The Fussy Baby

Every infant will have strengths and weaknesses but each one is perfect. Some infants easily self soothe while other so called “difficult infants” are slow to settle. In addition, some infants experience colic. You know your infant better than anyone, and you are in the best position to understand and respond to your child. Infants who have difficulty settling require more time and attention. If you invest the extra time and attention and limit the sensory distractions that bombard new infants and lead to unsettled behavior, you will reap major benefits.

Colic is the name given when an infant has fussy or extreme cranky periods usually in the evening. During these periods all attempts to soothe and settle the infant fail. These episodes can occur anytime during the day and for some infants they occur throughout the day. Most often the peak period is between 6pm and midnight. These fussy periods begin at two to four weeks of age and peak at about six weeks of age. They can last for up to 3 hours and gradually taper to one to two hours by three to four months. About 20% of all infants develop colic. It is normal and does not mean there is anything wrong with your infant. During these prolonged crying episodes infants may cry or scream inconsolably, bicycle their legs and pass gas. They often swallow air and their stomach becomes painfully distended.

Although there is no known cause of colic recent findings support colic being an indicator of a child being at risk for the future development of migraine headaches. Colic is felt to be due to a delay in the ability of the nervous system to self-regulate. Infants with colic appear to be oversensitive to environmental stimuli and have difficulty being consoled. The inability to self-soothe leads to constant crying and associated behaviors.

If you feel your child has colic talk to your doctor. There are several medical reasons for behavior that appears to be colic. These include food sensitivities and gastro-esophageal reflux.  These problems are treatable.

After delivery babies need to learn how to live in a new environment. Sounds, smells and visual sensations abound. Your infant is no longer living in the tight, warm and quiet environment of the womb. Your heart rate is no longer the primary sound your infant hears. This change in environment disrupts many babies. Allow your infant time to deal with the frustrations associated with this change. By providing ongoing unconditional love and support your infant will adjust to the new surroundings.

If you have a fussy baby it is important you remain calm and relaxed. Your infants can sense your emotions and negative emotions can heighten and exacerbate your infant’s behaviors. If you are tense or anxious consider asking someone to give you a break. A brief break allows you to find a positive balance.

Make sure a fussy infant is not cold, wet or hungry. Checking on all “comfort needs” is always the first step in the response to a crying baby. Some infants cry when they need to be burped. If you have concerns that your infant is sick check for a temperature and call the doctor.

If all comfort needs have been met and there is no sign of illness it is time to pursue common interventions for so called high needs babies. Walking with your infant provides a calming swaying movement. Make sure you do not over-feed your infant and consider skin to skin contact. Breastfeeding is always best. Stomach distension can make your infant uncomfortable so make sure to burp your infant. The use of a pacifier can also be very helpful. Sucking lowers your infant’s heart rate, evens out breathing patterns, encourages relaxation, decreases stress and promotes the onset of sleep. Sucking also decreases the risk of SIDS. Distractions such as making shushing sounds, playing soft music or softly stroking your infant’s head from the forehead to the back of the head are other ways to settle your baby. Always try to limit distractions and make sure the room is not too warm or too cold. Infants should always sleep on their backs. It is alright to try some tummy time if this position helps soothe your infant but you must remain in the room and watch your infant. Never leave a sleeping infant on his or her tummy to sleep. This increases the risk for SIDS.

Cry it out (CIO) approaches are not appropriate for infants. It is always best to respond right away to a crying infant and if you notice pre-crying behaviors such as anxious facial expressions, breathing pattern changes or jerky arm and leg movements it is best to pick up and try to soothe your infant.

Role of the Father

A Father must take an active role prior to the delivery of their new child. The paternal-maternal relationship must be supported and flourish prior to the delivery. The most visible roles of the father have included economic and physical protection. Yet roles of equal importance include the fostering of social-emotional, cognitive, language and motor development.

Fathers must be competent and caring role models. They must be attentive and responsive to the needs of their child. The quality of interaction is just as important as the quantity of interaction and it is important paternal involvement be supported and encouraged prior to and at the time of delivery to prevent fathers from disengaging from the care of their child.

Mothers and fathers can both experience post-partum depression. The added responsibilities, obligations and stress that come with a newborn can lead to depression. Intervention must be sought for post-partum mood changes. Two-way communication between parents and the sharing of feelings are the first steps in the identification and management of post-partum depression.

Although generalizations oversimplify gender patterns of support there are two types of support infants and children must receive. This support may come from traditional gender relationships or from non-traditional gender relationships. Gentleness and security are typical maternal support patterns while independence and confidence building are typical paternal support patterns. Fathers often provide a “rough and tumble” approach to life experience. They teach children how to manage aggressive impulses and how to learn how to control emotions. In this way fathers teach their children how to make their way through the rigors of the outside and often unforgiving world. These skills enable a child to develop the discipline to control emotions and frustrations. This leads to personality traits that support empathy, respect of others and the importance of genuineness.

Fathers must provide a secure, safe and supportive environment for their child. This must begin early in the child’s life and must be linked to the building of emotional competence. Emotional competence allows a child to recognize, respond to and understand emotions and leads to increased self-esteem and self-worth. The life skills that result from this training and modeling foster the development of social confidence and competence. Fathers who teach these skills to their child improve their child’s ability to initiate and maintain friendships throughout their lives.

When fathers engage in vigorous play intellectual development is supported. Children learn how to use their bodies to solve problems and learn the importance of exploration and risk-taking. Fathers support the use of more challenging language and focus on the importance of social communication and teamwork. Vigorous play improves motor skills for both large and small muscle groups, improves hand-eye coordination skills and encourages both one on one and team directed activities. Such activities encourage and support independent thought and behavior for a child.

Fathers are the model of so many important behaviors for children.  The goal of every father is to share what they love with who they love.

Birthmarks in Infants and Children

About 1% of newborns are born with congenital nevi or moles. These are brown or black in color and may be raised or flat with the skin. They grow with the child and are safe if less than 2-3 inches in size.  Children can also develop acquired nevi or moles following delivery. These are common in Caucasians who have an average of 10-30 pigmented nevi or moles. They often develop after age 5 years.  Warning signs for neoplastic changes include asymmetry, border irregularity and color change. If a nevi or mole “looks different” from neighbor nevi it needs to be evaluated by a doctor.

Sun freckles are common and increase with sun exposure. These dark spots are flat and run in families. They are more prominent in the summer. If your child is prone to freckles then sun protection is a must. Children with fair skin are prone to freckles as well as having an increased risk for skin damage due to unprotected sun exposure and have an increased risk of skin cancer and malignant melanoma.

Hemangiomas are raised red or reddish blue bumps. They are caused by the growth of blood vessels that cause an abnormal amount of blood vessels to grow. They are seen in 2% of infants and often develop after 1-2 months of age. Treatment usually is not needed but depends on size, rate of growth and location. Locations around the mouth, eye, and nose and in the throat raise concern for treatment. If multiple hemangiomas are present then there are concerns about internal hemangiomas on various body organs.

Flat angiomata are called “stork bites or angel kisses”. They are seen on the face an on the nape of the neck. They become more visible when an infant cries or becomes hot. No treatment is needed. They usually fade by school age.

Port wine stains are rare and often indicate an underlying medical condition. This type of birthmark can be seen on the face and limbs. They are large in size and dark red to purple in color. They are not raised.

Tips on Baby Basics

  • Be attuned and responsive to the needs of your infant by watching, touching and listening.
  • Always provide love, attention and affection to your infant.
  • Breastfeeding through one year of age is always best. Longer is better.
  • Breast feed your new infant every 1-2 hours until your milk comes in.
  • If your infant is urinating 6 times a day and the urine is clear and copious your infant is not dehydrated.
  • A double electric breast pump that is adjustable provides speed and efficiency benefits.
  • Breast milk can be kept in the fridge for four days and in the freezer for 3-6 months.
  • Always thaw breast milk overnight in the fridge or by immersing in tepid water.
  • Keep visitors to a minimum during the first few weeks of life.
  • Safety at home, in the car and out of the home is very important.
  • Dress your infant in layers to help with temperature regulation.
  • Always follow the “Back to Sleep” rules to decrease your infant’s risk of SIDS.
  • The use of a lubricant such as petroleum jelly in the diaper area after every diaper change prevents diaper rashes.
  • Consider giving your infant a soft full body massage with olive oil, coconut or Neutrogena bath oil twice a day to prevent skin dryness.
  • Infants startle due to sudden noises or an unexpected touch or body movement. This is normal.
  • Infants under 6 months of age cannot be spoiled.
  • The use of a body carrier helps both mother and baby.
  • Co-sleeping does have risks associated with it.
  • The best ways to calm a baby include walking or swaying, sucking on a finger or pacifier, upper body swaddling and making sushing sounds.
  • Watch a You Tube video about how to swaddle your infant. Leave the legs loosely wrapped but supported. This helps to prevent hip problems.
  • Infants who swallow excess air often feed less well
  • Three burping positions are the throne and shoulder positions, the belly flop on lap position and the walking strut with baby facing away.
  • Diaper changing stations need proper safety, set-up and hygiene.
  • Chewing, rubbing, cold and rare pain medications are the best ways to decrease teething pain.
  • Avoid cereal and pureed baby food before 4-6 months of age.
  • Never leave an infant alone in a tub and always check the water temperature.
  • Baths 1-2 times a week are often enough.
  • Tummy time can become fun time but it often takes practice and patience.
  • Always look for snooze clues such as eye rubbing and cranky behavior.
  • Sleep schedules are often irregular through 4-6 months of age.
  • After 4-6 months most infants benefit from scheduled naps twice a day.

Grandparent Boundaries

Grandparent wisdom and advice can benefit your child.  By the year 2030 30% of the US population will be over age 65.  Although many things have changed since grandparents raised children many things have not.  Grandparents can be the best models, mentors and memory keepers for a family. They can also be intrusive, rash and judgmental. Every parent must recognize the perils of this generation gap while at the same time understanding the wisdom and experience grandparents provide.

Whether you are a parent or a grandparent your goal is to keep your child safe.  It is important for parents and grandparents to avoid confrontations that can lead to resentment. Advice from grandparents often feels judgmental. Grandparents must be cautious not to intrude or interfere in the decisions their children make about raising their own child. Many times useful information is presented in ways that cause friction and wounds that are difficult to heal.

Parents must take the time to explain to their parents why they want things done differently in the past. Choose your battles carefully and focus on what is important rather than engaging in a battle for control. By explaining why you want something done differently you will be better able to engage your parents in a dialog concerning the care of their grandchild. This dialog will allow you to address the concerns of the grandparent rather than just telling them what you want done. Always seek middle ground and compromise on minor issues. On important issues always focus on the health and safety of your child and stand firm about the boundaries you set and the decisions you make.

Parents and grandparents must both learn how to suppress their egos. Many Grandparents view parents as children rather than as adults worthy of respect and parents view parenting advice from grandparents as intrusive and interfering. A parental “it is now my turn” mentality leads to discord and inevitable differences in opinion and prevents the development of reciprocal respect.

Parents must be flexible and at the same time set clear boundaries concerning the care of their child.  Grandparents must find the balance between sharing their experience and wisdom while not interfering and avoiding rash judgment and hostility. When parents and grandparents recognize each has a unique perspective to share the value of personal opinions increases.

Some things that need to be discussed include safety issues, discipline and technology. Smoke avoidance is very important. Infants and children of all ages should not be exposed to tobacco smoke. When placed in a crib a “back to sleep” position should always be used. Infants must not be overdressed since overheating increases the risk for sudden infant death syndrome (SIDS). The crib should be free of all toys and bumper pads are not needed. The mattress should be firm and there should be no loose cords that could lead to entanglement and strangulation. Baby powder and fragrances should be avoided and breastfeeding is best.  Supplemental food should not be introduced until 6 months of age. A rear facing car seat is best until age 2 years and a bedtime bottle should be avoided. Infants under 6 months of age cannot be spoiled. If an infant under this age is crying a cry it out (CIO) approach is not appropriate.

Eating patterns have also changed. Portions should be small and never encourage children to clean their plate if they are no longer hungry. A better response is to decrease future portions.  For discipline positive redirection and antecedent management have replaced negative punishment. Finally technology is moving forward rapidly. Technology is now imbedded within the lives of children. The focus should be on setting healthy boundaries concerning the use of technology rather than on avoidance and negative comments about the hazards and dangers of technology.

A Simple Word

Why is it so hard to say, ”No?”

I picked up my afternoon schedule and nodded yes. My secretary had just asked me if she could add two patients into my afternoon schedule.  Every slot on the day planner was filled, and I wondered how I was going to find time to fit everyone in. I tossed the schedule on the desk as the phone rang. “Dr. Barber your first patient is ready.” Head down, I took a deep breath in and walked out of my office.

Life is an emotional winter storm, chaotic and overfilled with promises and responsibilities. Minutes, hours and days are consumed by endless duties, lists and negative emotions. Parents are overwhelmed by fatigue and limited by time and opportunity. As responsibilities grow hopeful dreams fade, and parents stop living. Frozen and overwhelmed by shame, guilt, anger and fear parents silently accept the next demand, the next responsibility and the next chore.

Your brain is a wonderful instrument. Billions of synapses allow you to debate, disrupt, judge and detail what needs to get done. The brain drives us all to act or not to act, to think or not to think and to perform or not to perform. It becomes the storyteller of acceptance and excuses and the enforcer against saying the word “No.”

Excuses allow parents to say no when the brain is overpowered by inadequacy and negative emotions. Each of us is hardwired not to say “No.”  We want to be powerful and well-liked. We want to be change agents and competent models.  Responding with an excuse rather than the word “No” justifies rather than explains and shrouds us with avoidance rather than acceptance and communication. Excuses are a passive and protective stall tactic that bury our emotions and allow us to hide from and avoid our own feelings.  They harm us physically and emotionally and must be replaced with truth.

The best way do this is to recognize, understand and respond to your own needs and take control of your life by using the word “No.”  This word must be practiced and cultivated. It empowers both the speaker and the listener and allows you to disengage while encouraging the speaker to seek and find another solution. “No” informs the listener you are willing to give up control and makes the listener the agent of change. This heartfelt , mindful and trust filled act informs the listener that you do not have the desire or ability to take on one more task or responsibility and are confident that they do have the ability to find their own solution.

This act of saying “No” is the foundation of self-care. Self-care creates prosperity for all and increases your generosity and future ability to give. It eliminates the need to make excuses for self-neglect and supports responsibility for your own needs. Self-care enriches two-way communication and provides the energy to live an inspirational life filled with love, passion and good health.

Until my quadruple bypass 12 years ago I was an expert excuse-maker.  I always said “Yes” without pause or hesitation looking out and never in. Blind to self-neglect, stress and fatigue I was lost in a storm buried deep within my heart.  That day I woke up. You can too. It starts with a simple word.

Sibling Rivalry for the School-Aged Child

School-aged children must learn how to name and accept conflicting feelings about a sibling. These children must learn that they will need to cross many small streams during their lives, but they must always be aware that even a small stream after a heavy rain can become perilous to cross. By being aware of this danger most severe sibling rivalry issues can be avoided.

Learning how to recognize, understand and respond to jealousy and competition allows the school-aged child to learn how to build positive and supportive relationships. Learning how to name conflicting feelings is the first step to head off sibling rivalry. By responding to these feelings the older child is also preventing emotions from developing into unconscious drives that result in unhealthy and even risky behaviors. Unconscious drives can easily evolve into destructive behaviors such as tattling, physical or verbal aggressive behavior or the destruction of personal property.

The goal of every parent is to build lifelong positive and supportive relationships between all of their children. By being fair, not having favorites and not comparing children parents are setting a strong positive example of behaviors they support and endorse. This is done by focusing on individuality and not equality. By learning how to give and share in a non-judgmental and accepting fashion, children will be ready and able to reach out not only to sibs but also to others they meet and desire to develop positive relationships with.

Parents must paint a realistic picture of both the fun and less than fun aspects of having a new infant in the family. Infants are fussy, cry often, require constant attention and even require “smelly” diaper changes. By starting early and preparing the school-aged child for the work ahead you are more likely to find a partner in this endeavor rather than an adversary.

Parents who do not set a positive example run the risk of accelerating negative rivalry issues and supporting the evolution of negative behaviors. Parental responses must focus on being fair and never comparing children. There can be no favorites and unconditional love and support must be provided daily if your child is to have a secure sense of security. Weekly family meetings where the importance of love, unity, trust and positive self-worth are discussed can also be very helpful. It is essential all participants understand that everyone is entitled to an opinion and no one has the right to change or control the behavior of another. Parents must learn how to listen during these meetings, acknowledge the feelings of participants, sum up the situation and then support the development of a dialog between the participants. This is done by asking for solutions rather than providing solutions. Criticism must be avoided and positive behaviors supported.

The aim of a parent is to focus on prevention of rivalry rather than directing blame on a specific behavior or child. By learning how to arbitrate rather than judge parents are less likely to be drawn into a conflict where there is no right or wrong. This also prevents alienation and supports the ability of every child to resolve conflicts in a respectful fashion.

Sibling Rivalry for Preschoolers & Toddlers

In this age group the arrival of a new baby is often accompanied by jealousy and competition for affection and attention. Toddlers and preschoolers often respond with behavior and mood changes to replace what they perceive as lost attention. This is why it is very important for parents to prepare children for the arrival of a new infant who will require parental attention which previously was directed elsewhere.

Most of these issues can be prevented by taking the time to provide love, attention, affection and a sense of security for the displaced child. A secure attachment engenders trust and eliminates the fear of loss which drives many of the behavior problems that accompany sibling rivalry for the younger child.

It is also important schedules, routines and rituals be continued. Mealtime and bedtime routines should not be changed. Toddler and preschool aged children depend on these routines to anchor their daily schedule. In addition, bedtime and playtime rituals such as story time, bath time, meal time, going on walks and various playtime activities must be continued.  Your child is looking to your behavior as a sign that he or she is still loved and important. By continuing prior behaviors you can prevent sibling rivalry from evolving into negative behavior.

The arrival of a new infant in the household is a perfect time to support the older child’s independence. By giving your toddler the freedom and encouragement to explore the world you will soften the anxiety and potential sense of loss that a new infant can symbolize. It is also a time when your toddler can learn how to respect others. Toddlers and preschoolers both need to learn they should not try to control the behavior of another. When a toddler does not respect a parent or a sibling, future behavior issues are certain to follow. It is also important to encourage and help direct your preschooler to name these competitive and jealous feelings and by praising and rewarding his or her strengths you will encourage the development of good feelings which can replace bad feelings.

For the preschooler a new sibling provides the added opportunity to feel deserved and approved of. By focusing on the individuality and unique strengths of the older child you will be supporting and acknowledging the importance of a positive and supportive relationship between you both. It is important you are always fair and never compare children.  Beware of words or actions that can be interpreted by the older child as showing the new arrival to the family is your favorite. Allow your love to show you have no favorites.

The Breadbox

Why are memories so powerful?

“Joey, would you get some bread out of the breadbox?” “Sure, Mom,” I answered as I walked over to the counter and twisted the black knob. The breadbox was the size of a small microwave. I twisted the knob on the stainless steel front panel and reached in and pulled out two slices and remembered a trip to the bakery yesterday. “Mrs. Barber, what can I get you today?” The woman behind the counter asked. “A loaf of pumpernickel,” my mom answered.  The baker looked through the glass counter at me and asked, “Can I give Joey slice?”  My mom smiled and nodded her head. I reached my hand towards the top of the glass counter. “Thank-you,” I mumbled as I bit into the warm, fragrant and chewy bread. It was a taste and smell I will never forget.

In the next decade hundreds of thousands of people will die every year due to the ingestion of too much sugar, salt and fat. Yet, the real killer is not the food of today but the memories of tomorrow.

Every child has three lives: a life at home, a life at school and a life at work or play.  In the past the food we ate was dependent on cost, location and the season. Fresh, vegetable-based and regionally-available foods were at the center of our menu. Food did not come prepared, packaged or processed.  Limited choice and availability strengthened our resolve. A loaf of bread, saltines and graham crackers have now been replaced with an endless media parade of fast food restaurants, carbohydrates and snacks. There were no sugar or flavor additives and a pinch of salt was enough. We ate less, worked harder to prepare our food, and we were healthier.

My generation might be the last generation to rely on breadboxes, a well-stocked pantry, baking and family-owned corner restaurants. We remember family recipes, family meals, the smell of dinner cooking, aprons and lively discussions around a dishwasher-less  sink filled with pots and pans.

Yes, times have changed. The economy, a lack of opportunity, fatigue and our drive to possess has drained from many parents the ability to recognize the importance of healthy food. We make choices based on time and efficiency rather than good health.  We are conditioned to hear and see how food can make us feel good rather than keep us alive. Our tastes have been brainwashed. Food has become an escape and often an unhealthy reward rather than a lifestyle.

In the past we walked to the store and now we drive. Corner stores, bakeries and butcher shops have disappeared. In their place grocery chains with altars of processed, frozen and ready to eat sliced, diced and pre-packed or prepared foods have appeared.  Aisle placement is now both an art and science used to influence you on what to buy for you and your child. Plastic has replaced paper and the microwave has become the oven of today.

The bill for these choices we are influenced to make is coming due.  Corporate chefs have become taste conditioners. Healthy foods have disappeared under the guise of convenience. Our bodies and our taste buds are jaded by fat, sugar and salt at the expense of our health, our children’s health and the health of our children’s children. Labeling is an illusion and misrepresentation controls you. Food choice has been hijacked and the cost is your good health.

I remember the days before corporate America controlled the food that we eat. We learned how to cook meals and choose ingredients. We relied on heritage, seasonal availability and taste rather than what we saw or heard in the media. Stop this epidemic now. No fancy or expensive medicine is needed. Sit down with your child and talk about food. Make sure your child knows how to cook ten basic meals. Start this discussion at an early age. Teach by your words and example about the importance of a fresh, non-processed, healthy diet centered around vegetables, fruit, whole grains, vegetable protein and lean meats. Talk about the dangers of milk enriched with sugar and how cheese is a hidden source of unhealthy saturated fat. Make every meal an event your child will remember just as I remembered that trip to the bakery.

Today, parents have more challenges and temptations compared to parents of prior generations. The choice, however, is simple. Give in and allow these pirates to control how long you and your child will live or take control and choose a diet that supports a long and healthy life for you, your child and your grandchildren. The choice is yours.

Skin to Skin Contact After Delivery

Much has been written about the importance of the first hour following delivery. Your infant encounters a new and previously unseen world. Sounds begin to take on new meanings and basic processes we take for granted such as breathing and eating begin. It is a time of heightened perception for both parent and infant. It is a time when every parent must be both a soldier and an ambassador as their child encounters and enter a potentially hostile world.  Parents provide comfort and safety to the new infant.

Following delivery your infant experiences major physiologic changes that can cause imbalances in the respiratory, circulatory and metabolic systems. Your infant can become cold and glucose levels can drop. It is also a time when your infant is at increased risk for infection.  To help deal with this turbulence hospitals and professionals have enacted and supported policies to make this transition safe and loving.

Your first act as a parent should be to provide skin to skin contact with your infant. Studies have shown such contact provides physiologic stability for your infant.  Benefits include improved blood oxygenation and glucose levels and reduced stress hormone levels in your infant. Basic body functions including temperature regulation, respiratory pattern and blood pressure also improve. Your infant will cry less and more easily enter a quiet alert state.

Additional benefits include a fostering of a secure attachment between you and your baby. Skin to skin contact increases the release of maternal hormones that induce and encourage attachment between mother and baby.  One of these hormones is oxytocin which has been shown to increase relaxation, facial recognition and maternal to child attraction. Such behaviors are essential for the care and protection of your infant.  In this critical post delivery period these behaviors have been associated with an increase in touching, holding and positive speaking behaviors between mother and child as distant as 1 year following delivery.

In addition to attachment the skin to skin contact prevents the risk of stress induced by separation. Your infant has never been separated from you. It is well known that infants are able to sense physical separation from their mother. Harm from separation has been seen in animals. We must assume newborns are at risk for similar negative physiologic and brain affects.  In addition, recent brain research supports the importance of early attachment for normal brain growth in terms of both myelination and synaptic development. Specific parts of our brain involved with our emotional responses are especially sensitive and reliant on both activation and modulation during this critical period.  These effects impact our learning, memory and our sympathetic nervous system.  Holding, carrying and caressing during the newborn period and infancy fosters and supports brain growth and the development of self regulation in your infant.

A final benefit of skin to skin contact is the fostering of breastfeeding. This type of contact initiates a cascade of events that results in successful breastfeeding. Skin to skin contact is the first step in a progression of stages that result in familiarization of the infant with the mother’s nipple which is then followed by self -attaching and eventual suckling. Sleep then follows soon thereafter.  Early stages include crying, relaxation, awakening, increased activity and resting and crawling.

Skin to skin contact on the mother’s chest allows the infant to be closely monitored by both mother and staff. The infant should be positioned so the face and nares are visible and the infant’s color, skin perfusion and respiratory patterns can be followed closely.

Nursery routines such as weighing and bathing that interrupt skin to skin contact should be avoided. All nursery and post-partum activity should be directed to the immediate needs of the mother and infant. Actions that can be delayed until after the first breastfeeding include vitamin K injection, body measurements and eye ointment prophylaxis. Usually a hat is not required when mother and child are skin to skin and a diaper is often not needed except after a cesarean section.  The cord can be initially clamped away from the infant so the clamp does not pinch the baby and mother during skin to skin contact. The cord can be re-clamped and trimmed at the first bath. The first bath should be delayed until at least 8-12 hours following delivery.