What is life like right after birth?
- Examine risks and complications with newborns
- Explain the postpartum recovery period
- Compare the advantages and disadvantages of breast-feeding and bottle-feeding
- Discuss the nutritional concerns for infants, such as marasmus and kwashiorkor
The average newborn weighs approximately 7.5 pounds, although a healthy birth weight for a full-term baby is considered to be between 5 pounds, 8 ounces and 8 pounds, 13 ounces. The average length of a newborn is 19.5 inches, increasing to 29.5 inches by 12 months and 34.4 inches by 2 years old (WHO Multicentre Growth Reference Study Group, 2006).
For the first few days of life, infants typically lose about 5 percent of their body weight as they eliminate waste and get used to feeding. This often goes unnoticed by most parents, but can be cause for concern for those who have a smaller infant. This weight loss is temporary, however, and is followed by a rapid period of growth.
Newborn Assessment and Risks
Assessing the Newborn
There are several ways to assess the condition of the newborn. The most widely used tool is the Neonatal Behavioral Assessment Scale (NBAS) developed by T. Berry Brazelton. This tool has been used around the world to help parents get to know their infants and to make comparisons of infants in different cultures (Brazelton & Nugent, 1995). The baby’s motor development, muscle tone, and stress response are assessed.
The APGAR is conducted one minute and five minutes after birth. This is a very quick way to assess the newborn’s overall condition. Five measures are assessed: the heart rate, respiration, muscle tone (quickly assessed by a skilled nurse when the baby is handed to them or by touching the baby’s palm), reflex response (the Babinski reflex is tested), and color. A score of 0 to 2 is given on each feature examined. Perfect scores are rare while an APGAR of 5 or less is cause for concern. The second APGAR should indicate improvement with a higher score.
Low Birth Weight
We have been discussing a number of teratogens associated with a low birth weight such as malnutrition, cocaine, tobacco, etc. A child is considered to have a low birth weight if they weigh less than 5.5 pounds (or under 2,500 grams). In 2016, about 8.17 percent of babies born in the United States were of low birth weight and 1.4 percent were born with very low birth weight. Socioeconomic inequality is linked to low birth weight and it’s more prevalent in the United States compared to the UK, Canada, and Australia (Martinson & Reichman, 2016).
A low birth weight baby has difficulty maintaining adequate body temperature because it lacks the fat that would otherwise provide insulation. Such a baby is also at more risk of infection. And 67 percent of these babies are also preterm which can make them more at risk for a respiratory infection. Very low birth weight babies (under 1,500 grams or 3 pounds, 5 ounces) and extremely low birth weight (under 1,000 grams or 2 pounds, 3 ounces) have an increased risk of developing cerebral palsy. Many causes of low birth weight are preventable with proper prenatal care.
A child might also have a low birth weight if it is born at less than 37 weeks gestation (which qualifies it as a preterm baby). In 2016, 9.85 percent of babies born in the U.S. were preterm. Early birth can be triggered by anything that disrupts the mother’s system. For instance, vaginal infections or gum disease can actually lead to premature birth because such infection causes the mother to release anti-inflammatory chemicals which, in turn, can trigger contractions. Smoking and the use of other teratogens can also lead to preterm birth.
Anoxia and Hypoxia
One of leading causes of infant brain damage is lack of oxygen shortly after birth. Hypoxia occurs when the infant is deprived of the adequate amount of oxygen, leading to mild to moderate brain damage. Apoxia occurs when the infant undergoes a total lack of oxygen, which can lead to severe brain damage. This lack of oxygen is typically caused by umbilical cord problems, birth canal problems, blocked airways, and placenta abruption. Both hypoxia and anoxia can lead to cerebral palsy and a host of other medical disorders.
The postpartum (or postnatal) period begins immediately after childbirth as the mother’s body, including hormone levels and uterus size, returns to a non-pregnant state. The terms puerperium, puerperal period, or immediate postpartum period are commonly used to refer to the first six weeks following childbirth. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most maternal and newborn deaths occur during this period.
A woman giving birth in a hospital may leave as soon as she is medically stable, which can be as early as a few hours postpartum, though the average for a vaginal birth is one to two days. The average caesarean section postnatal stay is three to four days. During this time, the mother is monitored for bleeding, bowel and bladder function, and baby care. The infant’s health is also monitored. Early postnatal hospital discharge is typically defined as discharge of the mother and newborn from the hospital within 48 hours of birth.
The postpartum period can be divided into three distinct stages; the initial or acute phase, 6–12 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months. In the subacute postpartum period, 87% to 94% of women report at least one health problem. Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women. Various organizations recommend routine postpartum evaluation at certain time intervals in the postpartum period.
Postpartum uterine massage helps the uterus to contract after the placenta has been expelled in the acute phase. The first 6 to 12 hours after childbirth is the initial or acute phase of the postpartum period. During this time the mother is typically monitored by nurses or midwives as complications can arise.
The greatest health risk in the acute phase is postpartum bleeding. Following delivery the area where the placenta was attached to the uterine wall bleeds, and the uterus must contract to prevent blood loss. After contraction takes place the fundus (top) of the uterus can be palpated as a firm mass at the level of the navel. It is important that the uterus remains firm and the nurse or midwife will make frequent assessments of both the fundus and the amount of bleeding. Uterine massage is commonly used to help the uterus contract.
Following delivery if the mother had an episiotomy or tearing at the opening of the vagina, it is stitched. In the past, an episiotomy was routine. However, more recent research shows that routine episiotomy, when a normal delivery without complications or instrumentation is anticipated, does not offer benefits in terms of reducing perineal or vaginal trauma. Selective use of episiotomy results in less perineal trauma. A healthcare professional can recommend comfort measures to help to ease perineal pain.
Subacute Postpartum Period
In the first few days following childbirth, the risk of deep vein thrombosis (DVT) is relatively high as hypercoagulability increases during pregnancy and is maximal in the postpartum period, particularly for women with C-section with reduced mobility. Anti-coagulants or physical methods such as compression may be used in the hospital, particularly if the woman has risk factors, such as obesity, prolonged immobility, recent C-section, or first-degree relative with a history of thrombotic episode. For women with a history of thrombotic event in pregnancy or prior to pregnancy, anticoagulation is generally recommended.
The increased vascularity (blood flow) and edema (swelling) of the woman’s vagina gradually resolves in about three weeks. The cervix gradually narrows and lengths over a few weeks. Postpartum infections can lead to sepsis and if untreated, death. Postpartum urinary incontinence is experienced by about 33% of all women; women who deliver vaginally are about twice as likely to have urinary incontinence as women who give birth via a cesarean. Urinary incontinence in this period increases the risk of long term incontinence. Kegel exercises are recommended to strengthen the pelvic floor muscles and control urinary incontinence. Discharge from the uterus, called lochia, will gradually decrease and turn from bright red, to brownish, to yellow and cease at around five or six weeks. An increase in lochia between 7–14 days postpartum may indicate delayed postpartum hemorrhage. In the subacute postpartum period, 87% to 94% of women report at least one health problem.
At two to four days postpartum, a woman’s breast milk will generally come in. Historically, women who were not breastfeeding (nursing their babies) were given drugs to suppress lactation, but this is no longer medically indicated. In this period, difficulties with breastfeeding may arise. Maternal sleep is often disturbed as night waking is normal in the newborn, and newborns need to be fed every two to three hours, including during the night. The lactation consultant, health visitor, or postnatal doula (a person who helps the mother following the birth process), may be of assistance at this time.
During the subacute postpartum period, psychological disorders may emerge. Among these are postpartum depression, posttraumatic stress disorder, and in rare cases, postpartum psychosis. Postpartum mental illness can affect both mothers and fathers, and is not uncommon. Early detection and adequate treatment is required. Approximately 70-80% of postpartum women will experience the “baby blues” for a few days. Between 10 and 20 percent may experience clinical depression, with a higher risk among those women with a history of postpartum depression, clinical depression, anxiety, or other mood disorders. Prevalence of PTSD following normal childbirth (excluding stillbirth or major complications) is estimated to be between 2.8% and 5.6% at six weeks postpartum.
Another subtype, peripartum onset (commonly referred to as postpartum depression), applies to women who experience major depression during pregnancy or in the four weeks following the birth of their child (APA, 2013). These women often feel very anxious and may even have panic attacks. They may feel guilty, agitated, and be weepy. They may not want to hold or care for their newborn, even in cases in which the pregnancy was desired and intended. In extreme cases, the mother may have feelings of wanting to harm her child or herself. Most women with postpartum depression do not physically harm their children, but some do have difficulty being adequate caregivers (Fields, 2010). A surprisingly high number of women experience symptoms of peripartum-onset depression. A study of 10,000 women who had recently given birth found that 14% screened positive for postpartum depression, and that nearly 20% reported having thoughts of wanting to harm themselves (Wisner et al., 2013).
Maternal-infant postpartum evaluation
Various organizations across the world recommend routine postpartum evaluation in the postpartum period. The American College of Obstetricians and Gynecologists (ACOG) recognizes the postpartum period (the “fourth trimester”) as critical for women and infants. Instead of the traditional single four- to six-week postpartum visit, ACOG, as of 2018, recommends that postpartum care be an ongoing process. They recommend that all women have contact (either in person or by phone) with their obstetric provider within the first three weeks postpartum to address acute issues, with subsequent care as needed. A more comprehensive postpartum visit should be done at four to twelve weeks postpartum to address the mother’s mood and emotional well-being, physical recovery after birth, infant feeding, pregnancy spacing and contraception, chronic disease management, and preventive health care and health maintenance. Women with hypertensive disorders should have a blood pressure check within three to ten days postpartum. More than one half of postpartum strokes occur within ten days of discharge after delivery. Women with chronic medical (e.g., hypertensive disorders, diabetes, kidney disease, thyroid disease) and psychiatric conditions should continue to follow with their obstetric or primary care provider for ongoing disease management. Women with pregnancies complicated by hypertension, gestational diabetes, or preterm birth should undergo counseling and evaluation for cardiometabolic disease, as lifetime risk of cardiovascular disease is higher in these women. Similarly, the World Health Organization recommends postpartum evaluation of the mother and infant at three days, one to two weeks, and six weeks postpartum.
Delayed Postpartum Period
The delayed postpartum period starts after the subacute postpartum period and lasts up to six months. During this time, muscles and connective tissue returns to a pre-pregnancy state. Recovery from childbirth complications in this period, such as urinary and fecal incontinence, painful intercourse, and pelvic prolapse, are typically very slow and in some cases may not resolve. Symptoms of PTSD often subside in this period, dropping from 2.8% and 5.6% at six weeks postpartum to 1.5% at six months postpartum.
Approximately three months after giving birth (typically between two and five months), estrogen levels drop and large amounts of hair loss is common, particularly in the temple area (postpartum alopecia). Hair typically grows back normally and treatment is not indicated. Other conditions that may arise in this period include postpartum thyroiditis. During this period, infant sleep during the night gradually increases and maternal sleep generally improves. Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women. Ongoing physical and mental health evaluation, risk factor identification, and preventive health care should be provided.
Postpartum confinement refers to a system for recovery following childbirth. It begins immediately after the birth and lasts for a culturally variable length: typically for one month or 30 days, up to 40 days, two months, or 100 days. This postnatal recuperation can include “traditional health beliefs, taboos, rituals, and proscriptions. The practice used to be known as “lying-in”, which, as the term suggests, centers around bed rest. (Maternity hospitals used to use this phrase, as in the General Lying-in Hospital.) Postpartum confinement customs are well-documented in China, where it is known as “Sitting the month”, and similar customs manifest all over the world. A modern version of this rest period has evolved, to give maximum support to the new mother, especially if she is recovering from a difficult labor and delivery.
In other cultures like in South Korea, a great level of importance is placed on postnatal care. Sanhujori is the term for traditional postnatal care in Korea and is a practice followed by the majority of women for the purpose of proper recovery after giving birth. Deeply rooted in Korean culture, sanhujori has similarly evolved with today’s society from being heavily reliant on the mothers’ family members to include services that encompass its principles, which is apparent with the over 500 sanhujori centers (maternity hotels) in operation around Korea.
Bringing Baby Home
Benefits of Breastfeeding
Breast milk is considered the ideal diet for newborns due to the nutrition makeup of colostrum and subsequent breastmilk production. Colostrum, the milk produced during pregnancy and just after birth, has been described as “liquid gold. Colostrum is packed with nutrients and other important substances that help the infant build up his or her immune system. Most babies will get all the nutrition they need through colostrum during the first few days of life (CDC, 2018). Breast milk changes by the third to fifth day after birth, becoming much thinner, but containing just the right amount of fat, sugar, water, and proteins to support overall physical and neurological development. It provides a source of iron more easily absorbed in the body than the iron found in dietary supplements, it provides resistance against many diseases, it is more easily digested by infants than formula, and it helps babies make a transition to solid foods more easily than if bottle-fed.
The reason infants need such a high fat content is the process of myelination which requires fat to insulate the neurons. Therefore, there has been some research, including meta-analyses, to show that breastfeeding is connected to advantages with cognitive development (Anderson et al., 1999). Low birth weight infants had the greatest benefits from breastfeeding than did normal-weight infants. This meta-analysis showed that breastfeeding may provide nutrients required for rapid development of the immature brain and be connected to more rapid or better development of neurologic function. The studies also showed that a longer duration of breastfeeding was accompanied by greater differences in cognitive development between breastfed and formula-fed children. Whereas normal-weight infants showed a 2.66-point difference, low-birth-weight infants showed a 5.18-point difference in IQ compared with weight-matched, formula-fed infants (Anderson et al, 1999). These studies suggest that nutrients present in breast milk may have a significant effect on brain development in both premature and full-term infants.
For most babies, breast milk is also easier to digest than formula. Formula-fed infants experience more diarrhea and upset stomachs. The absence of antibodies in formula often results in a higher rate of ear infections and respiratory infections. Children who are breastfed have lower rates of childhood leukemia, asthma, obesity, type 1 and 2 diabetes, and a lower risk of SIDS. For all of these reasons, it is recommended that mothers breastfeed their infants until at least 6 months of age and that breast milk be used in the diet throughout the first year (World Health Organization, 2018).
Several recent studies have reported that it is not just babies that benefit from breastfeeding. Breastfeeding stimulates contractions in the uterus to help it regain its normal size, and women who breastfeed are more likely to space their pregnancies farther apart. Mothers who breastfeed are at lower risk of developing breast cancer, especially among higher-risk racial and ethnic groups (Islami et al., 2015). Other studies suggest that women who breastfeed have lower rates of ovarian cancer (Titus-Ernstoff et al., 2010), and reduced risk for developing Type 2 diabetes (Gunderson, et al., 2015).
A historic look at breastfeeding
The use of wet nurses, or lactating women, hired to nurse others’ infants, during the middle ages eventually declined, and mothers increasingly breastfed their own infants in the late 1800s. In the early part of the 20th century, breastfeeding began to go through another decline, and by the 1950s it was practiced less frequently by middle class, more affluent mothers as formula began to be viewed as superior to breast milk. In the late 1960s and 1970s, there was again a greater emphasis placed on natural childbirth and breastfeeding and the benefits of breastfeeding were more widely publicized. Gradually, rates of breastfeeding began to climb, particularly among middle-class educated mothers who received the strongest messages to breastfeed.
Today, new mothers receive consultation from lactation specialists before being discharged from the hospital to ensure that they are informed of the benefits of breastfeeding and given support and encouragement to get their infants accustomed to taking the breast. This does not always happen immediately, and first-time mothers, especially, can become upset or discouraged. In this case, lactation specialists and nursing staff can encourage the mother to keep trying until the baby and mother are comfortable with the feeding.
Most mothers who breastfeed in the United States stop breastfeeding at about 6-8 weeks, often in order to return to work outside the home (United States Department of Health and Human Services (USDHHS), 2011). Mothers can certainly continue to provide breast milk to their babies by expressing and freezing the milk to be bottle fed at a later time or by being available to their infants at feeding time, but some mothers find that after the initial encouragement they receive in the hospital to breastfeed, the outside world is less supportive of such efforts. Some workplaces support breastfeeding mothers by providing flexible schedules and welcoming infants, but many do not. And the public support of breastfeeding is sometimes lacking. Women in Canada are more likely to breastfeed than are those in the United States, and the Canadian health recommendation is for breastfeeding to continue until 2 years of age. Facilities in public places in Canada such as malls, ferries, and workplaces provide more support and comfort for the breastfeeding mother and child than found in the United States.
In addition to the nutritional and health benefits of breastfeeding, breast milk is free! Anyone who has priced formula recently can appreciate this added incentive to breastfeeding. Prices for a month’s worth of formula can easily range from $130-$200. Prices for a year’s worth of formula and feeding supplies can cost well over $1,500 (USDHHS, 2011).
When Breastfeeding Doesn’t Work
There are occasions where mothers may be unable to breastfeed babies, often for a variety of health, social, and emotional reasons. For example, breastfeeding generally does not work:
- when the baby is adopted
- when the biological mother has a transmissible disease such as tuberculosis or HIV
- when the mother is addicted to drugs or taking any medication that may be harmful to the baby (including some types of birth control)
- when the infant was born to (or adopted by) a family with two fathers and the surrogate mother is not available to breastfeed
- when there are attachment issues between mother and baby
- when the mother or the baby is in the Intensive Care Unit (ICU) after the delivery process
- when the baby and mother are attached but the mother does not produce enough breast-milk
One early argument given to promote the practice of breastfeeding (when health issues are not the case) is that it promotes bonding and healthy emotional development for infants. However, this does not seem to be a unique case. Breastfed and bottle-fed infants adjust equally well emotionally (Ferguson & Woodward, 1999). This is good news for mothers who may be unable to breastfeed for a variety of reasons and for fathers who might feel left out as a result.
Intriguingly, breastfeeding rates are higher among immigrants compared to non-immigrants (Dennis et al., 2019). In the United States, mothers born in the U.S. were actually less likely to breastfeed compared to foreign-born mothers (Gibson-Davis & Brooks-Gunn, 2006). This difference may contribute to what researchers have called the immigrant paradox (Coll & Marks, 2012).
Because immigrants are more likely to have a lower SES, one might expect their children less likely to be breastfeed and more likely to experience negative outcomes. However, research has often found the opposite pattern. In addition to higher rates of breastfeeding, children of immigrants tend to be healthier and experience greater long-term educational achievements than children born to women of the same ethnic and socioeconomic group. This counter-intuitive finding highlights some of the strengths that immigrants bring to their new communities and suggests fruitful avenues for more research.
Global Considerations and Malnutrition
In the 1960s, formula companies led campaigns in developing countries to encourage mothers to feed their babies on infant formula. Many mothers felt that formula would be superior to breast milk and began using formula. The use of formula can certainly be healthy under conditions in which there is adequate, clean water with which to mix the formula and adequate means to sanitize bottles and nipples. However, in many of these countries, such conditions were not available and babies often were given diluted, contaminated formula which made them become sick with diarrhea and become dehydrated. These conditions continue today and now many hospitals prohibit the distribution of formula samples to new mothers in efforts to get them to rely on breastfeeding. Many of these mothers do not understand the benefits of breastfeeding and have to be encouraged and supported in order to promote this practice.
The World Health Organization (2018) recommends:
- initiation of breastfeeding within one hour of birth
- exclusive breastfeeding for the first six months of life
- introduction of solid foods at six months together with continued breastfeeding up to two years of age or beyond
About 9 million children in the United States are malnourished (Children’s Welfare, 1998). More still suffer from milk anemia, a condition in which milk consumption leads to a lack of iron in the diet. The prevalence of iron deficiency anemia in 1- to 3-year-old children seems to be increasing (Kazal, 2002). The body gets iron through certain foods. Toddlers who drink too much cow’s milk may also become anemic if they are not eating other healthy foods that have iron. This can be due to the practice of giving toddlers milk as a pacifier when resting, riding, walking, and so on. Appetite declines somewhat during toddlerhood and a small amount of milk (especially with added chocolate syrup) can easily satisfy a child’s appetite for many hours. The calcium in milk interferes with the absorption of iron in the diet as well. There is also a link between iron deficiency anemia and diminished mental, motor, and behavioral development. In the second year of life, iron deficiency can be prevented by the use of a diversified diet that is rich in sources of iron and vitamin C, limiting cow’s milk consumption to less than 24 ounces per day, and providing a daily iron-fortified vitamin.
Children in developing countries and countries experiencing the harsh conditions of war are at risk for two major types of malnutrition. Infantile marasmus refers to starvation due to a lack of calories. Children who do not receive adequate nutrition lose fat and muscle until their bodies can no longer function. Babies who are breastfed are much less at risk of malnutrition than those who are bottle-fed. After weaning, children who have diets deficient in protein may experience kwashiorkor or the “disease of the displaced child,” often occurring after another child has been born and taken over breastfeeding. This results in a loss of appetite and swelling of the abdomen as the body begins to break down the vital organs as a source of protein.
Link to Learning
Breastfeeding could save the lives of millions of infants each year, according to the World Health Organization (WHO), yet fewer than 40 percent of infants are breastfed exclusively for the first 6 months of life. Most women can breastfeed unless they are receiving chemotherapy or radiation therapy, have HIV, are dependent on illicit drugs, or have active untreated tuberculosis. Because of the great benefits of breastfeeding, WHO, UNICEF and other national organizations are working together with the government to step up support for breastfeeding globally.
Find out more statistics and recommendations for breastfeeding at the WHO’s detail sheet on breastfeeding. You can also learn more about efforts to clampdown on exploitive formula milk marketing from the 3-paper Lancet series.
Additional Supplemental Resources
- The AAP Parenting Website
- The American Academy of Pediatrics (AAP) promotes pediatrics and advances child health priorities in a variety of ways. This website is dedicated to our mission – to better the health of children worldwide by empowering parents and caregivers with the needed resources and information.
- APGAR Score
- The Apgar score is a scoring system that is used to assess the health of the newborn and identify those who require emergent attention. It is a score ranging from zero to 10 and is calculated by evaluating the newborn based on 5 criteria. This video reviews how to calculate an APGAR score.
- Reflexes in Newborn Babies
- All full-term babies should be born with some natural reflexes like the sucking and walking reflex. Registered Nurse Sarah demonstrates some of these reflexes, which is a useful review for pediatric nursing students.
- Reducing fear of birth in U.S. culture
- This Tedx talk features Ina May Gaskin, MA, CPM, PhD (Hon), founder and director of the Farm Midwifery Center in Tennessee. The 41-year-old midwifery service is noted for its women-centered care.