So you've shown the new baby around the house.  Little Billy has met the dog, the cat, the gerbil and about 47 distant relatives.  What now?  Most pediatricians recommend a 1-2 week checkup visit to see how you and the baby are doing.  The transition to the "real world" can be quite dramatic for the new little one.  Perhaps the most important new job for the baby is feeding.  In the uterus, food was delivered through the umbilical cord.  But now, the infant must feed about every 3 hours and feeding for an infant is hard work.  An infant suckling for 20 minutes is like an adult running several miles... it can be difficult and exhausting.  It is the pediatrician's job to see that your baby is meeting her fluid and calorie needs.

Development History

Social - Infants at this age aren't exactly "social butterflies."  It is normal for an infant at this age to seem indifferent to the surroundings.

Communication - The infant should turn towards a soft voice.  Parent's voices should have a calming effect.  Crying is the infant's only means of communication... therefore crying may indicate hunger, fear, discomfort, pain, sleepiness, or irritability.

Cognitive - The infant should start "fixing" the eyes on faces or toys briefly.  Objects moved into the infant's view should catch the infant's attention but the infant probably won't follow the object out of the visual field.

Motor skills - Infants should have the primitive reflexes:

• Suck reflex - An infant should be able to suck vigorously.  You can test this by placing a clean finger in the infants mouth or pulling away a pacifier.  The suction should be strong. 
• Rooting reflex - Brushing a finger or pacifier on the infant's check should cause the infant to turn toward the object and attempt to suck.
• Palmar grasp reflex - Placing a finger or object in the infant's hand should cause the hand to close in a tight grasp.  Interestingly, this reflex occurs with the feet also.  The foot will attempt to curl around objects that brush against the sole.
• Moro reflex - This is the "startle reflex."  The infant with spread out the arms and shake in response to sudden noises or when your doctor lifts the infant (while she is on her back) by the arms and lets go.  (Obviously, this test should be done over a soft surface and the infant should not be "dropped" more than an inch.)
• Stepping reflex - If the infant is held under the arms and the tops of the feet are brushed against a bed or table, the infant will bend the knees and appear to be trying to step up.

Physical exam

Measurements - Height, weight, and head circumference should be measured and compared to normal values on a growth chart.  Many major medical problems present with growth delay.

Skin - Are there rashes or jaundice (yellow skin color)? Is the skin pink and warm?  It should be.  Jaundice is very common at this age and is most often harmless.  However, jaundice may indicate poor feeding, infection, or dehydration and this should be evaluated by your doctor.

Head - Is the fontanel soft and flat?  Does the infant still have a narrow-shaped head (molding) from birth.  The infant's head should begin to take a normal appearance.  Is there swelling on the head?  This can be due to bruising (cephalohematoma) or edema (caput succedaneum) from the birth process.

Eyes - Do the eyes move in all directions?  They should.  Do the pupils shrink in response to light?  They should.  Do the eyes move together? They should.  Do the pupils both shrink and dilate at the same time?  They should.  Is the pupil clear and does light cause a "red light reflex" when shined through the pupil onto the back part of the eye (retina)?

Heart - Are there any heart murmurs?  The normal heart murmurs that all infants are born with should now be gone.  However, it is not uncommon for infants to have mild murmurs due to normal blood flow through the heart and blood vessels.  Only your doctor can tell the difference between safe and abnormal murmurs.  Are the pulses in the legs and arms strong?  Abnormal leg pulses (femoral pulses) may indicate a narrowing of a major blood vessel (such as coarctation of the aorta).

Abdomen - Is the umbilical cord stump healing?  The umbilical cord remnant should fall off by a few weeks of age.  Is the belly soft?  It should be.  Are the liver and spleen the normal size?  The edges of the liver and spleen can normally be felt as far as about 2 cm below the rib cage edge.

Muscles and bones - Are the hip joints too loose?  This may represent congenital hip dysplasia.

Neurologic - Is the infant active when awake?  Are there any abnormal movements?  Does the infant have normal strength and tone?

Metabolic screen

Have the newborn metabolic screen results returned yet?  This may take several weeks in some states. 

Hearing test

This is most often performed in the newborn nursery.  Was this done?

Parent sanity check

Okay, I know, it's the baby we pediatricians should be worried about.  But it is actually very important for newborns (and all children) to have parents that are not overly stressed out.  Bringing home a newborn infant can be a stressful event.  And post-partum depression is REAL. 

The "baby blues"

It is normal for new parents to feel uncertain or overwhelmed with the brith of a new baby.  Many mothers feel exhausted after the birth of a child.  Poor sleep due to frequent infant feedings only makes the feeling of tiredness worse.  It is important for new parents to get as much sleep as possible.  Parents should try to sleep when the baby sleeps.  Two-parent homes should take shifts when possible.  Breastfeeding mother's may wish to pump breast milk to allow the father to give some of the feedings.  If a parent has significant episodes of sadness or desperation, he/she should seek medical care as soon as possible.

Safe sleeping

According to the American Academy of Pediatrics...

"Place babies to sleep on their backs to reduce the risk of SIDS. Side sleeping is not as safe as back sleeping and is not advised." 

See article on safe sleeping for infants...

Daily routines

Parents should attempt to maintain a regular schedule as much as possible.  Feedings should occur about every 3 hours.  Infants who are fed too frequently may only partially fill their stomachs or the infant's stomach may not be empty from the previous feed. 

Sleep times for your infant should be scheduled as much as possible.  The infant should be placed in a safe crib in a quiet environment.  The infant should be placed on her back and in the same crib (if possible).  Changing sleep locations may disrupt the infant's sleep pattern.

Feeding

Infants at this age should feed every 2-4 hours.  The average infant at this age will take between 15 - 20 ounces of milk per day.  It is difficult to know how much milk a breastfed baby is taking.  Clues that the baby is getting enough milk include:

• Wet diapers occur at least every 4 hours
• Good weight gain
• The baby is alert and active when she is awake
• The fontanel is soft and flat
• The skin is soft, smooth and pink
• The infant seems satified after feeding
• Breast milk leaks from the opposite breast during feeds
• Breast milk is visible around the baby's lips
• Swallowing sounds can be heard during feeding
• Milk can be heard in the baby's belly after a feed (don't shake your baby to find out!)
• Mild occasional spit ups reveal milk in the spit up material
• A pediatrician can use a scale to weigh the infant before and after feedings (a very accurate scale is required)
• Limited or no jaundice

Wet diapers

Your infant should have a wet diaper at least every 4-6 hours.  More frequently is okay!  Urine should have limited or no smell, a light yellow or clear color, and no blood. 

Note - a small amount of orange coloration on the diaper at the site of urination may be due to uric acid crystals, which are normal.  The presence of uric acid crystals may indicate your infant is not drinking enough so check with your doctor.

Stools

• There is a wide variation in what is considered normal frequency of dirty diapers.  Some infants have a stool only once every few days.  Others may have 10 small stools a day. 
• At 1-2 weeks of age an infant's stools should be yellow, loose and seedy.  The "seeds" are clumps of stool debris.
• There should be no blood in the stools and stools should not be pale (gray or white).

Vaccines

If your baby did not receive the first hepatitis B vaccine in the newborn nursery it should be given now. 

The CDC vaccine schedule can be viewed here.  CDC Vaccine Schedule.

Safety and preventative care

Your doctor should answer any questions you have regarding car safety seats, cribs, tobacco smoke, bathing, toy safety, etc. 

Most pediatricians while provide the family with a "when to call the doctor" checklist.  In general, you should call your doctor for any concerns or questions.  You should always call your doctor for:

• Poor feeding
• Difficult to arouse
• Blood in stools or spit up material
• Persistent spit ups
• Weight loss
• Fever
• Excessive crying

References

Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics, 16th Edition. Philadelphia: W. B. Saunders. 2000.

Hagan JF, Shaw JS, Duncan PM, eds. 2008 Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics.

Healthy child care by the Center for Disease Control, http://www.healthychildcare.org/pdf/SIDSparentsafesleep.pdf, accessed Sept. 24, 2010.

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