The 4th Trimester

Congratulations on becoming a parent!! No matter how many books you have read or how many children you’ve been around, you and your baby are a unique new pair, and this is your new family. Just like any relationship, it is going to take time to get to know each other and figure out what works and what does not work. The most important things to remember are to be patient with yourself and your child, to trust your gut and to ask for help.

Before leaving the hospital with your baby , be sure to schedule an appointment with your pediatrician. Usually, we like to see breastfeeding babies within 1-2 days and formula feeding  babies 2-3 days after hospital discharge. If your baby had any complications like jaundice or infection, the pediatrician might want them seen the day after discharge. Your first newborn appointment at your pediatrician’s office is to make sure that feeding is going well and that everyone is adjusting to the newborn period. Many babies, especially breastfeeding ones, can lose up to 10% of their birthweight. This happens because breast milk supply takes 3-5 days to kick in and another 2-3 weeks to become well-established. However, the initial days of breastfeeding is important to transfer colostrum. Colostrum is like a protein bar for babies. Found in the first days of breastfeeding, it is a small amount, but it is full of nutrition and immune boosting properties.

Feeding babies around the clock until they are back to their birthweight is important. Most breastfeeding babies need to eat every 1-2 hours and formula fed babies every 2-3 hours. It is also important to monitor the amount of urine output and stooling. Once feeding is adequate, stools transition from the dark, tarry, meconium stool to yellow, seedy, and loose. Some breastfeeding babies will even stool during every feed. Also, their gassiness can rival an adult, so don’t be alarmed if this is the case!

Often, parents report their baby’s stomach sounds loud or gurgling and that they look uncomfortable. This is due to the normal digestive process. Babies’ intestines are getting used to the process of digestion outside the womb. Frequently, babies will draw up their legs and then pass gas. Sometimes this brings relief but sometimes it takes a little longer to be soothed. Trying different feeding positions, burping more frequently, or having your baby upright over one’s shoulder with the legs dangling can also provide comfort. Occasionally, an over-the-counter gas aid (like simethicone) has been found helpful and may be recommended by your pediatric provider.

All infants cry more during the first three months of life than at any other time. If your baby is extremely fussy and you are not sure why, call your pediatric provider (our nurse advice line is available 24/7). If your baby has a fever or 100.4 rectally or higher, is vomiting, has diarrhea, has feeding difficulties, decreased urine output, or breathing difficulties, call your pediatrician ASAP. Once your baby has been medically evaluated and you have been reassured that your baby is not sick, you might want to learn more about colic as a cause of the fussiness. Colicky babies tend to cry for no apparent reason at least three hours a day, more than three days a week starting at three weeks of age and this lasts for about three months. The good news is that colic symptoms resolve spontaneously in 90% of babies by eight to nine weeks of age.  However, until colic resolves, parents are concerned, frustrated, and very tired.

Having a colicky baby can be exhausting and a source of stress in families leading to marital conflict as well as maternal and paternal depression. Exhaustion can also lead to accidents. Often, people make poor decisions when stressed and overtired. It can also place babies in danger when a tired parent falls asleep with a baby in their arms, on the couch or in the bed, which can increase the risk for SIDS (Sudden Infant Death Syndrome) and infant suffocation. This is the perfect time to call in reinforcements from friends, family or even a babysitter. People are more than happy to hold an infant so that a parent can rest, nap, eat or even shower. A more rested parent is better equipped to deal with a crying, fussy baby in a safer manner. In addition to providing parents with support, there are several techniques that can be used to help sooth a fussy infant. Dr Harvey Karp discusses some of these methods in “The Happiest Baby On the Block” book and DVD. He utilizes infant calming techniques that are based on recreating the essential elements of the experience of living in the womb.

The key ingredients of his method for soothing babies are the "5 S's" (see below). Many of the 5 S’s are things that parents and caregivers have been doing intuitively all along.

• Swaddling
• Side/stomach position
• Shushing
• Swinging
• Sucking

Swaddling takes a bit of practice to get it just right. Initially, babies may resist the process but usually settle into it once they are properly wrapped: arms snug and straight at the side while letting the hips be loose and flexed. Babies should not be swaddled all day, just during fussing and sleeping.

The back is the only safe position for sleeping, but it is not ideal for calming. The side or stomach position can be achieved by holding a baby on their side, on their stomach or even over your shoulder. Make sure to support their head and neck while doing this movement. For those football fans, think about the Heisman Pose and how the football is being held/cradled close to the body and then you will achieve this position.

Shushing is like white noise to the baby. It recreates the sound of the blood flow in the womb and helps calm them.

Swinging also helps to recreate the jiggly nature of the womb and soothe a fussing baby. To do it properly, the head and neck always need to be supported while moving the baby back and forth about an inch. NEVER, EVER, shake your infant as this can cause traumatic brain injury or even death.

Sucking on a pacifier or even a clean finger rounds out the final S.

Some babies benefit from one or two calming techniques while others need all five; however, there are still some babies that remain fussy. For those that have not responded to any of these soothing tactics, it is best to talk with your pediatric provider again. During this follow up visit, there may be discussions of trying a hydrolysate formula for formula-fed infants or hypoallergenic diet for mothers of breastfeeding infants. This would also be a good time to discuss any other interventions that you might have heard about from friends and family that might include over the counter products such as probiotics, gas drops, herbal teas, or other infantile colic remedies.

Remember, that this 4th trimester is a time of change for you, your baby, and your family. There will be many ups and downs along the way. We at Annapolis Pediatrics are here 24 hours a day, 7 days a week, to assist you in any way we can. It is our goal to help you become the best parent you can be while enabling you to raise a happy and healthy child.