are considered, yes, all medicines including vaccines have side effects. But vaccines are launched for public use only after extensive testing and research. Your doctor will tell you about common expected side effects of the vaccine. You are advised to contact your doctor if you face any problem after vaccination

As already discussed, immune system has its own limitations. Some antigens need to be repeatedly exposed to immune system to establish an effective immune memory. It is same way that some tough subjects take more time to learn.

Like we forget things after some time, immune memory for also wanes with time. So a repeat dose of the vaccine helps to refresh the immune memory and maintain effective protection

Yes, there are many such vaccines. But they are still given in the developed countries by their government in their national immunisation programme. indian government is also trying to gradually cover more vaccines, and recently rotavirus and pneumococcal vaccines are added in Indian national immunisation programme.

As a parent, you are advised to get ALL the vaccines given by the government, AND also other vaccines recommended by Indian Academy of Pediatrics if you can afford the cost.

Don't worry, most of the vaccines are effective even if given at a later date. But you should avoid delaying, because a vaccine will work only after a lag period after it has been has administered. When vaccines are given at a later date, it is called catch-up vaccination. Contact your doctor and you will be advised an individualised catch up schedule as per age and vaccination status of the child.

Complementary Feeding

Feeding of child after 6 months in addition to breastfeeding

Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods. This transition is referred to as complementary feeding.

We first need to understand that complementary feeding is bridge that the mother has to make between liquid to solid transition and to empower the baby to ‘family pot feeding’.

Appropriately thick homogeneous complementary foods home-made from locally available foods should be introduced at six completed months while continuing breastfeeding.

To provide more calories from smaller volumes, food must be thick in consistency– thick enough to stay on the spoon without running off, when the spoon is tilted

Foods can be enriched by making a fermented porridge,  use of germinated or sprouted flour and toasting of grains before grinding

The food should be a balanced diet consisting of various (as diverse as possible) food groups / components in different combinations. Easily available, cost-effective seasonal uncooked fruits, green and other dark colored vegetables, milk and milk products, pulses/ legumes, animal foods, oil/ butter, sugar/ jaggery may be added in the staples gradually

Practice responsive feeding. Self-feeding should be encouraged despite spillage. Each child should be fed under supervision in a separate plate to develop an individual identity.

WHO recommends these principles of complementary feeding:

? TIMELY – meaning that they are introduced when the need for energy and nutrients exceeds what can be provided through exclusive and frequent breastfeeding;

? ADEQUATE – meaning that they provide sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs;

? SAFE – meaning that they are hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats;

? PROPERLY FED – meaning that they are given consistent with a child’s signals of appetite and satiety, and that meal frequency and feeding method – actively encouraging the child, even during illness, to consume sufficient food using fingers, spoon or self-feeding – are suitable for age.

Though every child is different, following guidelines are helpful to understand what to feed:
6 to 8 months:
Texture: Start with thick porridge, well mashed foods.
Frequency: 2-3 meals per day plus frequent breast breastfeeding. Amount: Start with 2-3 table spoonfuls
9 to 11 months:
Texture: Finely chopped or meshed foods and foods that baby can pick up (finger foods).
Frequency: 3-4 meals plus breastfeeding. depending upon appetite. Offer 1-2 snacks.
Amount: 1/2 of a 250 ml cup/bowl
12-13 months:
Texture: family foods, chopped or meshed if necessary
Frequency: 3-4 meals plus breastfeeding. Depending on appetite offer 1-2 snacks
Amount: 3/4 to one 250 ml cup/bowl

Unhealthy foods should be avoided. Indian Academy of Pediatrics has grouped them under acronym JUNCS:
J: Junk food (foods high in fats, especially saturated and trans-fats, sugars and salts, and foods lacking in micronutrients/minerals)
U: Ultra processed foods, which undergo fractioning of whole foods into substances (sugars, oils and fats, proteins, starches and fiber), hydrolysis or hydrogenation, food assembly, coloring and flavoring. Most of the open and eat advertised foods are ultra processed foods.
N: Nutritionally inappropriate foods. Home-made foods can also qualify to be nutritionally inappropriate if prepared in recycled oil, or contain high amount of sugar, fat or salt.
C: Caffeinated/colored/carbonated beverages
S: Sugar sweetened beverages and juices

Research has time and again proved the disadvantages of bottle feeding. Hence bottle feeding shall be discouraged at all levels.

The term ‘weaning’ should be avoided and breastfeeding should be continued

Forced feeding, threatening and punishment interfere with development of good/ proper feeding habits.

Associating feeding with screen exposure should be avoided

Avoid foods which can pose choking hazard, like whole grapes, peanuts, pomegranates, or food chopped to equivalent size.

Do not give up on newly introduced food items. ‘Neophobia’ is the rule in them and any new item may have to be offered several times for acceptance.

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Dr Mayank Rawat
Dr Khushboo Sharma
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