You’ve finally welcomed your bundle of joy into the world and now it’s time to go home for the first time. Let’s face it, the vast majority of us, including pediatricians, are pretty clueless about what to do next. Babies don’t come with instruction manuals and you can’t go back to where they came from to get your questions answered. Luckily, between many books, the Internet and your pediatrician there is help along the way. (Just be careful to check your sources because not everything you read on the internet is accurate!) You are also likely to get lots of advice, some solicited and some unsolicited, that is frequently confusing and even contradictory to what you have heard. Don’t worry. You will get to know your baby and be able to use your own instincts over time.  But in the first few days of life this guide can be helpful.

Feeding

The evidence is clear that breastmilk is perfectly formulated to give all of the nutrition your baby needs, as well as important antibodies to fight infection.  Breastmilk also changes as your baby grows and his/her nutritional demands change.  The only thing breastfed babies need besides breastmilk is vitamin D.  The recommendation is 400 IU/d which can be found at any drug store in liquid formation and the dosing is usually 1 drop orally. Babies used to get vitamin D from the sun since not very much is passed in the breastmilk; inactive vitamin D is activated to active vitamin D by sun exposure. However, due to the dangerous radiation from the sun and the damage it can do to the skin, we now recommend keeping babies out of the sun.  Therefore, extra vitamin D is needed. Babies who are breastfed have less respiratory and gastrointestinal infections, healthier weights when they are older and less autoimmune disorders like allergies and diabetes .  They also rarely have constipation, have a decreased risk of SIDS (sudden infant death syndrome) and spit up less. That being said, it can be very hard and stressful.  My best advice is to first surround yourself with supportive family and friends. It isn’t helpful if Grandma is over your shoulder telling you that you are starving your baby and you need to give a bottle. Second, try to relax.  Lay back and lay baby on your chest skin to skin and watch what happens. Just be sure not to fall asleep with baby on your chest, especially on a couch or chair.  Finally, keep your expectations low for the first 2 weeks. Babies will breastfeed on average every 2-3 hours. You won’t sleep much or get any laundry done and you might feel like a feeding machine, but don’t give up. Once breastfeeding is well established it is very gratifying and is actually pretty easy in the long run.

A small percentage of women do not make enough milk to breastfeed so baby ends up on formula. Furthermore, some dyads are actually better off bottle feeding because of the toll the stress of unsuccessful breastfeeding takes on mom.  Of course, some moms choose to formula feed or are unable to breastfeed due to medical concerns or are in an adoption situation.  Either way, if you are giving formula start with 1-2 ounces per feed.  These babies will usually feed every 3 hours on average.  Make sure to let your baby be the guide and never overfeed.  Babies who gain weight too quickly in the first week of life can be at increased risk for obesity later on.  Choose a formula that you are most comfortable with after reading the ingredients or talking to your pediatrician.  It’s best to start with a standard cow’s milk formula and go from there if you run into problems. Always mix the formula according to the instructions on the can, never water it down. Babies should not get extra water.

Pees and Poops

What goes in must come out.  However the patterns change frequently so it is helpful to know what to expect.  In the first few days of life the baby will have on average about 1 wet diaper per day of life until the milk comes in, which is about day 4-5.  After that expect 6-8 or more large wet diapers per day.

The initial poops that babies have is called meconium.  This is black and sticky like tar.  One sign that your baby is getting enough milk is that the meconium starts to turn to lighter, not-so-sticky poop over the first few days.  By day 4 or 5 you should see yellow seedy poops with just about every feeding.  This is very normal because colostrum, besides being chock full of antibodies, is like a laxative helping to clear out the meconium.  It will usually be present in breastmilk for 6-8 weeks.  After that you may not see a poopy diaper for a whole week!

Green poops are very common for formula fed babies. You may also see green poops in breastfed babies who are having short feedings on both breasts. This means they are getting large lactose loads and not enough of the thicker, fattier milk. If your breastfed baby is gassy and having green foamy poops, try to feed longer on each breast. The only poop colors I worry about are bright red blood, no color at all, or a return to dark tarry poops.

Sleep

This is a big one.  New parents are very sleep deprived.  Newborn babies will sleep on average 18-20 hours in a day but since they are feeding every 2 hours that sleep is broken up.  That means mom and dad’s sleep is also broken up.  I know everyone recommends to sleep when baby sleeps but that is not as easy as it sounds. However, it is super important to get your rest so try to rest when you can. Take advantage of friends and family who want to come stay with your baby while you sleep.

Make sure your baby is sleeping on his/her back on a firm mattress without a bumper, pillow, or extra bedding/blankets around.  This is to reduce the risk of SIDS, as well as to prevent suffocation and strangulation.  The American Academy of Pediatrics does not recommend bed sharing for newborn babies but does recommend room sharing for the first 6-12 months.  However, I was once there and I can admit to falling asleep with baby next to me.  I have written about the risks of bed sharing and the latest AAP guidelines, which can be found here.  If you wake up to find baby in bed with you, gently move him/her to a bassinet next to your bed. The newborn period is not the time to sleep train so don’t be afraid to swaddle your baby and put him/her down already asleep.  I usually talk to parents about sleep routines at the 2 month visit and sleep training at 4 months.  Babies should not be swaddled beyond 4 months of age or once they can roll over.  Check out my Sleep FAQ.

 Jaundice

Babies are born with an extra supply of blood.  When those blood cells are broken down, they release a chemical called bilirubin. For everyone over 1 week of life with a normally functioning liver, bilirubin is processed by the body and disposed of properly. For infants under 1 week of life they can’t process the bilirubin so it relies on pee and poop to leave the body.  As stated above, until feeding is well established, pee and poop might be slow. This means a potential build up of bilirubin in the body which causes the skin and eyes to look yellow. If the bilirubin is too high, it can cross into the brain and be dangerous so if your baby is looking yellow, see your pediatrician.

There are other risk factors that increase the risk of jaundice including premature birth, incompatibility between mom and baby’s blood types, family history of jaundice and other rare conditions.  Your doctor will be able to tell you if your baby is at an increased risk for jaundice and what you can do for it.

Safety

Your number 1 goal with a newborn (aside from feeding) is to keep him/her protected.  Some important pointers are as follows:

• Have your child sit rear facing in the back seat strapped tightly into an infant car seat at all times putting blankets over the straps, not under
• Avoid any smoke exposure
• Do not leave your child alone on any surface
• Never leave your child unattended in a bathtub for any reason
• Keep your hot water heater below 120 degrees
• Never put anything around your baby’s neck (including amber necklaces)
• Be sure to get the Vitamin K shot in the hospital to avoid unnecessary hemorrhagic disease*
• Always follow the ABC of sleep: Alone. Back. Crib (without bumpers)

*Families are increasingly refusing the vitamin K shot for reasons I don’t really understand. I think some parents confuse vitamin K with a vaccine and I think most don’t understand why we give it. For more information on vitamin K deficient bleeding, take a look at this information sheet from the CDC. With more and more refusals, it is possible we will see more devastating stories like this one, about a baby who died of hemorrhage to the brain due to vitamin k deficiency.

Skin Care

When babies come home they still have the stump of their umbilical cord attached.  Until this dries up and falls off it is best to avoid putting your baby in the bath.  You can still wash your baby, just avoid getting the cord wet. (If you are reading this before baby is born and have questions about cord blood banking, this is a great article.)  Once it is time to fully bathe your baby, choose products that are free of irritating dyes and fragrances.  You might notice a lot of dryness and peeling but you don’t have to worry.  This is baby losing the outer layer of skin that was necessary to protect him/her from the amniotic fluid.  I recommend leaving it alone as it is self-limited and not dangerous.  If you want to do a massage with your baby or decide to moisturize the skin, make sure to also choose dye free and fragrance free ointments like Vaseline or Aquaphor.  Straight baby oil or coconut oil are also good choices.

You may also notice different rashes throughout the first month of life.  These are not dangerous and generally don’t require treatment.  If you have any concern, see your pediatrician.  Here is a sample of what you might see:

• Birth marks like Mongolian spots (flat blue discoloration usually on the back) and stork bites (pink discoloration usually on the bridge of the nose, eyelid or back of head)
• Erythema toxicum are scattered red spots with white bumps in the middle that come and go in the first few days of life
• Milia are small white bumps on the tip of the nose or chin
• Acne is caused by hormonal exposure in utero and does not require treatment in the first month of life
• Foreskin (if uncircumcised) should never be forced back

Emergencies

Hopefully this is something that never happens to you, but just in case, it is good to keep your doctor’s number handy and also know how to get to your closest pediatric emergency room.  You should also post the number for Poison Control on all of your phones.

• If you notice your baby looks blue or is not breathing, call 911 immediately.  It may be a good idea to take an infant CPR class.
• Any fever (temperature over 100.4 degrees Fahrenheit) requires a visit to the doctor at this age to rule out a serious bacterial infection.  For more information on fever and why it isn’t necessarily an emergency past the first 2 months of life, see my post here.
• If your baby is extra sleepy or you are unable to arouse your baby, seek medical care immediately.

There is so much to know about caring for a newborn that it would be impossible to cover everything in one simple blog post.  Hopefully, this guide will get you started.  As always, if you have any questions see your pediatrician.