We recognize that your decision to go home early may be based on many considerations including your personal preference, your personal finances, your insurance company’s decision to limit payment for uncomplicated deliveries, and your obstetrician’s determination that you personally are doing well. Discharge at 24 hours has become more routine. However, the transition from the protected environment that your infant knew while inside your body to the outside world is a process that will not be complete for several days.

The first three to five days of life are most critical. Many heart murmurs cannot be heard until the third or fourth day. Jaundice may occur early or late. Certain infections show no signs or symptoms until the infant is three to four days old. Therefore, in order to more closely observe newborn infants, we recommend that his/her hospital stay be at least two days. This also gives you an opportunity to rest, relax, and quietly “get to know” your new child.

The latest guidelines for Perinatal Care, written by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, states that there is “an element of medical risk” in the early discharge (less than 48 hours) of a newborn. We feel that it is important for you to be aware of this risk in making an informed decision to take your baby home early.

Should you choose to request discharge prior to 48 hours, nurses in the nursery will no longer be monitoring your infant and you will have to assess your infant for complications that can arise during the first few days. We, along with the nurses at the hospital, will try to provide you with the information you need to care for your newborn infant during this critical period. In addition, we want to see your baby in the office
48 to 72 hours after discharge. Please call (480) 839-9097 to make the appointment.

Many babies sleep a lot for the first 24 hours after birth and begin to awaken and become more alert by the third day. Their appetite increases about the same time and by the third day most infants are eating 6-8 times in a 24 hour period. Breast fed infants may nurse more often. If your baby does not appear to be interested in eating at least 6 times a day or if you are changing less than 6 wet diapers a day, please call.

Prior to discharge your infant has urinated and had a bowel movement, so we know that the “plumbing” is working. You will see approximately 6 wet diapers in a 24 hour day. By the third day, you will see more than one and as many as 10-12 bowel movements a day. Initially these will be dark, greenish black, and thick, but they will become more yellow, watery and runny by the third day.

Jaundice (a yellow color of the skin, or the whites of the eyes) is common in newborns. It usually peaks on the 3rd or 4th day of life. It is caused by the breakdown of extra red blood cells that are no longer necessary. Part of these broken down cells become bilirubin, a yellow compound that causes the yellow color. Usually there is no problem. However, certain illnesses can occur that increase the breakdown of red blood cells or that interfere with the breakdown of bilirubin by the baby’s liver. Even without such problems, the level of bilirubin can rise to harmful levels. This is one reason that we want to see your child in the office 48 to 72 hours after discharge. If his/her color looks yellow to you in the meantime, please call. We may need to see him/her earlier.

If your infant is a boy and has been circumcised, you will see the head of the penis somewhat red and swollen until healing is complete. However, if there is a large amount of bleeding from the circumcision that occurs after you are home, or if the entire penis looks red and swollen, please call.
It is normal for the hands and feet of newborns to look blue at times and to feel cool to the touch. However, if you notice a persistent blue color around the lips, please call the office.

Many infants have rashes over the first few weeks of life. The most common rash looks like little red raised bumps similar to “flea bites”. Sometimes it will be blotchy, with a little whitish or yellowish head. This is normal, and will go away within a few days or a week or so. However, rashes that look like a blister and appear to be filled with fluid may not be normal. If your infant develops a blistering rash, please call.

Most problems that occur during the transition period produce similar symptoms. These are:

• Fast breathing (over 60 times per minute when sleeping)
• Poor color (pale or bluish color)
• “Grunting” sound with each breath
• Poor feeding
• Weak cry
• Fever (over 100.5 °F) or low temperature
• Poor muscle tone – “floppy”
• Irritability or unable to get comfortable

If you notice any of the above with your infant, call or bring your infant back to the hospital for immediate evaluation.

As infants make the transition from intrauterine life to extrauterine life, many changes occur. Most of the time this happens without difficulty but problems with your child’s adjustment or transition can produce the symptoms listed above. The three major areas in which problems occur are infection, metabolic abnormalities, and circulation/breathing.

At birth, the flow of blood through the heart and lungs changes dramatically. Occasionally, an infant is born with a structural defect of the heart that causes no problem during the pregnancy but major difficulties after birth. Sometimes these defects are not apparent until the baby is several days old. If problems develop, the signs are usually rapid breathing, poor color, poor feeding, and persistent fussiness. If any of these occur, call us, or bring your infant back to the hospital.

Newborns are very susceptible to severe infection. The birth process is stressful and presents many opportunities for infection to occur. These infections can be in the skin, the lungs, the gastrointestinal tract, the coverings of the brain or directly in the blood. Infection in a newborn rarely presents with a fever. Usually the temperature is low – 96°F or lower rectally. Once established, an infection can spread very rapidly in an infant. The signs and symptoms described above, such as poor color and tone, decreased activity, fussiness, and change in breathing patterns can all be seen with an infection. If you think that your child may have a serious infection, take him/her immediately back to the hospital for evaluation.

During pregnancy, the placenta maintains normal levels of many chemicals in the body. After birth, the infant must do this alone. Rarely, infants have “inborn errors of metabolism” which usually means the absence of an enzyme which interferes with normal chemical processes and allows the build up of toxic chemicals. This may result in extremely poor responsiveness, like a coma, or the opposite, extreme irritability or convulsions. Any of the symptoms mentioned earlier may occur. These problems are rarely even suspected on the first day of life since toxins have not had time to accumulate. If you feel your infant might be having any of these problems, please bring him/her back to the hospital or to the office for evaluation.

It is very important to get as much rest as possible and to relax and enjoy your new baby. Do not have visitors, if possible; but if you do, do not let them hold and handle your infant. Tired, overstimulated and stressed infants can behave like the sick infants described above.

Call as soon possible to make the follow up appointment (between 8:00 A.M. and 5:00 P.M. Monday through Friday). If your newborn shows the pattern of signs and symptoms described above, call immediately, or bring your infant back to the hospital for evaluation.

Circumcision is the removal of the loose skin (foreskin) over the end of the penis. In the United States today, most of the male population is circumcised. However, in Europe and most parts of Asia, circumcised males are a minority. Circumcision is the result of religious tradition which has become a social tradition as well.

There are many reasons why parents may wish to have their son circumcised. The most frequently cited is so the boy will “look like his father.” Some feel that a circumcised penis is easier to keep clean (and it is), but in an industrialized Western society that encourages bathing and cleanliness, this is not a major cause for concern. There are studies that have shown a lower incidence of urinary tract infection and a rare penile cancer in circumcised males.

Circumcision is a surgical procedure and complications can occur. They are extremely rare. Complications include excessive bleeding, loss of the skin of the penis, loss of the skin of the scrotum, damage to the head of the penis, damage to the urethra (the tube that carries the urine from the bladder to the outside) and painful scars. Very rarely, infection can arise in the circumcision site resulting in overwhelming illness and death.

If your child has been circumcised, there is little in the way of special care that is required. An antibiotic ointment or Vaseline applied to the head of the penis for the first four or five days will prevent the penis from sticking to the front of the diaper and causing pain. A very small amount of blood staining is sometimes seen on the diaper and is no cause for concern.

For those who have not had their male children circumcised, do not attempt to retract the child’s foreskin. It is not necessary and can be harmful at this age.

Jaundice is the name given to a yellow discoloration of the skin and eye that occurs in infants, children, and adults. This coloration is caused by an excess amount of bilirubin (pronounced billy-roo-bin) in the skin and blood. Bilirubin is a yellow pigment and is normally found in small amounts in everyone’s body.

Bilirubin is created and released when red blood cells have broken down (red cells live about 120 days). Most babies have an excess of red blood cells at birth, and it is natural for the baby’s body to break down these excess cells. As more cells are destroyed, more bilirubin is created and eventually, unless it is excreted from the body, the level builds up and the skin assumes a yellow color. In older children and adults, this bilirubin is easily passed through the liver where it is processed and excreted from the body. In newborn infants, however, organs such as the liver are not fully developed, and processes are still active that result in an increased amount of bilirubin being recirculated to the liver. Both the immature liver, and the recirculation of bilirubin result in increased levels of bilirubin in the blood of most infants.

Occasionally there are other factors which will cause the baby’s red blood cells to break down more rapidly. The two most common conditions are called ABO incompatibility and Rh incompatibility. If the jaundice in your child is caused by either of these conditions, we will discuss it with you in more detail. Jaundice is usually seen around the second or third day of life. With some babies going home at less than forty eight hours of age, it is possible the jaundice will not show up prior to discharge. Therefore, if your infant leaves the hospital prior to forty eight hours of age, we will suggest that he/she be seen again at three to four days of age. If your baby should get very yellow or orange prior to or after his/her first office visit, call us.

The most common treatment for jaundice is with phototherapy lights or a “bili blanket”. The phototherapy light consists of a series of special fluorescent lights that are placed over the baby’s crib or basinette. The light results in a chemical reaction in the skin, which breaks down the bilirubin (photodecomposition). The broken down bilirubin is excreted by both the liver and kidneys. This light is generally used for several days depending on the results of the laboratory tests. During this time that he/she is under the light, his/her eyes will be covered with a mask to prevent eye damage from the bright light (this is not necessary with the bili blanket). His/her position will be changed frequently to assure that all areas are exposed to the light as much as possible.

Contrary to the well-intentioned suggestion of some, do not place your infant in sunlight in an attempt to bring down the bilirubin. Direct sunlight can quickly sunburn; sunlight filtered through glass still contains considerable amount of infrared and may seriously over heat your baby. There is no safe yet effective method of using sunlight to bring down the level of bilirubin. However, feeding breast milk or formula frequently is beneficial and highly recommended. Unfortunately, feeding water or glucose water is not helpful and there is very good evidence that water or glucose water feedings actually make the bilirubin level higher.

The phototherapy lights are well tolerated. Some children become fussy because they miss being wrapped up in their blankets, and others sleep contentedly. Occasionally, they will develop a skin rash which is temporary, and rarely will develop a greenish cast to the skin. Stools often become more frequent (this increases the excretion of the bilirubin) and become green in color.

Occasionally, readmission to the hospital is necessary to treat jaundice effectively. Very rarely, treatments in addition to phototherapy are indicated. If your child has a level of bilirubin that warrants consideration of other treatments, we will discuss them with you in detail.