creation date: 2026-10-01 18:46
tags: Interventions
Newborn Counselling
Background
New parents will often have similar questions regarding the care of their neonate. It is often practical to give them a set of commonly relevant answers in advance to avoid anxiety.
Bilirubin & Weight Loss
Bilirubin and jaundice
Physiologic jaundice occurs due to:
- Rapid turnover of HbF (90 days compared to 120 of HbA)
- Immature liver causing reduced bilirubin conjugation
Additionally, added risk may be present due to:
- Positive hemolysis (eg. DAT+, Coombs+)
- Hematoma from instrumentation
Hyperbilirubinemia needs to be monitored via TSB levels and based on the value and the hours of life may result in:
- Exchange transfusion (for very severe cases)
- Phototherapy (1-3 lights)
- Follow up in babies clinic in 24-48 hours (depending on trajectory)
- Discharge and follow up with family physician
Parents should return to care should they notice the infant’s jaundice worsens. Additionally, jaundice may cause poorer feeding, sleepiness/lethargy, or fussiness.
Weight loss
Neonates are expected to lose up to 10% of their birth weight in the first 5 days of life. This is because about 10% of the birth weight is excess water (eg. within the lungs) which are lost.
After the first week, neonates are expected to gain 20-30g per day, reaching their birth weight by 14 days of life.
Neonates may need to be monitored or even admitted if they may lose >10% of their birth weight. If their gain is low, a thorough feeding assessment is warranted. In cases of breastfed babies, where exact volumes of feed is unknown, supplementation with bottle is likely necessary.
Feeding, Voiding, & Stooling
Feeding
Neonates feeding should be occurring at least every 3 hours. Each feed should be approximately 10 mL per day of life up to the 9th day, where it will plateau around 90-120 mL per feed (assuming a q3h schedule, may be less if they are feeding more frequently).
Neonates should be woken up every 3 hours if they are sleeping to ensure they are feeding at that interval. Parents should maintain this until at least 2-4 weeks of life and birth weight has been regained, whereby the feeds can be stretched a bit longer.
Duration of feed should be around 20 minutes. Long feeding durations expend energy resulting in sleepiness.
For formula-fed infants, ready to feed formula should be used early in life, especially if premature, low birth weight, or weakened immune system.
Voiding and stooling
Neonates should have at least one stool and one void prior to discharge, with meconium expected in the first 1-2 days of life.
As a rule of thumb, neonates should have at least 4 wet diapers and 4 stools in a 24 hour span. Stools should be yellow/green/seedy as stool pale/lacking in colour may suggest an issue with biliary system.
Parents should be instructed to wipe front to back for female infants.
It should be noted that exclusively breastfed infants are more likely to be constipated as infant bodies are very effective at retaining fluid content from breast milk.
Expected Findings
Sneezing and congestion
As neonates transition from a fluid-filled lung within the womb to an air-filled lung, the fluids must either be expelled or absorbed. This manifests as sneezing or gurgling noises within the nasal cavity over the first 1-2 weeks.
This is more common with c-section neonates as many do not experience the “squeeze” that triggers the transition.
Vaginal discharge and pseudomenses
In female neonates, a mucousy, yellow-clear discharge or blood may be discharged from the vaginal in the first week of life. This is normal as the neonate experiences withdrawal from the maternal hormones.
Reflux
Infants have physiological reflux due to an not fully developed pyloric sphincter. As a result, gastric peristalsis can cause flow of milk back into the esophagus. This peaks around 4-7 months and result by 12-18 months.
It may manifest as spit up, gurgling sounds, or feeding discomfort. Parents are encouraged to keep baby upright for 20 minutes after each feed to allow for settling.
Caput succedaneum
Normal swelling of the scalp may occur due to the pressure during delivery. This is benign as long as the swelling does not continue to grow.
Returning to Care
Fever
Babies under 1 month should not have fever. Any fever should prompt ED visit. As such, it is advisable to avoid any chance of infection within the first month (eg. strictly necessary visitors only).
Others
- Poor feeding
- Lethargy
- Dehydration (sunken fontanelles, eyes)
- Vomiting
- Seizures
General Anticipatory Guidance
Sleep safety
- Baby should sleep in a crib or bassinet next to your bed
- Safe sleep: firm surface, no pillows, toys, or bumper pads
- Sleep on their back
- Sleep in onesie or sleep sack, not swaddled in blankets
Childproofing the home
- Lock away medications and cleaning products
- Remove choking hazards
- Use stair gates and window guards; do not use walkers on wheels
- Cover electrical outlets and secure furniture to walls
Bathing
- No bathing early, keep umbilical cord dry until it falls off
- Sponge bathes okay
- Do not leave baby unattended in bathtub once bathing, maximum of 49 degrees C
Car safety
- Rear facing car seat in the back, ideally middle position until at least 1 year and 10 kg
- Latch should be snug over chest at nipple line, with 2 fingers of space between latch and chest
- Detached car seats are not for sleeping (angle can cause positional asphyxiation if they fall forward)
Low efficacy products
Chiropractor: adjustments are low harm (except for neck, risk of dissection), but also waste of money. For torticollis, recommend physiotherapy
Biogaia in the context of healthy baby: useful for gastro or cases of antibiotics induced diarrhea but outside of instances where microbiome is affected, it has no benefit
Home monitoring socks: often has false positives for low SpO2 - parents should consider pleuth and also clinical context such as cyanosis when worrying about monitor beeps
References
Tools / Guidelines
Resources for parents:
SickKids - About Kids Health
CPS - Caring for Kids