Medical Info: Newborn Behavior

Margaret James, ARNP, IBCLC

Q: Is it normal for babies to hiccup so much?
A: Yes. Many newborns hiccup several times daily, often associated around feeding or burping times. They last about 10 minutes regardless of what you do. It usually last for the first few weeks or so.

Q: Is my baby is getting a cold? He sneezes a lot.
A: Sneezing is the normal way that babies clear the mucus production that we all have. Sometimes they sound congested before they sneeze. If the baby is feeding well, and seems to be breathing okay it should be okay. Any baby younger than 2 months with cold symptoms, poor feeding, or a fever of 100.4 or greater should be seen by a physician. If you are not sure, call and speak to a triage nurse.

Q: My baby breathes funny. Sometimes she breathes real fast and other times she seems to hold her breath for a few seconds. Is this normal?
A: This is a normal breathing pattern for a newborn and young infant. Call the office if the fast breathing continues and is more than 60 breaths in one minute, the baby is sucking in the muscles between the ribs and the ribs appear to stick out, the nose is flaring with the breaths, you hear a grunting sound as she breathes, or there is a persistent blue color to the skin. Any of these symptoms needs to be medically evaluated.

Q: How long does it take for the umbilical cord to fall off?
A: Usually within the first 2 weeks. Sometimes you will see a few spots of blood before and shortly after it comes off. Your healthcare provider will need to see the baby if it continues to ooze or has a foul smell.

Q: Why does my baby seem to "jump out of his skin" when he hears a loud noise or somebody bumps him?
A: This is the normal and expected Moro reflex. They often cry at the same time. This usually diminishes over the first month. You didn't do anything wrong or hurt the baby in any way when this happens. In fact, at the well child exams, we check to see if the Moro reflex is present.

Q: I think my baby has diarrhea. The stools (poops) are yellow and watery. She is stooling during or after every feeding. What is normal?
A: Infants fed breastmilk often have very watery, yellow stools. Formula fed infants also have yellow stools, but they are often more mushy. The number of stools should be about 4 (or a total of about 4 tablespoons)
daily during the first 11/2 week. Around day 9, babies start through their first growth spurt and stooling slows down. Formula fed infants usually continue stooling daily, however breastfed infants can go several days between dirty diapers. Many parents consider this to be constipation. Constipation is not defined by how long the infant goes between stooling, but by the consistency of the stool. Constipated stools are very hard and often like little rocks. A mushy stool every 2-3 days can be a normal pattern for some babies. All babies grunt, strain, and have red faces from time to time.

Q: Most of the time, my baby's stool is yellowish, but the last few have been green. He acts okay and is feeding normally. Should I be worried?
A: If everything else is normal, greenish stools for a few days are okay. For the breastfed infant, it could means that more foremilk (higher in lactose) has been in the diet. This is a normal occurrence and can vary from feeding to feeding. If the stools remain greenish or don't seem normal to you in other ways (mucus, unusually foul smelling, baby seems to have stomach ache), call the triage nurse and she will help you decide if the infant needs to be seen.

Q: My baby has so much gas!!!
A: Most babies are gassy during the first few months. They can get gas by the normal digestion process and taking in air as they feed or cry. Make sure that they aren't sucking in air when they feed by keeping air out of the bottle nipple or making sure the lips form a seal at the breast. Keeping the baby upright at about a 45 degree angle during the feeding should help too. Also, don't shake the bottle before you offer it. This incorporates bubbles within the liquid. Mix the formula or expressed breastmilk by stirring it or rolling the bottle in your hands. Many babies respond well to gentle abdominal massages, a warm moist cloth on the abdomen, or gently pressing the knees toward the abdomen. Try not to over feed the baby. This usually causes more discomfort rather than relief.

Q: How do I know if I am overfeeding my baby?
A: A hungry baby has folded arms and legs, and is looking for something to suck, and often cries. An overfed baby has folded arms and legs, is desperately looking for something to suck, and is crying as if in distress. These similar behaviors can be very confusing to parents. The difference is in the timing of the behavior. A satisfied baby comes off of the bottle or breast and is fairly content, often drifting off to sleep or is quietly alert. The overfed baby seems content for about 10-15 minutes then starts fussing, desperately sucking at the fist, grunts and strains. I call these the Thanksgiving babies. They feel like they ate the whole turkey at the Thanksgiving feast! Overfeeding is thought by some to be a contributor to the behavior called colic. However, not all babies with colic are overfed.

Q: My baby was eating every 2-3 hours, but for the last day or so, she has wanted to eat every hour! How often should I feed my baby?
A: During the first 2-3 weeks as you get to know your baby, feed on demand. For the first few days, the baby is sleepy and often doesn't awaken to feed. They should be awakened to feed every 2-3 hours. By day 4, they are more alert and will suckle at their fist or start sucking at their lips or tongue. These are the first cues of hunger. Crying is a late sign of hunger. Between days 9-14, they go through the first growth spurt and will want to feed very frequently for a few feedings in a row. This usually last 3-5 days and will happen again around 3 weeks. A growth spurt can be identified by frequent feeding, decreased stooling, grunting and straining. This is normal infant behavior.

Q: How do I wake up my baby to feed her? She sleeps so soundly.
A: Babies go through cycles of deep sleep and light (REM) sleep. The deep sleep is usually cycled in 30-40 minute segments. It is difficult to awaken a baby during this sleep pattern. During the light sleep, they will make cute little facial expressions and the eyes will move. This is when you attempt to awaken them for feeding if necessary.

Q: How much formula should I feed my baby?
A: Simple math.
* Feeding Rule #1 - Double and triple the rounded off weight in pounds and this gives the range of formula for 24 hours.
o Example: 6 lbs x 2=12 ounces/24 hrs. 6 lbs x 3=18 ounces/24 hrs.
Therefore, a 6 pound baby needs between 12-18 ounces per day. A 7 pound baby needs 14-21 ounces per day, and so forth.
These estimates are based on the caloric need of the quickly growing infant. Don't force the baby to take the larger number. This guideline is true for the first 2 months or until the higher number is 32. When they are taking 32-36 ounces per day, they are usually ready to start solids.

* Feeding Rule # 2 - During the growth spurts when the infant is cluster feeding (normal behavior for breast and bottle fed infants around 2 and 3 weeks), match the hours and the ounces for infants over 6 pounds. For example, if they go 2 hours between feeding, offer 2 ounces. If they request to eat in 1 1/2 hour, offer 11/2 ounce. This will keep them from over feeding while getting the extra calories they need during a growth spurt. Smaller babies will take a little less than this estimated amount.

Q: If I choose to give formula to my baby, does it matter what formula?
A: Not really. The important thing is to choose one and stick to it so the diet is consistent. Most of the choices are as follows:
* milk based ( ex: Enfamil, Similac, Good Start, store brand) - these are modified cow milk and lactose which is the natural sugar of milk
* soy based ( Prosobee, Isomil, Alsoy, store brand) - these are soy protein and often corn syrup
* special formulas (Nutramigen, Alimentum)
* milk based without lactose (Lacto Free) - the natural milk sugar has been replaced by corn syrup but the protein is milk based

The hospitals usually receive equal supplies from the makers of Enfamil and Similac. If your baby is bottle fed, he will probably be sent home with either one of these. It is not recommended that breastfed infants receive formula from the hospital at discharge. You also probably have samples from these companies from other sources. It is best to discuss the choices with the baby's doctor to help decide what is best for your baby. The American Academy of Pediatrics recommends that infants be exclusively breastfed for the first 6 months of life.

Q: What is colic? How do I know if my baby has it?
A: This question is difficult to answer, in that colic still remains somewhat of a mystery. The American Academy of Pediatrics answers it in the following way:

"Does your infant have a regular fussy period each day when it seems you can do nothing to comfort him? This is quite common, particularly between 6:00 P.M. and midnight - just when you, too, are feeling tired from the day's trials and tribulations. These periods of crankiness may feel like torture, especially if you have other demanding children or work to do, but fortunately they don't last long. The length of this fussing usually peaks at about three hours a day by six weeks, and then declines to one or two hours a day by three months. As long as the baby calms within a few hours and is relatively peaceful the rest of the day, there's no reason
for alarm. If the crying does not stop, but intensifies and persists throughout the day or night, it may be caused by colic. About one fifth of all babies develop colic, usually between the second and fourth weeks. They cry inconsolably, often screaming, extending or pulling up their legs, and passing gas. Their stomachs may be enlarged or distended with gas. The crying spells can occur around the clock, though they often become worse in the early evening.Unfortunately, there is no definite explanation for why this happens.
Most often, colic means simply that the child is unusually sensitive to stimulation. As he matures, it will decrease, and generally it stops by three months...." (Shelov, Steven P. M.D. Caring for Your Baby and Young Child: Birth to Age 5. pp. 139-140. Bantam Books, 1993)

If the above behavior describes what you and your baby are going through, the infant needs to been seen medically to rule out other possible causes of this crying. Colic is difficult for everyone involved. Patience and understanding that "this too shall pass" is needed by parents, grandparents and healthcare workers. Much has been written about ways to sooth the infant with colic. Use whatever method works best for you and your baby. Ask for a handout on colic at your next appointment.

Questions about Breastfeeding:

Q: Why is breastfeeding so painful?!
A: In the first week or two, this is usually due to poor positioning/latch. The following three guidelines can be helpful:
* A. Alignment. The infant must have ear, shoulder, and hip in one straight line when placed at the breast. This applies for any position the mom chooses.
* B. Bring infant to the breast. When the breast is taken to the baby, the baby latches onto the nipple rather that the areola and "nipple feeds" rather than breastfeeds. (A toe curling "ouch!")
* C. Chin and nose must touch the breast during the feeding. This is what keeps he nipple to the back of the infant's mouth (the soft part of the mouth).

Q: My milk has just "come in" and my breasts are so hard. What do I do?
A: Feed the baby. You may need to express some of the milk so that the breast can become soft enough for the infant to latch onto. Cold compresses on the breast for about 20 minutes several time daily will help also. Warm compresses make it worse. "Engorgement" usually occurs if the breast isn't being relieved of the newly produced milk. Early and frequent feeding at the breast is the best way to prevent engorgement. It usually last 24-48 hours. Speak to a triage nurse if you need help.

Q: Should I limit the time I feed my baby on the breast? How do I know when to feed from both breasts or just one side?
A: Lactation guidance no longer recommends that infants limit feedings to a certain number of minutes. Watch the baby, not the clock. As long as the infant is swallowing while breastfeeding, keep her on that breast. When she stops swallowing or comes off naturally, offer a burp and then the other breast if she acts hungry. If she is hungry, she will take the second breast. If not, she will act uninterested. Once they are going longer than 3 hours between feedings, they will usually take both breasts during a feeding.

Q: What foods should a breastfeeding mother avoid?
A: Very little in the mother's diet actually causes problems. Foods such as onion, broccoli, cabbage, and Italian spices can change the flavor and smell of the milk and some babies acknowledge this change. They might not form a complete seal at the breast due to this change, therefore causing more air intake during feeding. Some babies react to cow's milk protein that can pass into mother's milk. If the infant seems to be in distress after feeding, a trial elimination of cow's milk products can be tried for a couple of weeks. If you do this, be sure and get your dietary calcium through another source. Caffeine may affect the infant, so limit this until you get to know your baby better and can judge if this is the case in your baby. Also, don't force liquids. Drink to thirst or if your urine appears concentrated.

Q: My baby has been breastfeeding well, but recently it has become painful. What's happening?
A: The most common cause after 2 weeks if painless feeding has been established is a yeast infection. You may feel burning as the infant feeds and breast can remain painful to touch after the feeding. Call our office or your physician's office for guidance. The infant needs to be evaluated for thrush and both of you may need to be treated with an antifungal medication. If your nipple is cracking and possibly bleeding, it may also be a bacterial infection and your physician needs to be consulted.

Q: How do I know if I have mastitis?
A: Mastitis is an infection of the tissue of the breast. Symptoms include fever, soreness, redness and firmness of part of the breast, and flu-like symptoms. Call your physician for treatment. It is okay that you continue to fed the infant while you have mastitis - in fact, it is important that you do so. The milk needs to flow to prevent further infection or damage to the breast.

Q: My breasts aren't red and I don't have fever, but they have a sore lump. What should I do?
A: Lactating breasts often have lumps even as far as up under the arms. They are not usually sore. Soreness may be a blocked milk duct. Warm compresses over the lump and massages above the lump toward the nipple usually works. They usually resolve in 24-48 hours. If not, seek medical help.

Q: I have a painful white blister on my nipple. It hurts to feed. What's up?
A: This is similar to the above question but the blockage is at the point of exit for the milk. Again, warm moist compresses and expressing the milk to unplug the opening. Seek medical help if it persist greater than a day or so.

Q: I think my milk supply is less than it should be. How do I build it back up?
A: It's a "take and make" process. Offer the breast more often so that your body is encouraged to increase the supply. If this is not possible, pump for about 10 minutes after the infant breastfeeds. This should communicate with your body that more milk is needed. Have you started on a birth control pill lately? This often decreases milk supply. Discuss this with your physician. Other options can be discussed over the phone in an attempt to find what is best for you.

Q: How long can I store milk - at room temperature, in the refrigerator, or in the freezer?
A: There are many numbers floating around regarding milk storage, but to make it simple and be within safe limits you can use the following guidelines:

* 3 HOURS at room temperature
* 3 DAYS in the refrigerator
* 3 MONTHS in the freezer

As with formula however, any time the infant takes milk from a bottle, he must complete that bottle within an hour. Once he has gotten saliva into the milk, it cannot safely be saved for later use.

Q: When can I offer a bottle? What bottle nipple should I use? What about a pacifier?
A: If breastfeeding is well established (usually after 3 weeks), it really doesn't matter. Most babies go back and forth easily at this age. This will be governed by your lifestyle. It is important that moms who plan on returning to work soon establish an alternative feeding method for the babysitter to use. Whatever type nipple the baby uses is best for that baby. In most cases, infants do best with a nipple that has a wide base and long nipple. Choices include Nuk and Avent, but there are many other types. Buy one of each and see what works best. The same is true with a pacifier. Most breastfed infants spit the pacifier out initially.

Q: My 2 month old baby used to take 20 minutes or longer to feed. Lately he has shortened the time to10 minutes or less. Is there something wrong with my milk?
A: It is normal that the more proficient the infant is at obtaining the milk, the shorter the feeding. If the infant is gaining well and acts happy and content, all is well. Welcome to the wonderful world of breastfeeding!