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THE FIRST SIX WEEKS OF LIFE - a parent's guide
Dr Simon Rowley - Paediatrician
Introduction
The first six weeks of life are an important time for both
parent and baby. Although the adaptation from intrauterine
life to postnatal life takes place in the first few minutes
and then hours from a cardiorespiratory point of view, the
gastro-intestinal, renal and neurological adaptation takes
much longer.
From a helpless infant whose responses are relatively
immature and disorganised the baby becomes an assertive
individual who is clearly able to indicate his/her needs,
who may smile, initiate a type of conversation, listen and
track visually by six weeks.
The success of this venture relies to a large extent on
a good maternal-infant relationship, and that in turn depends
on adequate support from other family and community members.
Feeding & Growth
Infants will lose weight in the first few days of life.
They are born with some extra body fluid to enable this
to happen and the initial milk (colostrum) is high in calories
which compensates for the low volume.
Weight loss is acceptable up to 10% of the total body
weight. For a baby weighing 3kg this represents 300g. By
5-7 days most babies will have regained their birth weight.
Over the next few weeks an average weight gain of 150-200g
a week is normal so that by 6 weeks of age an average term
infant will be approximately 1kg above birth weight.
It is important to acknowledge that babies in utero grow
according to the nutritional transfer from the mother. This
seems to be more important at this stage than the direct
influences of hormones (such as growth hormone) and genetic
influences.
Following birth the baby may therefore show a shifting
growth pattern catching up or down according to how big
their parents are (genetics). One should not be alarmed
if the baby therefore starts off at the top of a graph and
moves downwards towards the middle or vice versa over the
first few months provided they are well.
Babies tend to settle into a rhythm of feeding by the
end of the first week but this is variable and it may be
normal for a baby to feed every 2 hours or alternatively
feed every 6 hours. The vigour and success of feeding may
be an indicator of general health and babies who feed poorly
may be unwell (e.g. heart problems or an infection).
Bowel Motions
Babies who are breastfed may have bowel motions with every
nappy change or alternatively may only have one bowel motion
every 6-10 days. Either pattern is normal. Some babies will
seem to squirm and get a little uncomfortable after several
days without a bowel motion, but the stool itself is soft
when it arrives and therefore is not true constipation.
Occasionally babies will develop constipation particularly
if they have been mildly dehydrated at any time. An occasional
bottle of diluted prune juice might help with this. Drugs
to relieve constipation should be avoided unless they have
been prescribed by the doctor. Occasional green bowel motions
are of no concern if the baby is feeding well and there
is no vomiting.
Vomiting
Many babies will spill small amounts after feeds and this
is not necessarily abnormal. Unlike adults, it is not uncommon
or particularly abnormal for babies to have gastro-oesophageal
reflux, i.e. reflux of stomach contents into the mouth.
This does not necessarily need treatment provided the baby
is not suffering extreme discomfort, losing weight or the
vomitus does not contain blood. Before drug treatment is
prescribed it is usual to try simple measures such as slowing
down of feeds, 'winding', propping after feeds, and using
thickened feeds if not breastfeeding.
More obvious vomiting of large amounts is not normal and
may represent either a surgical obstruction in the bowel
or indicate the baby has another systemic illness such as
urinary infection or meningitis. Green vomiting (bile) is
particularly abnormal and regarded as needing immediate
assessment by a doctor (possible bowel obstruction) and
then surgical referral.
There is one condition called pyloric stenosis which comes
on at between 3 and 6 weeks. These babies have projectile
vomiting and if not treated will lose weight and become
quite sick. They have an overdeveloped muscle at the exit
of the stomach (the pylorus) and the treatment for this
is a minor surgical operation to release the tight muscle.
This condition is more common in boys but can occur in girls
and there is often a family history.
Crying
There have been many studies on the amount of crying that
is acceptable in babies in the first weeks of life. Up to
two hours a day is not uncommon. You are lucky if your baby
has regular biological rhythms and will wake/feed/sleep
without much crying. Crying may indicate the baby has needs
to be met however, e.g. they are in discomfort because they
are wet or dirty, they are hungry, they want company or
occasionally because they have other pain which might be
regarded as pathological.
Before deciding that such babies have colic it is important
that they are thoroughly examined by a doctor who will look
for herniae etc. Infantile colic tends to come on in the
2nd - 3rd week, be more common in the afternoons and evenings,
their nighttime sleep pattern is usually normal and they
are babies who are otherwise thriving.
Colicky babies tend to have a lot of wind and will cry,
arch themselves back or draw their legs up as if in discomfort.
Babies with severe gastro-oesophageal reflux will also cry
and it is sometimes difficult to decide which is contributing
to the unsettled behaviour.
Jaundice
Infants are born with immature enzyme systems in the liver
and often become jaundiced (yellow) on the 2nd or 3rd day
of life. This usually peaks at around 3-5 days and resolves
between 1-2 weeks. Babies are more likely to get jaundiced
if they are very bruised after delivery because there are
increased red blood cells breaking up and releasing the
yellow pigment into the circulation.
Any jaundice in a term baby beyond 2 weeks should be evaluated.
The most common cause is 'breast milk' jaundice. This is
benign and self limiting and usually lasts for approximately
2 months. It is due to substances in the milk which cause
a delay in the metabolism of the jaundice pigment. No treatment
is necessary. It is however a diagnosis of exclusion.
There are other more serious causes of prolonged jaundice
which do need to be looked for. The presence of normal coloured
bowel motions and clear urine is reassuring as the more
serious causes of jaundice in the newborn infant tend to
have abnormal bowel motions and very dark urine. However
it is important to check the type of bilirubin in any baby
with prolonged jaundice and refer to a specialist if abnormal.
One of the more potentially serious causes of early jaundice
is when the baby has a different blood group from the mother
and the Coomb's test is positive. This tells us that the
baby's blood cells have antibodies on them which are causing
them to break up and release jaundice pigment. The antibodies
have been made by the mother in the pregnancy against the
baby's blood cells. After delivery they wear off quickly
but the baby may need treatment to keep the jaundice levels
safe.
Very high levels of jaundice have the potential to damage
the brain and cause hearing loss which is why we institute
treatment. Treatment consists of phototherapy, light at
a particular wave length which changes the jaundice pigment
(bilirubin) to a less toxic and more easily eliminated product.
Babies need to have their eyes covered for protection during
phototherapy.
Skin Rashes
The most common rash we see is called toxic erythema neonatorum.
These spots occur randomly over the whole body. They often
look like little insect bites, raised yellow centres surrounded
by an area of redness. They will come and go for several
weeks and probably represent a minor allergic phenomenon
as the baby reacts to new substances in their environment
and feeding. No treatment is necessary for them.
On some occasions similar looking yellow pustules may
occur in the so called dirty areas, e.g. under the armpits,
in the groin, in the nape of the neck. These might represent
a skin infection due to staphylococcal bacteria and should
be swabbed and treated with an antiseptic if the infection
is confirmed. Occasionally an oral antibiotic syrup may
be necessary.
Other areas which are also vulnerable include the umbilical
stump. Any redness, swelling or discharge from the umbilical
stump should be seen by a health professional and treated
appropriately. Infection of finger and toenails (paronychia)
that presents as red and peeling fingers and toes around
the nail is also a sign of staphylococcal infection needing
treatment.
Nappy rashes are common. These are usually just the skin
sensitivity to ammonia and other products in the stools
and urine. The best initial treatment is to expose the areas
as much as possible. Barrier creams can be used to keep
water off the skin. Occasionally thrush (candida infection)
can occur and this will need treatment with an anti-fungal
agent. Swabs should be taken first by the doctor.
Thrush can also present in the mouth as white plaques
on the tongue or sides of the cheeks. An oral anti-thrush
agent needs to be used in these circumstances. If the baby
is breastfeeding, the mother may also need to apply an anti-fungal
cream to her nipples.
Another common skin rash is cradle cap or seborrheic dermatitis.
This occurs as a scaly brownish plaque and rash occurring
in the scalp, occasionally on the eyebrows. It is a dry
skin condition. Soap should be avoided and it can be treated
with adding oil to the skin. There are several available
baby lotions that can be used or a simple oil such as olive
oil or almond oil can also be applied.
Eczema which occurs in the elbow creases and behind the
knees and other similar places does not usually occur before
six weeks of life. This will usually need treatment with
hydrating creams and occasionally steroids.
Snuffles & Fevers
A fever in a baby under six weeks of age is always abnormal.
The normal temperature is somewhere between 36.8°C and
37.4°C.
Temperatures over 38°C may indicate a serious infection
and the baby should be seen by a doctor immediately. Low
grade fevers around the 37.4 mark are of less concern if
the baby is clinically well.
Babies may get colds, develop nasal snuffliness. They
should also be seen by a doctor but not necessarily need
any treatment. If another family member also has a cold
at the time, this is often a clue as to what might be the
cause.
Fast breathing (above 50 breaths/min) is also of concern.
Parents need to be aware however that babies have periodic
breathing so that short bursts of panting or fast breathing
may be quite normal. In such babies the panting breathing
will be followed by periods of normal breathing. In the
pathological situation where there might be an illness or
pneumonia the fast breathing is more persistent and not
accompanied by slowing down. Breathing difficulty that interferes
with feeding is severe enough to warrant assessment by a
doctor.
Genitalia
Babies, particularly boy babies, may develop inguinal herniae.
These are lumps in the groin or in the scrotum which represent
bowel coming down through a weakness in the abdominal wall.
They should be seen by the doctor immediately and usually
surgical correction is offered within a two week period.
They can occasionally strangulate and cut off the blood
supply to the bowel in the hernia, which is why they need
repair. Scrotal swellings may also indicate a hydrocele
which is simply fluid in the scrotum. This will resolve
without treatment, but obviously a hernia needs to be ruled
out.
Occasionally the testicle may twist on its axis and strangulate.
This causes intense pain and there will be redness and swelling
as well. This is a medical emergency and a Paediatric Surgeon
will need to intervene as soon as possible to relieve the
strangulation otherwise the testis may die.
Umbilical herniae are very common and do not need any
treatment. They never strangulate and more than 95% of them
will resolve without any intervention within two years.
If they persist beyond this period of time they may require
a simple operation to correct them.
Development
Over the first six weeks an infant develops a social smile.
This may be seen as early as the first few days of life
but more commonly babies are seen to smile in their sleep
rather than in response to social interaction. Some babies
will be delayed with their social and visual responses and
parents need not be overly concerned particularly if the
baby has been born preterm.
Other developmental milestones to be achieved by six weeks
include being able to fix on a face and follow a moving
object through an arc. Some babies will also have some head
control although the head may still lag when being pulled
to the sitting position.
It is reassuring to see infants of 4-6 weeks of age showing
an interest in the human face, i.e. studying their parent
or caregivers face intensely. Babies that do not do this
may either be receiving inadequate stimulation or have a
neurological problem.
Immunisations
At six weeks of life the baby normally has a medical check.
It is important to discuss with the doctor any concerns
you have, and this is the time where the first immunisations
are given.
The paediatric recommendations are that immunisations
are not delayed beyond this time, particularly because whooping
cough and meningitis protection is needed early to prevent
the complication of these conditions which are most severe
in the very young. If the baby has a mild respiratory infection,
i.e. snuffles without fever, it may still be possible to
proceed with the immunisations.
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