Your baby has just been through one of the hardest battles he will ever face. It's a tough job to be pushed down the birth canal and out into the world. Often baby needs help and must be delivered with a vacuum extractor or forceps, or by Cesarean section.

No matter how your baby arrives, it is wonderful to meet him. Your newborn is amazing. When he enters the world, all his major organs are functioning. He can see, hear, smell, taste and feel. He may look like he has no awareness of what's going on, but he is very sensitive to events taking place around him.

Baby's Birth Weight

"How much does he weigh?" is one of the first questions new parents ask. What a baby weighs at birth is influenced by many factors, including your health during pregnancy, medications, smoking, nutrition, diet, length of the pregnancy (early or late) and the size of your partner. The average weight at term is 7 pounds, 2 ounces, but this can vary widely.

In addition to weight, other measurements are taken, including length (average is between 18 and 22 inches), head circumference and abdomen circumference. Your baby's weight may fall a little in the days following delivery. Most babies lose a few ounces after birth because they are born with extra body fluid that they lose during the first 5 days. They generally regain the weight in the next week, so before 2 weeks of age, they are back to their original birth weight.

From birth to 1 month old, most babies gain 0 to 1 ounce of weight every day! By the end of 3 months, baby will have gained an average of 1 to 2 pounds each month! On average, babies double their weight by 6 months and triple their weight by a year. You'll really see changes in him/her over the next few months.

When baby is born, he/she is measured for length. Many babies lose a little length measurement in the days following birth if the birth was vaginal and his head was pointed. Over the next 3 months, baby will grow about 1 to 1H inches a month. By age 1 year, your baby will have grown from 9 to 11 inches, compared with his length at birth.

What Does Baby Look Like?

If you're like most new parents, the first thing you do when you meet your baby is to examine him from head to foot. What does he look like? Does he have hair? Does he have 10 fingers and 10 toes? Is he normal? These concerns are universal. If your baby is average size, he'll weigh between 7 and 8 pounds, and be between 18 and 22 inches long.

His Head and His Face

As you check him out, you may notice that his face is puffy and his head is slightly misshapen and has a "mashed" or "conehead" look. It's common for a baby's head to look like this because the skull, which is actually made up of several bones, changes shape (molds) to move through the birth canal. You may think his head looks enormous-it is! At this time, his head is G of his body, which is one reason it's hard for his skull to fit through the birth canal.

Your baby's face might look a little askew, as if he'd been in a fight or slid down a slippery slide on his face. His nose may be flat and his chin a little out of place. He may have some bruises on his face. The skin over his brow may be wrinkled and loose, and his eyes may be swollen and bloodshot. As with his misshapen head, this is due to the exertion of birth. His eyes will appear blue or be dark; however his true eye color won't be evident until he's about 6 months old.

The two soft spots on the top of his head are called fontanelles. One is close to the crown; you'll be able to see and to feel his pulse there. The other is above his brow on his forehead. These spots decrease in size as his bones grow together. It's OK to touch them gently; they're covered with a thick, protective membrane.

You may also notice the crown of baby's head is lumpy, swollen and discolored. This is called a caput and results from his head pushing against the mother's cervix and the birth canal. The caput quickly disappears; it will look better every hour and often appears normal by the time you go home in a few days. It may take as long as 10 days for a misshapen head to look normal.

A pea-sized bump on the back of baby's head is probably a lymph node. Don't worry about it. If baby has a bump near the top of his head, it might be caused by overlapping bones in baby's skull. Bumps will disappear as baby's bones fuse together.

If he has hair, you may be surprised by the color. However, this hair is usually temporary, so don't worry if you don't like it. His real hair (the permanent kind) will begin to grow soon, although some babies don't get permanent hair until they're close to a year old (or older!).

You may notice a few blisters in your baby's mouth. Check his thumbs and fingers for any thickened or callused areas. Most babies suck their thumbs or fingers in the uterus; your baby may have. He may have a nursing tubercle on his upper lip, which stiffens the lip and makes grasping your nipple or a bottle nipple easier for him.

If his chin quivers and/or his legs and arms seem shaky, it just means that more electrical impulses are being sent to muscles than are necessary, which results in these movements. This is normal, and they will decrease over the next few months.

Baby's Skin

Next you may look at the skin on his body. Most babies are covered with a thick, white, waxy coating when they're born, called vernix; it protected his skin while he was in the uterus. When he's cleaned up, you may be able to see the veins through his skin, which is still thin. His hands and feet may peel. He may have birthmarks. See the discussion of birthmarks below.

The pigmentation of babies of color may not be evident for hours or even a few days after birth. Many are born with light skin that darkens. If baby's a little blue in color, it may be caused by mucus in his air passages. Most is suctioned out, and he coughs out the rest.

His skin may appear yellow or orange-tinged by the second or third day-about half of all newborns experience jaundice. The color is caused by the inability of baby's liver to remove breakdown products of blood cells, and the buildup causes the skin to look yellow or orange. A mild case of jaundice resolves in about a week or 10 days; it may last slightly longer if your baby breastfeeds

It's interesting to note as you examine him that your baby's skin is the most developed sensory organ he has right now. He'll love it when you gently rub and stroke him.

Delivery Marks

Delivery marks occur in almost every delivery. They can occur while the baby is in the uterus, during the descent through the birth canal and during delivery. The use of forceps or a vacuum extractor to assist with delivery may increase the chance of delivery marks. Marks can vary from a misshapen head (it's nothing to worry about and will change rapidly after birth) or a flattened ear or nose, to bumps and bruises. Forceps may leave marks on the side of the head, in front of the ears. A vacuum extractor may leave a mark on the back or crown of the head.

These marks fade and go away within a few hours to a few days. Lotion may be helpful in some situations. Call the doctor if any of the marks get bigger or if they don't fade after the first few days. If they become warm to the touch or hard, let your doctor know.

Birthmarks

Many different types of marks may be seen on a baby after birth. These include salmon patches or stork bites, hemangiomas or strawberry marks, Mongolian spots, café au lait spots, port-wine stains, spider veins (nevi) and pigmented nevi (beauty marks). All are discolorations or marks on the skin. Salmon patches, also called stork bites, are pinkish areas usually found on the back of the neck, the forehead, the face or eyelids. They are caused by blood vessels in the skin. Some are temporary and should disappear within a year. Some are permanent.

• Hemangiomas, also called strawberry marks, are fairly common birthmarks. About one in 10 babies has them. They are caused by an overabundance of blood-vessel cells. They are often red or pinkish, as well as being raised and spongy. They may not appear until a few weeks after birth and may continue to grow somewhat during the next 6 to 12 months. Most disappear by age 10 and leave no scar.
• Mongolian spots are flat, blue- or gray-colored marks, which look like bruises, found on the back and buttocks. They are caused by a high concentration of pigment cells in the skin. These spots are not a sign of disease and should fade during childhood, but they may never disappear completely.
• Café au lait spots are flat spots, usually tan to light brown in color. They can be found anywhere on the body and are usually permanent. There is no treatment for these spots, but if baby has more than six spots that are larger than 1/5 inch in diameter, have them checked out by the doctor. Café au lait spots are sometimes found in conjunction with a rare neurological disorder.
• Port-wine stains are pink to purple to red in color and usually flat. They are usually permanent. They may fade somewhat, and/or they may be removed by laser surgery when baby is older. If port-wine stains appear on any part of the face, they should be checked regularly.
• Spider nevi are dilated blood vessels that look like the legs of a spider; they usually fade by 1 or 2 years of age.
• Moles or pigmented nevi come in several colors from light brown to black. They are caused by an increase in the number of pigment cells in the skin. Moles present at birth should be watched for any change in size and color. Large moles (over 3 inches wide) may be removed to avoid risk of melanoma. Keep an eye on any birthmarks your child has. Call the doctor if a birthmark grows or changes color.

If a mark is close to the eye or on baby's face, your pediatrician will check it. In most instances, birthmarks are checked to see if they fade or go away on their own. Laser surgery is being used in many instances to remove birthmarks and moles. Other treatments may be possible in specific cases.

Examining Other Parts of His Body

Baby's hands and feet are so small they may amaze you. He'll probably hold his hands in tight fists. His fingernails may be paper thin; don't be surprised if they already need trimming! A newborn's legs are bowed, and his feet turn in.

Often his legs are drawn up against his tummy-this is called the fetal position. If you gently pull them out, his legs may appear short. And when you let them go, it's almost as if they were on rubber bands-they pull right up against his body!

His feet have only a heel bone at this time. The cartilage that makes up the rest of his foot will become bone later. His peanut-shaped feet may turn inward. Your baby's heel is usually pricked for a blood sample, so it may look sore or inflamed. His hips may seem loose-jointed and crack when they move. This is normal and caused by hormone's from his mother. Your pediatrician will examine your baby for signs of a dislocated hip, which can be treated.

His tummy may be prominent; this isn't fat, it's caused by a lack of muscle tone. This disappears as he becomes more mobile in the next few months.

Your baby's genitals may appear swollen and enlarged; this can happen with either sex. A girl may have a vaginal discharge. Don't worry — this is normal and will clear up in a few days. These symptoms are caused by the mother's hormones crossing the placenta.

In a few cases, a baby may experience a bone break or fracture or a dislocation during delivery. These conditions heal well with no lasting result and are usually treated by bandaging them.

You must use great care when lifting your baby. Dressing must be done carefully; bathing may have to wait awhile. If you notice a hard lump between baby's ribs, it's a bone called the xiphoid process. Soon it will be covered with muscle and fat as baby develops, so don't be concerned about it.

Your baby may also have a hollow vertical area running down his tummy. This is caused by the two muscle bundles on either side of the abdomen — they haven't grown together yet but will as baby grows older.

Baby's Bowels

Even though you probably never imagined it, now that baby is here, you'll probably find yourself concerned about his bowels. It doesn't only mean changing diapers; your baby's stools can be an indication of his health. Your baby's first bowel movement is called meconium. It consists of cellular material and other substances from his digestive tract as he developed in the womb; it looks yellow-green, brown or like black tar.

Your baby must get rid of this material in the 48 hours after birth before normal digestion can begin. If he doesn't, your doctor may be concerned about intestinal obstruction. Once your baby passes the meconium, his stools will be yellow-green and look like small seeds. If you breastfeed your baby, his stools will look different than a baby's who is fed formula.

Baby's Senses

It may seem incredible, but soon after birth, a baby can recognize his mother's voice and her scent. Before your baby is born, he is already sensitive to sounds, light and temperature. His senses develop quickly once outside the womb. As we've already mentioned, he can hear, see, feel and taste when he is born. Let's examine what his senses are like at this time.

Taste

Your baby is born with a desire for sweet things, which is suited to the flavor of formula or breast milk. His taste for bitter, salty and sour develop later. At this time, he can distinguish bitter and sour tastes.

Hearing

Baby's hearing is not fully developed at birth. Parts of the ear are immature, so your baby can't hear the range of sounds you can. Low-frequency sounds can be heard by baby at birth; this includes the human voice. Baby knows your voice because he heard it inside the womb!

Studies have shown that babies prefer the sound of the human voice to any other sound. To help baby develop his hearing, speak to him often in a slow, exaggerated voice. You'll both enjoy the interaction, and you'll help him develop his hearing.

Sense of Smell

Researchers believe that your baby's sense of smell is well developed at birth. It's been found that within hours of birth, a breastfeeding baby will use his nose to find his mother's nipple.

Amazingly, it has been demonstrated that your baby's sense of smell may be developed in the uterus-certain food flavors and odors, such as garlic, cross the placenta to the baby. If you love garlic and onion, baby may already be familiar with them! If you breastfeed, this continues because flavors pass into your breast milk.

Your baby will learn about some smells as he grows. He will learn which smells are "good," such as those associated with foods, and which smells are unpleasant.

Touch

From birth, a baby is sensitive to touch; as we've already said, his skin is the largest organ of his body. It doesn't take long for him to become familiar with the touch of those close to him. Your touch will soothe him or stimulate him.

It's important to know how to touch your baby. A baby likes a firm touch. It makes him feel secure. He also likes to be stroked and massaged — that's why we include different massage techniques in the first 6 weeks of discussions.

Massaging your baby has benefits for him and for you. Studies show that babies who are massaged for 10 to 15 minutes before bedtime or napping may sleep better and be less irritable.

Sight

Eyes may be quite developed by birth and capable of seeing many things. However, the baby's brain isn't as fully developed, so he doesn't see as well as an adult. That's one reason you'll have to hold an object very close to baby for him to see it, about 8 to 12 inches away.

He can distinguish light from dark and prefers black-and-white patterns. If you move an object farther away from him, his eyes may cross; he can't focus both eyes on the same thing just yet.

Vision and Hearing Tests

Today, many hospitals and physicians are testing a baby's hearing and vision before he leaves the hospital. A baby's eyes are usually tested shortly after birth for eye disease and proper function, especially if there is a family history of problems. Some doctors recommend babies be examined for many types of eye abnormalities, including congenital cataracts.

When found early and treated, a baby may avoid long-term problems. If a problem is discovered, your baby may need to see an ear, nose and throat specialist (ENT) or an ophthalmologist.

Without tests, problems may not be detected until a child is 2 or 3 years old. Hearing is tested by recording electrical brain activity in response to various sounds or by listening for an echo in the inner ear.

If your baby has a hearing loss, it could affect the way his speech develops. Today, hearing aids can be fitted in a baby as young as 6 months old!

Tests on Your Baby

Immediately and shortly after birth, your baby will be subjected to a variety of tests to assess his health and to provide his physician with information about any potential problems. Below is a discussion of some of the tests he may be given.

• Apgar Score - This test was developed by Virginia Apgar, M.D., and is used to assess your newborn's overall condition immediately after birth. The baby is evaluated at 1 minute and 5 minutes after birth; a score of 0, 1 or 2 is possible in five areas-heart rate, color, muscle tone, respiratory effort and reflex irritability. Scores from the five criteria are added together, for a maximum total of 10. An average score for most babies is 7 to 9 (pediatricians' babies are the only ones to score a perfect 10!). The Apgar score is used to determine the baby's health following delivery but is not used to predict future health.
• Comprehensive Newborn Screening The comprehensive newborn screening test can detect more than 30 metabolic disorders in a newborn, including sickle-cell anemia and phenylketonuria. Amazingly, the test can be performed with one drop of baby's blood! This is an important test because the sooner a metabolic problem is discovered, the sooner it can be treated. Many of these conditions are treatable if found early.
• PKU-Phenylketonuria If a baby is born with the disorder, he can't process phenylalanine, which is present in nearly all foods. Left untreated, phenylalanine causes brain damage and mental retardation. If found early, the problem can be prevented by feeding baby a special formula. A special diet will be necessary as the child grows older; it may need to be followed for life.
• Coombs Test Blood is taken from the umbilical cord for testing if the mother's blood is Rh-negative or Type O, or if she has not been tested for antibodies. It detects whether Rh-antibodies have been formed in the baby.
• Reflex Assessment This assessment tests for several specific reflexes in baby, including the rooting and grasp reflexes. If a particular reflex is not observed, further evaluation will be done.
• Neonatal Maturity Assessment Various characteristics of baby are assessed to evaluate his neuromuscular and physical maturity. Like the Apgar test, each characteristic is assigned a score, and the sum indicates baby's maturity.
• Brazelton Neonatal Behavioral Assessment Scale The test covers a broad range of newborn behavior and provides information about how a newborn responds to his environment. It is usually used when a problem is suspected, but some hospitals test all babies.
• Blood Tests for Particular Problems Blood is taken from baby's heel for a blood screen. Tests are done on the blood to look for anemia, congenital hypothyroidism, galactosemia, congenital adrenal hyperplasia (CAH), biotinidase deficiency, maple-syrup urine disease, homocystinuria, medium chain acyl-CoA dehydrogenase deficiency (MCAD) and blood-glucose levels. Results often indicate whether baby needs further evaluation or special treatment.

Baby Functioning after Birth

Baby's functioning after birth includes his first attempts at breathing, coughing fluid from the lungs, sneezing, movement of legs and arms, and often passage of urine or a bowel movement. With those first breaths, your baby goes from being totally dependent on blood flow from the placenta to using his own lungs and airways to breathe. The blood flow in the heart changes-blood that was diverted from the lungs directly to the body before birth now flows through the chambers of the heart into the lungs then into the body.

New parents are often concerned about baby's color. "Are they always so blue?" they ask. The answer is, "Yes," but the baby soon turns pink. Hands and feet are the last areas to turn pink.

Following delivery, the baby is often quiet but is soon crying and moving. The nurses weigh, measure and evaluate your baby in the moments after birth. During this time, baby becomes more alert. Your baby exhibits several reflexes. They are discussed below.

• When you touch or rub his cheek, his mouth will open and he will make a sucking motion; this is the rooting reflex. Baby outgrows this by about 4 months.
• With the sucking reflex, baby sucks vigorously when you put something into his mouth-your finger, nipple or a pacifier. Baby outgrows this by about 4 months.
• The baby will throw his arms and legs out, then quickly draw them in when his position is changed suddenly. This is called the Moro reflex. Baby outgrows this at about 3 months.
• The grasping reflex (also called palmar grasp) causes baby's hand to become a fist when his fingers or palm are touched. Baby outgrows this at 5 to 6 months.
• The startle reflex becomes evident as the Moro reflex fades. When startled by a loud noise, baby may look frightened and flex his arms and legs. This appears around 3 or 4 months of age and lasts until about age 1.
• With the tonic neck reflex, baby will extend his arm and leg outward when you turn his head to one side while he is lying on his back. Baby outgrows this by about 5 months.
• The stepping reflex occurs when baby is held upright. He places one foot in front of the other, as if taking a step. Baby outgrows this by about 2 months.
• When you put your baby on his tummy, he'll move as if he were crawling. This is called the crawling reflex. Baby outgrows this by about 3 months.
• With the swimming reflex, baby will hold his breath and move as if swimming if you put him underwater. Baby outgrows this around 6 months.
• The parachute reflex occurs if baby feels as if he is falling; he'll try to grab on to something overhead. This appears around 3 months of age and lasts until about age 1.

Baby's Care in the Hospital

Visit by the Pediatrician

Your baby will be visited in the hospital by the pediatrician you have already chosen, if you chose one. If you did not select someone, a pediatrician on call for the hospital will examine baby. The pediatrician will examine the baby, perform a circumcision if you request it and meet with you and your partner. He or she will lay out a schedule of follow-up visits in his or her office.

Be sure you know how to contact the pediatrician or the pediatrician's office if you have any questions or problems. If you have questions, ask your pediatrician or obstetrician. No question is "dumb," so ask! You may want to make sure your partner is present when you ask a question. It's always good to have two sets of ears at such an exciting and stressful time as this is.

Circumcision

As parents, you may decide to have your son circumcised, which means the foreskin of his penis is removed by a surgical technique. This is usually performed at the hospital as a surgical procedure, or a clamping device may be used to remove the foreskin. However, if you are Jewish or Muslim, it may be done as part of a religious ceremony, outside of the hospital.

Today, about 65% of all male babies are circumcised-in the 1970s, that number was as high as 80%. It is not unusual today for a couple to decide not to have their son circumcised.

Other than for religious purposes, infant boys are circumcised for two reasons. First, many couples don't want their son to look different from his father or other boys his age at school. The second reason is health related, including reducing urinary-tract infections (UTIs) in the first year of baby's life and reducing a man's chances of developing cancer or contracting syphilis or HIV in later life. The reduction in UTIs falls from 1 in a 100 for an uncircumcised male to 1 in 1000 for a circumcised infant during baby's first year.

The American Academy of Pediatrics (AAP) has taken a neutral stand on circumcision. They have concluded there is no right or wrong answer to the question. The association believes the decision is up to the parents and is based on medical reasons and cultural and religious beliefs.

However, the AAP does state that pain relief is essential when a newborn is circumcised. Various techniques are available and recommended, including dorsal penile nerve block, the subcutaneous ring block or a topical anesthetic cream. Risks with the procedure are minor and include some bleeding and local infection. The wound usually heals in about 10 days.

If you decide to have your son circumcised, performing the surgery at this early age will have little effect on him. (Postponing it until later years can be significantly more painful and can carry higher risks.) If your son was born prematurely, you may be able to have him circumcised before he leaves the hospital. However, some doctors prefer to wait until he is a few weeks older to perform this procedure. The doctor in the neonatal intensive-care unit (NICU) will advise you.

If you decide not to have the procedure performed, your child will not be the only child who is uncircumcised as he grows up. Statistically, about N of his male friends and acquaintances will also be uncircumcised.

Circumcision requires surgical permission from you and your partner; it won't be done without your consent. When you meet with your pediatrician before baby's birth, circumcision may be a subject you want to cover. If you don't have that opportunity, you can always discuss it before baby leaves the hospital.

Dislocated Hips

Dislocation of a baby's hip(s) occurs more often in baby girls and in babies delivered in the breech position. About 1 in 60 newborns are affected; 85% of these are girls. When your baby is examined by the pediatrician in the hospital, his hips are checked to see that the upper leg bone (femur) fits in the hip socket (pelvic bone). A "hip click" (a clicking sound) may be heard when the legs are pulled apart. Skin folds on the buttocks may not be symmetrical or one leg may appear shorter than the other. If left uncorrected, he may limp when he begins to walk.

Today, surgery is rarely required to correct the problem. Splints are usually used for a few months, sometimes called pillow or diaper splints; they keep the hips widely separated. It's like wearing three or four diapers at one time. In some cases, plaster splints (like a cast) or braces are used. In most cases, the problem is corrected before the end of the first year.

If Your Baby Is Premature

Premature birth is defined as birth before 37 weeks of gestation (pregnancy). However, we see babies born very early; some come into the world as early as 23 or 24 weeks of gestation. And the incredible thing is that they often survive! At this time, a baby born at 28 weeks has a 90% chance of living — 45 years ago, he wouldn't have had a 50% chance of surviving.

Premature birth occurs for a number of reasons that we can determine, including multiple babies, placental problems or pre-eclampsia in the mother, early labor that cannot be stopped and illness in the baby. However, for nearly 50% of all premature births, the cause is unknown.

If your baby is born prematurely, you may not be prepared for the event. You may feel sad if you go home without your baby. You may be angry that everything didn't turn out perfectly. Don't be too hard on yourself or your partner. Be thankful you are able to take care of your baby so he will get a good start in life.

Baby's Care

When a baby is born prematurely, often called a preemie, the type of care he receives depends on how early he was born. Some babies are not extremely early, and they won't require the extensive care other babies will. Babies born closer to term may need some stabilization before they are moved to the infant nursery, but they are often soon on their way to going home. Other babies need extensive care and will not be able to go home for weeks or months. The rule of thumb is that the earlier a baby is born, the longer he will need care. All premature babies are individuals. Your baby will be evaluated and tended to based on his unique needs.

Immediate Care for Your Newborn

When your baby is born prematurely, many things can happen very quickly. A preemie needs more care than a full-term baby; much of the care is necessary because his body cannot take over and perform some of his normal body functions.

If baby is having difficulty breathing, the nursing staff will help him with his breathing, which can be done in many ways. Immediately after delivery, your baby may be helped in any of the following ways.

• A hood (a large translucent plastic box) may be placed over baby's head to provide additional oxygen if he needs it.
• A bag and mask may be used if baby is not breathing on his own.
• A continuous positive airway pressure (CPAP; pronounced CEE-pap) device may be used. It is a two-pronged tube that fits in baby's nose to provide uninterrupted pressure to baby's lungs.
• A dose of surfactant may be administered to help his lungs work more effectively. A A UAC (umbilical artery catheter) may be inserted in an artery in the umbilicus (umbilical-cord site) to measure blood pressure, to take blood samples and to give medications.
• An I.V. may be inserted into a vein for administration of medication.
• An endo-tracheal (ET) tube may be placed if baby needs to be on a ventilator.

After baby is tended to in the delivery room, he will be moved to the infant care nursery or to a special neonatal care unit for further treatment, evaluation and care. See the discussion that follows.

Your Baby's First "Home"

If your baby needs wide-ranging, in-depth care, he will be moved to the neonatal intensive-care unit, also called the NICU (pronounced NICK-U). If your hospital does not have this special unit, your baby may be transferred to another hospital that has a NICU and services to care for him.

The nurses and physicians who work in these units have received specialized education and training so they may care for preemies. A neonatologist is a pediatrician who specializes in diagnosis and treatment of problems in newborns. Neonatal nurses are registered nurses who have received additional, special training in caring for premature and high-risk newborns. You will meet these professionals in the NICU.

In addition, you may also meet and work with pediatric nutrition specialists, lactation consultants, neonatal respiratory therapists and social workers. All are there to help you and your baby.

If you cannot be at the hospital all the time due to other responsibilities or distance or some other factor, call the NICU to check on baby. Most NICU staffs welcome it. You may hesitate because you believe you are bothering them. In most cases, they encourage parents to be involved and to contact them. Ask about it at one of your visits to baby.

Seeing Baby for the First Time

The first time you see your baby for any length of time may be after he has been moved to the NICU. You may be overwhelmed when you see him. All the monitors and equipment can be scary and intimidating. However, be assured that they are all being used to help give your baby what he needs to grow and to continue to develop.

You may be amazed by the size of your baby. The earlier he was born, the smaller he will be. Most preemies don't have much fat on their bodies — a baby usually gains fat during the last few weeks of your pregnancy. When baby comes early, he hasn't had a chance to gain this extra weight. Without the fat, he will need help staying warm. Your baby may be in a warmer or isolette to help him maintain his body temperature. He may be unclothed, without blankets, so the nurses can watch his breathing and body movements more closely.

Baby may have a lot more body hair than you expected. This is called lanugo. His skin may look thin and fragile, and it may be wrinkled. Wrinkling is due to the fact he has not gained much fat; he's not as plump and round as a full-term baby.

Become Involved with Baby

As soon as you are able to visit the NICU and spend time with baby, personnel will encourage you to become physically involved with him. In the early days, you may not be able to hold your baby, but you may be able to touch him or to stroke him gently. As time passes and baby matures, you will probably be able to hold him. You will also be encouraged to care for him, such as changing him and feeding him. Information on feeding can be found on page 28.

When you are with baby, talk softly to him. You may be surprised how quickly he will recognize your voice and respond to you. Your love and attention are important to baby's physical development and to his psychological growth. Lots of contact with your baby helps him grow and thrive.

Massage for Preemies

In various cultures, vigorous massage is common for a newborn. Some researchers believe these babies develop certain abilities at an earlier age than usual because massage is a part of their daily routine. Massage stimulates respiration, circulation, digestion and elimination, and it helps babies sleep more soundly. Experts believe massage relieves gas and colic, and it also helps the healing process by easing congestion and pain.

For a premature baby, medical experts believe massage therapy can help in many ways. In fact, studies show nearly 75% of preemies who were massaged gained more weight and performed better with developmental tasks. One study showed that massaged infants gained nearly 50% more weight than those who were not massaged.

Babies who were massaged were also awake and active for longer periods. They scored better on various scales and left the hospital 6 days sooner than babies who were not massaged! If you find this technique interesting and want to try it with your baby, talk to the nurses in the NICU. They will know various techniques to use and can suggest what might work best for your baby.

Kangaroo Care

When you are able to hold baby, nurses may encourage you to offer kangaroo care. Kangaroo care is skin-to-skin contact that is good for baby in many ways. This technique is very effective in keeping baby's body temperature normal. In fact, studies have shown that a mother's body temperature adjusts to keep baby's temperature at the right degree. Baby's breathing also becomes more even, and his heart rate and blood oxygen levels remain steady when held in the kangaroo position.

You are encouraged to hold your unclothed baby (he'll have a diaper on) against your bare chest. The personnel in the NICU can offer you some sort of privacy in which to do this. Both mom and dad can offer this care. This type of contact helps you both bond with baby.

It has also been shown to improve parenting abilities because parents become more attuned to their baby's cues. Kangaroo care is also very important for your baby. Studies show that premature babies who are held this way for an hour or more every day were more alert and maintained eye contact better as they matured.

Inside the NICU

You'll see many pieces of equipment and various machines in the unit. All are there to help provide the best care possible for your baby. Monitors record various information, ventilators help baby breathe, lights warm baby or help treat jaundice. Even baby's bed may be unique.

Equipment in the NICU is made specially for premature babies to take care of their special needs. For example, ventilators provide a smaller volume of air with each breath. Beds may contain radiant warmers to help maintain a baby's body temperature. NICUs provide constant monitoring and round-the-clock care. They are the best chance a preemie has to develop and to grow so that he can be released from the hospital and go home.

The neonatologist and NICU nurses will determine what kind of care and treatment baby needs, including the type of equipment that will best help him. Various pieces of NICU equipment and what each is used for include:

• ventilator-—machine that helps baby breathe through a tube inserted into his throat
• blood-pressure monitors — small inflatable cuffs attached to baby's arm to record blood pressure
• cardiorespiratory monitors — sensors that keep track of baby's breathing and heart rate
• oxygen saturation monitor or pulse oximeters — sensor that monitors amount of oxygen in baby's blood; attached to the foot or hand

• feeding tube — plastic tube passed through the nose or mouth to help baby feed A overhead warmer-lights mounted overhead or on stands that can be moved; used to keep baby warm
• temperature monitor — sensor attached to baby to measure body temperature
• bilirubin lights — lights for phototherapy; used to treat jaundice A I.V. lines and/or pumps-intravenous lines placed in baby's veins to deliver medication, nutrients or liquids
• snugglies — device used to maintain fetal position and make infant comfortable
• umbilical-artery catheter — catheter inserted in an artery in the umbilicus to measure blood pressure, to take blood samples and to give medications

Feeding Your Preemie

Feeding is very important for a premature baby. In fact, a baby being able to feed on his own for all of his feedings may be one of the milestones the baby's doctor looks for when considering when to release a baby.

Premature babies often have digestive problems. They need to be fed small amounts at a feeding, so they must be fed often. Special preemie bottles and nipples must be used. Babies tire easily, and they need to learn to suck or to practice sucking. Feeding your preemie may be a time-consuming task, but it's worth it when you see him begin to grow.

For the first few days or weeks after birth, a premature baby is most often fed intravenously for two reasons. The first is that when a baby is premature, he often does not have the ability to suck and to swallow, so he cannot breastfeed or bottlefeed. Second, his gastrointestinal system is too immature to absorb nutrients. Feeding him by I.V. gives him the nutrition he needs in a form he can digest.

Tube Feeding

When baby matures somewhat, the I.V. feedings will cease, and he will have a feeding tube inserted. It is used until he gains enough strength and maturity to nurse or to take a bottle. Tube feeding is often called gavage feeding. Tubes are made of soft, pliable plastic. Different tubes have been designed to deliver food by various pathways directly to baby's tummy or upper intestine. Each tube has its own name, which indicates the route and the destination, and include:

• OG tube — this tube goes through the mouth, down the esophagus, into baby's tummy
• NG tube — tube goes through the nose to the stomach
• OD tube — this tube goes through the mouth to the duodenum, the part of the small intestine into which baby's stomach empties
• OJ tube — tube goes through the mouth to the jejunum, which is farther past the duodenum

When baby is tube fed, he will receive fortified breast milk or high-calorie preemie formula through the tube. Once baby's gastrointestinal system demonstrates it can absorb nutrients, the amount will be increased, and he may also be offered a bottle or given the opportunity to breastfeed.

The end goal is to have baby breastfeeding or bottlefeeding for every feeding. This accomplishment is a major one. How quickly your baby moves from one form of feeding to another depends on his strength, maturity and growth. Even though he may be able to take some feedings from the breast or a bottle, he may be given supplemental feedings because he tires quickly and can't get all the nourishment he needs from the breast or a bottle. That's why you may see a baby who is feeding from a bottle also has a feeding tube.

Baby may be offered a preemie-sized nipple or pacifier. These encourage development of his sucking and swallowing reflexes. They can also help soothe baby when he is fussy.

Breast Milk Is Best for Premature Babies

Babies in NICU feed as often as every hour, although time between feedings may range from 1 to 3 hours. If you are going to breastfeed baby, you will need to supply breast milk for that purpose. Pumping may be the answer. Studies have shown that any amount of breast milk is beneficial for a preemie, so seriously consider this important task.

Two nutrients present in breast milk are extremely beneficial to preemies. DHA and ARA are two fatty acids important in baby's brain development and eye development. However, premature infants miss out on these important nutrients in the womb because they are born early. If you cannot breastfeed, ask the NICU nurses if your baby will be fed a special preemie formula that contains these nutrients.

The composition of your breast milk when your baby is born prematurely is different from the milk when baby is full term. Because of this difference, baby may also be supplemented with formula that contains extra protein, carbohydrates, sodium, folic acid, calcium, iron, phosphorous and vitamins A, D and E. In addition, these nutrients may be in a form that is easily digested and absorbed by baby. You may be advised to use similar formula when you take baby home.

Most preemies need about 55 calories per pound of body weight. If they cannot get all the nutrition they need from breast milk, they may be supplemented with formula developed especially for preemies.

Problems Some Preemies May Have

When a baby is born prematurely, he hasn't had time to finish growing and developing inside the womb. Being born too early can impact on baby's health in many ways. Many of the problems a premature baby encounters pass quickly; some take longer to correct. Some are lifelong. In addition, some problems appear rapidly; others develop weeks or months after birth. In some cases, they are not evident until a child starts school.

Today, with all the medical and technological advances medicine has made in the care of premature babies, we are fortunate that many children have few, or no, long-term difficulties. Research has shown that the earlier a baby is born, the greater the chance of him having problems. It's not uncommon for extremely premature infants to have more problems than infants who were born later. Risks for the very premature infant are still very high. However, researchers continue to explore new ways of treating premature babies and increasing their quality of life.

After baby is discharged from the hospital and you take him home, you may be advised to keep him away from germs as much as possible. His immune system is immature and needs time to develop. That may mean staying away from crowds, keeping baby inside and not allowing too many people to hold him. You may also be asked to take your baby to the pediatrician weekly for weight checks.

Your baby may have diverse problems after birth and in the course of his life. He may experience anemia, hearing or vision problems, feeding and growth problems, and problems breathing. He may have developmental delays and/or learning disabilities that do not become evident for quite a while. Some problems are discussed below. Some are short term; others may need to be dealt with for the rest of the child's life.

Jaundice

Jaundice is a condition in which the liver cannot get rid of bilirubin, the product of used red blood cells. It is more common in premature babies than in full-term babies. A premature baby's liver is less mature than a full-term baby's, so often it cannot process bilirubin effectively. Thus it builds up in baby's body, turning skin and sclera (the whites of the eyes) a yellow color.

If your baby has jaundice, he may be given phototherapy. He may be placed under a bilirubin light in the NICU. If he is treated with phototherapy, he may have to wear special goggles or eye patches to protect his eyes. Phototherapy may be administered for 7 to 10 days.

Apnea

Apnea is defined as a pause in breathing. Preemies typically have irregular breathing rhythms. They often breathe in spurts-a period of deep breathing followed by a shorter period of 5- to 10-second pauses. This is called periodic breathing. If the period of pauses lasts longer than 10 or 15 seconds, baby is said to be having an A/B spell. A is for apnea (a pause in breathing); B is for bradycardia (slow heartbeat). This apneic episode may trigger alarms on baby's monitoring devices.

After an A/B spell, baby's breathing and heart rate often return to normal spontaneously. If baby experiences frequent A/B spells, the neonatologist may prescribe medication to help regulate breathing. He or she may also suggest an apnea monitor for baby to wear or to sleep on when he goes home, if he continues to suffer from the problem.

Important note: A baby that is at risk for apnea should always sleep in his own bed. Do not allow him to sleep with you or to sleep in a family bed!

Respiratory Distress Syndrome (RDS)

RDS is a breathing problem caused by immature lungs in a premature baby. In the past, this condition was called hyaline-membrane disease. Lungs lack surfactant, which gives them the elastic qualities needed for easy breathing. Doctors are able to diagnose RDS shortly after birth. Diagnosis is based on how much breathing trouble baby is having and a chest X-ray. Treatment includes supplemental breaths.

A baby with RDS is often put on a ventilator, also called a respirator, that gives him these extra breaths. Some babies also need CPAP; a plastic tube fitted into the nostrils provides pressure to keep tiny air sacs in the lungs inflated.

If your baby has RDS, he will be monitored very closely. He will probably wear an oximeter or saturation monitor to indicate the level of oxygen in his blood. He may also have frequent blood tests to measure carbon dioxide, oxygen and pH levels in his blood to determine how well he is breathing. These tests will indicate whether any changes are necessary.

Broncho-Pulmonary Dysplasia (BPD)

If your baby requires a ventilator or supplemental oxygen a month after birth, he is considered to have BPD. Medication may be used to help with his breathing. He may also need supplemental oxygen for a prolonged time. If your baby has BPD, take care to keep him from getting exposed to germs. If he develops a bad cold or pneumonia, he may need a ventilator.

A baby with BPD may need supplemental oxygen when he goes home, especially if you live at a high altitude. As he grows and matures, his breathing should become easier. However, children who experience BPD early in life may be more prone to asthma and episodes of wheezing.

Undescended Testicles

The incidence of undescended testicles is higher in premature baby boys than it is in full-term baby boys. Testicles normally descend about 2 months before birth. If a baby is born before that time (before 32 weeks of gestation), his testicles may not have descended. Sometimes hormones are used to bring the testicle into place. If it has not descended by the time baby is 15 months old, surgery may be required. Left untreated, the condition can cause infertility.

Patent Ductus Arteriosus (PDA)

Before birth, baby doesn't use his lungs in the womb, so a blood vessel, called the ductus arteriosus, reroutes blood away from the lungs. In addition, the fetus manufactures a chemical called prostaglandin E, which helps keep the ductus arteriosus open. At birth, levels of prostaglandin E drop, the ductus arteriosus closes and blood is sent to the lungs. In a premature baby, prostaglandin E levels may not drop, and the baby continues to produce it. This keeps the ductus arteriosus open, which can cause breathing difficulties. Your doctor may treat baby with medication to stop the production of prostaglandin E. If medication does not work, surgery may be required.

Intracranial Hemorrhage (ICH)

When a baby is born earlier than 34 weeks of gestation, he is at greater risk for bleeding into his brain. This is called intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH). The earlier a baby is born, the higher the risk. If a baby has ICH or IVH, he is at risk for developing problems later in life, such as cerebral palsy, spasticity and mental retardation.

Bleeding most often occurs within the first 72 hours after baby's birth. Ultrasound is used to examine the baby's head to determine if bleeding has occurred. If an episode of ICH or IVH is mild, no treatment is necessary. Your baby will be observed closely by those in the NICU. For more severe cases, treatment will be ordered. The type of treatment will be determined by your physician.

Retinopathy of Prematurity (ROP)

Fifty years ago, some very premature babies who survived had severe vision impairment; some were even blind. The problem was called retrolental fibroplasia. It was believed to be caused by the use of oxygen. Today, we have a better understanding of the problem and now call it retinopathy of prematurity.

The problem is most common in very premature babies. It's uncommon for babies born after 33 or 34 weeks of gestation to have it. When a baby is born early, retinal development of the eye is incomplete. ROP occurs when the delicate retina development is disturbed because baby is born too early.

If personnel in the NICU believe your baby may be at risk for ROP, an ophthalmologist who specializes in premature babies can examine your baby after he is 6 weeks old. Most cases of ROP are mild and resolve on their own. If the problem is more severe, treatment with cryotherapy may be necessary. We are fortunate that retinal detachment and blindness are uncommon today. ROP mainly affects only the very smallest, unstable preemies.

Respiratory Syncytial Virus (RSV)

RSV often begins as a cold; it can develop into pneumonia or bronchiolitis. See Week 12 for a complete discussion of RSV. The problem can arise quickly, so call your pediatrician immediately if baby develops wheezing and/or rapid breathing with a cold, once he is home.

Because there is no medication available to treat the problem, prevention is key. Keep baby away from crowds, and wash hands frequently during the cold season (winter and early spring). In addition, talk with your pediatrician about protective immunizations.

Taking Baby Home

At some point, you will be able to take your baby home. If you have more than one baby, you may take them home separately, when each gains sufficient weight and is feeding well enough to leave the hospital. It's hard not to be able to take them home together, at the same time. Some babies need more time in the hospital because of complications. However, you can look forward to the day you'll all be together.

Your baby will be ready to go home when he:

• has no medical problems that require him to be in the hospital
• can maintain a stable body temperature
• can take all of his feedings on his own (no tube feeding)
• is gaining weight

This can be a wonderful experience, but it may also cause you some concern. Will you be able to meet his needs? Will you be able to care for him? The people in the NICU will help you prepare for this important event. Many NICUs let you room in with baby just before you take him home. It's a great opportunity to take care of baby on your own while you have the nursing staff at hand.

The personnel in the NICU can help you plan any special care needs before you take your baby home. Once home, most preemies do well. When you are home, ask your partner to help you and to share the responsibility of parenting. Ask for help-or accept it-from others who offer it, including family, friends and neighbors. You'll be glad you did.

Preemie Equipment You May Want to Consider

Your lives will be different when you take your preemie home. It's not the same as bringing a full-term baby home. You may need different equipment or not need some equipment yet. Your schedule may be very hectic because you have to feed baby more often. You may have your hands full tending to your baby and any other children you have.

For baby's first trip home and for future trips in the car, you may want to consider a car bed. This device allows baby to lie flat. This position is often better for preemies because they may have trouble breathing in a normal-size car seat. Or you may want to consider Cosco's Ultra Dream Ride (may not be available in India); it's a car bed for preemies as small as 5 pounds. It converts to a rear-facing car seat that you can use until baby is 20 pounds.

If you didn't get one in the hospital, consider buying a couple of preemie pacifiers. There are many on the market. This type of pacifier fits baby's tiny mouth more comfortably.

You're going to need preemie diapers. They are designed for premature babies weighing between 1 and 6 pounds. Disposable preemie diapers are adjustable (they have an expandable back panel) and have the narrowest crotch of any diaper available to allow for proper leg positioning. They are also absorbent and can absorb up to 2H ounces or 5 tablespoons of liquid. If you want to use cloth diapers, ask at the hospital about where you can purchase them. If you are planning to use a diaper service, call the company and ask if they supply preemie diapers.

As for clothing, you may want to wait to buy a lot of clothes for baby, other than essentials, such as gowns that are open at the bottom, T-shirts or one-piece sleepers. As baby starts to grow, he'll probably grow quickly and will soon be out of these very small clothes.