We try to keep our charges reasonable though we realize that these days health care is expensive. Payment (usually a co-pay) is requested at the time of service to help us keep our costs down. If your insurer is an HMO or PPO with whom we have a contract, we will bill your company for you. If we do not have a contract with your company, we require you to pay the bill at the time of service. You will file with your insurance company for reimbursement. If you have problems or concerns with your account balance, let us know. 

• When you register at the hospital before the baby is born, the hospital will ask you the name of the baby’s pediatrician. The staff pediatrician or neonatologist will see your newborn in the hospital. Your infant will have a complete physical exam by the doctor.
• If you have chosen to have your baby boy circumcised, the doctor will discuss it with you and perform the circumcision after the physical exam.
• The doctor at the hospital will discuss with you when to follow-up with our office. We typically want you to call us to schedule an appointment once the baby has been home for a night. We then see most infants when they have been home 2-3 days.
• While still at the hospital, the State of Ohio newborn screening blood test will be done (see further information below). We also are following the national recommendation to start the Hepatitis B vaccine series while your baby is still in the hospital. Therefore, your baby will receive their first immunization there. Newborns now also have their hearing checked and a heart screen (oxygen saturation test) in the hospital before they are discharged to home.

These visits are scheduled to monitor growth and development, screen for more common illnesses, administer immunizations, and perform complete physical exams. The initial routine office visit is 2-3 days after discharge from the hospital. After that initial visit, the routine schedule is the following:

• 1 month - check-up
• 2 months - check-up and vaccines
• 4 months - check-up and vaccines
• 6 months - check-up and vaccines
• 9 months - check-up and hemoglobin check
• 12 months - check-up and vaccines
• 15 months - check-up and vaccines
• 18 months - check-up and vaccines
• 24 months (2 years) - check-up
• 30 months (2 1/2 years) - check-up
• Each year from 3-18 years - check-up and update vaccines as needed

Immunization schedules may change as recommendations are updated by the American Academy of Pediatrics.

• You will do the most interacting with your baby during feeding. Relax and enjoy these times. Whether you choose breast or bottle to feed your baby, no other food or liquids are needed during the first 4 months of life unless instructed by us. Please consult our office is you feel a change is needed in your baby’s diet.
• Find a comfortable and quiet place that allows you and your infant to enjoy feeding time. For your infant’s safety, do not smoke or hold hot liquids during any feeding. Do not prop bottles. This can lead to choking, lung problems, and an increased risk of ear infections. Putting infants to bed with a bottle can cause cavities and frequent ear infections.

• Early on, feed your infant every two to three hours during the day and every three to four hours at night. If the baby shows good weight gain at the first visit, which typically occurs at 10-14 days of age, you can then begin feeding the baby “on demand”.
• Mothers should wash their nipples with water before and after each feeding. Nursing your infant in a quiet place may help you relax, allowing your milk to flow easily. Be sure your infant’s mouth covers the entire areola (the dark area around your nipple). Limit your feedings to 10 to 15 minutes on each side, alternating the side that you start with each feeding. Attempt to burp your baby (for just a minute or so) between each breast and at the end of the feeding. Continue with a daily multivitamin while nursing and drink enough fluids to quench your thirst.
• Use a pacifier if the baby wants to suck beyond the feeding. Sucking is an instinct and pacifiers provide the non-nutritive sucking they desire. You can wean your infant from the pacifier around twelve months of age.
• Expect that your milk will come in by day 3 or 4. You should see a steady increase in the number of wet diapers. There should be at least one wet diaper in the first 24 hours. In the second 24 hours there should be at least two wet diapers. By day 4 and 5 there needs to be six wet diapers in a day. This is our best sign the baby is receiving adequate hydration/nutrition. Please notify us if the baby is not having six wet diapers in a 24 hour period by day 5. In this situation, we will often bring the baby in for a weight check.
• During the first two weeks of nursing, supplemental feeding with formula will occasionally be advantageous. This is true in cases of severe nipple pain, maternal exhaustion/anxiety, poor urine output, or increasing jaundice.
• Bowel movements will change from black to green to mustard yellow in color. Your newborn should have at least one stool per day the first few days. Please call the office if you have questions or concerns about your infant’s wet diapers and bowel movements.
• If nursing is going well at the first infant check-up, your doctor will assist you in introducing the bottle to your baby if you plan on using bottles in the future. If bottles are not introduced early, an infant will sometimes resist them altogether.
• Sore nipples are a common problem among nursing mothers. Air drying your nipples after feeding can help reduce chaffing. Expressing a small amount of milk and rubbing it on your nipple helps heal cracked areas. Apply over-the-counter 100% lanolin after feedings. Remember to limit feeding times to 20-30 minutes total. Don’t let your infant use you as a pacifier.
• Stored breast milk and/or formula are appropriate for mothers who must be away from their babies. Do not microwave breast milk or formula because it can alter the vitamin content and cause burning. Check with your obstetrician or pediatrician before taking any medications while nursing.

• Feeding on demand is again what is best for the baby. Encourage feeding without forcing the baby to empty the entire bottle. On average a newborn will eat from ½ to 1 ounce every 2 to 3 hours the first couple days. By the follow-up appointment in the office at 10-14 days of age, the average newborn is taking 2-3 ounces every 2 to 3 hours. The amount that your baby eats (within reason) is not important as long as the nutritional needs are met and your baby is growing well.
• A milk-based formula with iron, including Similac Advanced and Enfamil Premium, is a good choice for most formula-fed infants. Cow’s milk is not appropriate for infants under one year of age and can cause anemia and other harm if given in your infant’s diet. Iron as a medication may cause constipation, but recent studies show no increase in constipation in infants on ironfortified formula versus low-iron formula. The iron in an infant’s formula is important to keep the infant from becoming anemic and promotes optimal neurological development. Occasionally infants have difficulties with milk-based formulas. If problems occur, please discuss them with us. We do not recommend changing formulas without contacting us.

• All equipment used in formula preparation should be clean. Washing items with hot water and dish soap or running them through the dishwasher are both acceptable methods of cleaning. It is not necessary to sterilize bottles each time. Some mothers like to boil the bottle’s nipples after purchase and then use one of the above cleaning methods. Use a bottle brush when washing by hand to get rid of any old formula. Wash your hands well prior to preparing the formula. Mix the powdered or concentrated formula exactly as directed on the package. It is not necessary to boil city water used in formula preparation. Formula may be stored in clean bottles in the refrigerator for 24-48 hours after mixing and then should be discarded. After each feeding, discard the unused portion of the bottle if not used within an hour.
• When warming formula, use a pan of heated water (you can heat this water in the microwave, but not the formula itself), a bottle warmer, or hold the bottle under warm water. Do not microwave or boil the formula. Always test the temperature of formula prior to feeding it to the baby.

• Most babies “spit-up” or have a “wet burp” and may do it with most feedings. If this becomes a problem, burp your infant more frequently during feedings. Positioning the baby upright during and after the feedings may help the baby keep the breast milk or formula down. Elevate the head of the bed by using a pillow under the mattress. Never let your infant sleep on a pillow.
• Vomiting large amounts or projectile vomiting that is persistant or becomes progressively worse needs to be brought to our attention.

• Stooling patterns in infants vary greatly. Some infants have one stool every 1 to 3 days and others have a stool 6 to 12 times a day. As long as the stools are not very hard, they are normal. The only color change that likely indicates a problem for your infant and we need to be aware of is if your infant’s stool has bright red blood. Yellow, green, gray, and brown are all normal colors for bowel movements.
• Most babies grunt, groan, occasionally cry, and get red in the face when having a bowel movement. This is normal and common for infants. If stools are hard, you may add 1/4 – 1/2 teaspoon (1.25 – 2.5 ml.) of over-the-counter Milk of Magnesia to a bottle once or twice daily for a week to help your baby through this phase of constipation. If a young infant has not had a stool for 2 to 3 days and seems distressed, you may try using some rectal stimulation with a rectal thermometer with the end lubricated with Vaseline petroleum or K-Y jelly. This will often result in the infant having a bowel movement. This may be used on occasion, but if you find yourself doing this regularly, the infant should be placed on Milk of Magnesia. Contact us if you have questions or concerns.

• Baths should not be given in a tub until the umbilical cord falls off and the circumcision is healed. Before tub baths, sponge baths are recommended. Your infant needs to be bathed every 1 to 3 days. Bath water should be warm at all times, and mild infant bath soap should be used. Wash your baby’s eye area with a soft cloth and no soap, and then continue cleaning the rest of the face, head, and body using the mild infant bath soap. Your baby’s hair may be washed with the same bath soap or a baby shampoo. Never leave your infant alone, even just for a short time, during the bath!
• Do not use Q-Tips in your child’s ears. This can be very dangerous to the ear canal and ear drum. Cleaning the outer part of the ear canal with a warm, wet washcloth is all that is necessary.

• Infants often have dry, flakey skin in the first few weeks of life. This skin will gradually flake off without special treatment, and it does not seem to bother the infants. No lotion is required. However, if you would like to use a lotion, use a mild infant’s lotion and avoid the infant’s face.
• At about two weeks of age, you may notice an outbreak of baby acne on the face, neck, and chest and shoulders. This acne resolves on its own without scarring and without treatment. It frequently looks much better by the 2 month check-up.
• Also developing for many infants at two weeks of age and afterwards are flakey areas on the scalp and forehead, in the eyebrows, and behind the ears. This is called “cradle cap” or seborrheic dermatitis, and is a common condition with yellow or clear oily crusts and scales. It generally lasts for 4 to 8 weeks, occasionally longer. It can be helped by washing daily with mild soap and water. The next step is to try massaging in baby oil and gently brushing it with a baby hair brush afterwards. If worsening, cleaning daily with Head and Shoulders® shampoo, Selsun Blue® shampoo, or Neutragena T-Gel® shampoo on a wet washcloth can help. To remove the scales and flakes, gently brush with a soft infant brush after massaging baby oil into the area and allowing it to stay in place for 15 minutes.

Cloth or disposable diapers are acceptable. Clean the diaper area well with warm water or disposable wipes with each change. Change both wet and soiled diapers frequently to help decrease the number of diaper rashes. To protect and heal the diaper area when there is a flat red irritation or rash, over-the-counter creams and ointments such as A&D®, Desitin®, and Balmex® will be helpful. Red raised rashes with small red dots on the edges that do not respond to the above treatments often indicate a yeast infection. These rashes are treated with clotrimazole over-thecounter cream (often found in the foot care section of the pharmacy), available as generics and the name-brand Lotrimin AF cream. It should be applied to the rash twice a day for 5-10 days.

• Normally the umbilical cord will begin to dry in the first few days of life. The cord then falls off between the 5th and 30th day of life. For years, it was recommended to clean and dry the umbilical cord with alcohol with each diaper change. It was thought this helped prevent an infection at the area and reduced how long it took the cord to fall off. A large scientific study looking at thousands of newborns a few years ago showed that the alcohol was no better at preventing infection and the cord fell off no sooner when alcohol was used. Therefore, it is fine to use alcohol on the area a few times a day, but is not necessary. However, if the cord area develops an odor or is seeping, we would recommend you do use the alcohol.
• There is occasionally some bloody discharge from the navel just before or after the cord separates. Clean with alcohol if this occurs. If after the cord falls off a large yellowish blob of tissue remains at the navel, please contact our office during regular office hours. This is called a granuloma and may require in-office treatment.
• Occasionally a bacterial infection occurs at the umbilical cord area. An infection causes redness to spread out onto the skin around the umbilical area, often with foul-smelling discharge at the cord-site. Call us right away if your child develops these findings.

Rectal temperatures will be the most reliable means of taking the temperature in infants, especially for infants 8 weeks of age and younger. In order to take the temperature, apply Vaseline to the end of your rectal thermometer. Lay the baby on their back. Using one hand securely hold both feet up and out of the way. With the other hand insert the thermometer into the baby’s rectum approximately ¾ - 1 inch. Continue to hold the feet with one hand and the thermometer with the other hand. In an infant, a rectal temperature of 100.5 degrees or above is a fever. You need to contact us immediately, day or night, if your infant less than 8 weeks of age has a rectal temperature of 100.5 degrees or above. Do not give an infant Tylenol without first being instructed by your physician to do so.

After circumcision, the tip of the penis where the foreskin has been trimmed away is red and raw. It needs to be protected from sticking to the diaper by applying Vaseline petroleum jelly with each diaper change. This should be continued for 7-14 days until the area is well healed. You may fasten diapers loosely while the area is healing. To clean the area, wipe gently with a soft wet cloth. You may notice a yellow substance on the raw areas. This is a normal way the area heals. If the circumcision area has prolonged bleeding with more than just occasional oozing of reddish material, please contact us. Also, if the penis looks more swollen and red after a few days with yellow or green drainage, please contact us as we will want to have the area examined to see if an infection has occurred.

If you choose not to have a circumcision done, the penis needs normal cleaning in the newborn period. Do not, however, pull back the foreskin. This can cause injury to your son. The foreskin will slowly retract on its own over the next few years, often by 5 years of age. The foreskin will gradually separate from the penis and become fully retractable. During this period, you may clean the head of the penis by gently retracting the foreskin until you meet resistance but no further.

A newborn screening blood test is required by state law and the blood is drawn at the hospital with a poke on the foot. It tests for a number of diseases which can be treated if diagnosed at birth. The test is done at 24 hours of age or later at the hospital. The results are sent to our office at about 10-14 days of age of your infant.

• All necessary vitamins are in the infant formulas. It is now recommended that all breast fed infants who exclusively breast feed or who breast feed and supplement with less than 16 ounces of formula per day need a daily supplement of vitamin D. This is available as over-the-counter vitamin D infant drops. The dose is one drop (400 IU). Another option is the over-the-counter vitamin drops Tri-Vi-Sol and ViDaylin ADC (both of these contain vitamins A, D, and C). The dose is 1 ml. per day (400 IU).
• Fluoride helps protect our teeth. Infants who drink powdered formula mixed with city tap water will get enough fluoride every day. All other children may require a fluoride supplement. Ask us at the office for advice and a possible prescription for the fluoride.

Many babies become jaundiced in the first couple weeks of life. Jaundice is a yellowish-orange color to the skin. It can cause the whites of the eyes to become yellow. The jaundice often is first noticed at the second to third day after birth. It typically peaks at the fourth to fifth day after birth. Some breast fed infants will become jaundiced later. The jaundice will likely simply flush out of the baby’s skin over a few days with the baby feeding and having bowel movements. However, if the baby appears more yellowish-orange and is increasingly sleepy or hard to waken for feedings, please contact us.

You may notice that your daughter or son has swelling underneath their nipples at birth. This is a normal response to the mother’s hormones. It typically lasts less than 4 months, occasionally longer. Please contact us if the swollen areas become very red or tender.

Female infants may have a whitish discharge and a scant amount of blood from the vaginal area. This is normal, typically lasts a few days to a few weeks, and is related to the mother’s hormones. You may gently clean the area, remembering to wipe the area front to back to keep from spreading bacteria from the rectal area to the vaginal and urinary areas.

• Infants should be dressed for their environment. Young infants often should be dressed as you would dress yourself plus one extra light layer. No shoes are needed until the walking age, although crib shoes may be used.
• When taking the baby outdoors, avoid extremes of heat and cold. Always avoid direct sunlight to prevent sunburn, as an infant’s skin sunburns easily. When your child is six months of age and older, we strongly recommend using sun screen whenever your child will be sun exposed. Reapply the sun screen according to the directions.

• Although new babies do little more than eat, fuss, and sleep, each has its own personality. These personalities may vary from very calm to fussy. Relax and enjoy your baby for who they are. The most important thing is to be sure your baby is well fed, cared for, loved, and enjoyed.
• There are normal things to expect from your infant. An infant’s breathing is irregular and sometimes noisy. They may get frequent hiccups, occasionally look cross-eyed, startle, pass gas, grunt with bowel movements, spit up, cough, and sneeze. Infants may cry to tell you they are hungry, tired, wet or dirty, cold or warm, over-stimulated, or needing socialization. You will learn over time what your infant’s cries mean. Soon you will be the best expert on your own infant.

All infants cry. You will learn to distinguish what your baby’s cries mean. The time an infant spends crying may increase dramatically at 3 weeks of life and may not drop off until around 3 months of age. Crying episodes may be more pronounced in the evening when the baby has had a stimulating day. Babies often cry before falling off to sleep. Try to remember that every cry does not mean hunger and that infants should not be fed every time they cry.

• Colic is when infants have prolonged episodes of fretful crying and difficulty being comforted. Colic is seen in about 10 to 15% of all infants and is most pronounced between 3 weeks and 3 months of age. These crying episodes often remain a mystery, even after all of the infant’s needs seem to be met. The crying episodes are no one’s fault although parents often blame themselves and feel helpless. Many of these episodes pass after a few months without any specific cause (reflux, allergy, formula intolerance, etc.) being found. Here are some suggestions to calm irritable or fussy babies:
  • Change the baby’s position.
  • Remember that babies like to be dry, warm, and full.
  • Swaddle the baby snugly in a soft blanket.
  • Provide a pacifier (or the infants hand and fingers) for sucking. Infants need to suck frequently even when they are not eating. This is a normal state of development called non-nutritive sucking.
  • Decrease the amount of external stimuli (light and noise) by going to a quiet room.
  • Rock the baby in a cradle, chair, or using a bouncy seat.
  • Walk slowly around the house while holding the baby securely.
  • A car ride with the infant in their car seat may be very calming.
  • Soft repetitive lullaby at nap time or bed time.
  • Talk softly with a “shushing” sound.
  • Your infant may need a few minutes to adjust from one situation to another.
  • Attempt to remain calm. Use gentle, soft motions. Do not nervously bounce or jiggle your baby. Avoid hard patting. Infants can pick-up on their parent’s anxiety and frustrations. NEVER, EVER SHAKE YOUR BABY.

• If you are becoming frustrated with your infant’s crying and find yourself getting angry with the baby or yourself, then it is time to take a break! Use your family and friends for support and help. You will find that even a short break can give you a new outlook, allowing you to handle the situation more calmly than before. If there is no help available to you, simply lay the infant in their crib. Allow the baby to cry while you take a break for a few minutes.
• Sometimes it takes a while to learn what will comfort your baby. Your infant will become more “settled” at around three months of age. Try to remember that the fussiness will end. In the meantime keep looking for ways to comfort your baby and don’t be worried that comforting a newborn will spoil the baby.
• You may find the following book helpful: Dr. Harvey Karp’s ‘the Happiest Baby of the Block: the New Way to Calm Crying and Help Your Newborn Baby Sleep Longer’ (2003).

To decrease the risk of the baby getting sick, keep the number of people around the baby to a minimum. Avoid crowded places (church, shopping malls, etc.) for the first 6-8 weeks. Allow no visitors who may be sick. Remember to have everyone wash their hands before picking up or touching the baby.

• Newborns will sleep an average of 15 to 18 hours a day. Some will sleep more or less. It is best for your newborn to sleep in its own room as soon as you feel comfortable with this situation. Babies who sleep in their parents’ room tend to awaken more often at night as well as awaken their parents. It can be a difficult transition for a baby when the parents later decide it is time for the baby to sleep in its own room.
• It is best to start good habits early with helping the baby learn to fall asleep on their own. If the baby is laid down in their crib or bassinet while they are drowsy but not yet asleep, they will learn to fuss for a short time then fall asleep on their own. A baby frequently put down in their crib or bassinet when they are already asleep may awaken right away or need you to rock them back to sleep.
• By four months of age the average baby may sleep 6 to 8 hours at night and 10 to 12 hours by six months. There is quite a bit of variation with this. Feeding a young baby solid foods (cereal, etc.) usually plays very little role in the baby sleeping through the night. It happens developmentally at the right time for most babies. It is a coincidence that we begin cereal about 4 months of age and most babies sleeping through the night at that time.
• Babies should sleep in a safe crib or bassinet on a firm mattress with a soft sheet. Infants should never use a pillow. Never leave the side rails of the crib down when you are not at the bedside. Your baby may surprise you by rolling over when you think it is impossible.

The following is a list of items to keep on hand in case you need them:

• A rectal thermometer
• Pedialyte
• A bulb syringe for the nose
• Tylenol infant drops
• Vaseline
• Alcohol swabs (for use with the umbilical cord).

Two other over-the-counter things you may find it useful to buy ahead of time are Benadryl Allergy Elixir and Neosporin ointment.

If you see any of the following signs or symptoms in your infant, you should contact us immediately: a rectal temperature of 100.5 degrees or higher in an infant less than 8 weeks of age, an infant who is lethargic (like a limp doll) or excessively irritable, repeated vomiting (not “just” spitting up) or refusal to eat several times in a row, difficulty or rapid breathing, or an infant “who just does not look good” (you will be the best judge of this).

• There has been a major decrease in the number of SIDS (sudden infant death syndrome) since the national recommendation by the American Academy of Pediatrics in 1992 that infants should be put down to sleep on their backs. Overall, since 1992 there has been a better than 50% reduction in SIDS deaths in the USA.
• The following are risk factors, amongst others, for SIDS: sleeping on the stomach (“prone sleeping”), sleeping on soft surfaces, the mother smoking during pregnancy, overheating, preterm birth, and the parent sleeping with the infant in the same bed.
• The most recent AAP recommendations, as of June 2010, include the following. Infants should sleep on their back. Side sleeping is not as safe as sleeping on the back and is not advised. Use a firm surface for the infant to sleep on. Keep soft objects and loose bedding out of the crib. Do not smoke during pregnancy or around your infant. The risk of SIDS is less when the baby sleeps near but not in the same bed as the mother. Using a pacifier when the infant is put down to sleep (and not reinserted once the baby falls asleep) may protect against SIDS. Avoid overheating (overdressing for bed and over bundling).
• There may be some conditions (including gastroesophageal reflux) where we will recommend a change to these specific recommendations.
• The entire AAP document on SIDS can be viewed on line at their website www.aap.org. Use the search tool to search for documents relating to “SIDS”.

Ohio law requires all children to ride in a car seat until they are both 4 years of age and weigh 40 pounds. The safest place for infants and children is the rear seat of the car, especially the middle of the back seat. Infants and toddlers should be in rearfacing car seats until 24 months of age. Do not put a rear-facing car seat in the front seat with an active air bag. All children 2 years or older (or those younger than 2 years of age who have outgrown the rear-facing weight or height limit for their car seat) should use a forward-facing car seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat's manufacturer.

• Always leave the side rails up when the baby is unattended.
• The crib should be free of cracks, splinters, and lead paint.
• The distance between the crib slats should be less than 2 3/8 inches.
• The mattress should be the same size as the crib so that arms, legs, and head do not become caught between the mattress and the frame.
• Keep small objects out of the crib and out of the child’s reach.
• Avoid low-hanging toys, strings, or mobiles. Babies can strangle on these. Also beware of pacifier strings, chains, and necklaces.

• Never leave a baby unattended on any surface. You cannot be sure when a child will decide to roll.
• Never leave babies alone with pets or young children.
• Never leave babies alone in the home or car, even for a moment.
• The American Academy of Pediatrics strongly advises against using a walker and we agree. Many serious injuries have happened to children using walkers. Walkers also do nothing to help a child to learn to walk and may delay crawling.
• Many people will give you advice about your child. Some of this can be very useful. Many opinions on caring for children have dramatically changed as a result of scientific research over the last few years. Some older beliefs or practices are now considered unsafe. You need to do what you think is best based on a reasonable and educated judgment. Remember that you know your baby better than anyone. Think about the issue and come to an appropriate decision. We are available to you when you need us.

This becomes an important decision for many two-career families. You should make a well-researched decision about child care. Please consider the following: child safety, training of the child care provider (CPR, knowledge of child development, resources for emergencies), attitudes of the care giver, references, personal convenience, and financial needs. Begin looking early for the best situation for your family. Remember to inform the care giver of your child’s medical history, allergies, and any medications. Provide care givers with emergency phone numbers.

Books:

• ‘American Academy of Pediatrics Your Baby’s First Year’, 1998.
• ‘American Academy of Pediatrics Caring For Your Baby and Young Child, Birth to Age 5’, 1998.
• ‘Your Child’s Health’ by Dr. Barton Schmitt, MD, 2005.
• ‘Heading Home With Your Newborn: From Birth to Reality’ by Drs. Jana and Shu, MD, 2005.

Websites:

• The American Academy of Pediatrics: www.aap.org
• Hilliard Pediatrics: www.hilliardpeds.com