24.2: Basic Newborn Care
By the end of this section, you will be able to:
- Identify universal care items for the newborn
- Describe successful infant feeding along with the preparation and storage of both formula and breast milk
- Describe the expected voiding and stooling pattern of a newborn, including that of a breast-fed newborn and a formula-fed newborn
- Discuss circumcision care in the newborn and when to notify the physician if a problem occurs
A nurse’s responsibility in any scenario is multifaceted. In caring for the birthing parent and newborn after birth, basic newborn care is a priority. At this time, new families are experiencing a myriad of emotions. They are thrilled and excited, exhausted and exhilarated, anxious and confident all at the same time. What they want and need is gentle, reassuring guidance from their nurse, informing them that their feelings are perfectly normal and what they are doing is perfectly fine. The nurse can let the parents know that because their voices were audible to the fetus in utero, their baby learned to recognize them in the third trimester (Yale University, 2018). Therefore, after birth, newborns can recognize the parents’ voices and those of siblings and other family members, depending on prenatal exposure. Information such as this helps to promote parental bonding and ease anxiety for new parents. Research also shows that as early as 1 week after birth, some newborns will turn their head toward a voice that they recognize to seek it out and will even recognize it in another room (Yale University, 2018). Therefore, parents should keep holding their baby close and talking softly to them.
Safety questions will arise regarding prevention of newborn injury and timing of immunizations. Umbilical cord care and care of the circumcised and/or uncircumcised penis will also present as points for communication and education with the family. Probably foremost in the minds of parents is the issue of feeding because this comes up in the delivery room almost immediately after giving birth. Both breast-feeding and bottle-feeding mothers need assistance and teaching. The topic of what is normal for bowel movements for breast-fed and bottle-fed infants is another related topic. There is much for the maternal-newborn nurse to understand and to be able to teach the new parent about the basic care of the newborn.
Protective Environment and Universal Well Newborn Care
Immediately after birth, the nurse is responsible for essential newborn care, beginning with thorough drying. The baby’s breathing is assessed after birth, and an Apgar score is assigned, usually by the nurse or by the provider who oversees the delivery. As part of the Apgar score, breathing and heart rate are assessed and, if needed, resuscitation is begun. (For an explanation of Apgar scores, see Chapter 22 Immediate Care of the Newborn.)
The primary goal of care immediately after birth is to assist the newborn in their transition to extrauterine life by establishing effective respirations. If the baby appears stable, skin-to-skin contact with the birthing parent is initiated, and breast-feeding or chest-feeding, when feasible and desired, is begun. The newborn is wet with amniotic fluid, blood, and body fluids, so temperature regulation is also a priority, and protection from heat loss is essential. The nurse dries the infant thoroughly, removing all wet linen, and covers the newborn with warm, dry linen while the baby remains skin-to-skin or in the parent’s arms. Research (Mardini et al., 2020) shows that delaying the baby’s first bath, in addition to preventing hypothermia while maintaining body heat, is one way to protect the infant from infection. At birth, babies often have a white substance called vernix on their skin, which is made up of skin cells from earlier in development (Figure 24.2). Vernix helps to fight against bacterial infections such as those caused by group B streptococcus and Escherichia coli (E. coli ), which can lead to pneumonia and meningitis . Vernix also helps to stabilize the baby’s blood sugar levels by preventing the production of stress hormones in response to bathing too early. Delaying the first bath also provides more time for parents and baby to bond without interruption, which in turn promotes and supports a better start to breast-feeding.
Before bathing, infants are covered in amniotic and maternal bodily fluids, as noted previously. Medical staff could risk infection by any number of viruses and infections through exposure to these fluids. By following universal precautions, the medical staff protect themselves and ensure a healthy and protective environment for the baby. Universal precautions will continue to be used for both the birthing parent and baby, even after the baby’s first bath.
Newborn screening begins at 24 to 48 hours after birth, while they are still hospitalized. All babies in the United States get newborn screening after birth, with approximately 4 million babies being screened each year (U.S. Department of Health and Human Services, 2021b). Several drops of blood are obtained from a heel stick , and the blood is sent to a laboratory, where it is analyzed for biochemical and genetic markers indicative of hidden congenital disorders. If markers are found, follow-up programs exist so that the baby can receive immediate medical attention and services to minimize the effects of the underlying disorder, which may be entirely asymptomatic at this point.
Newborn screening consists of three essential components:
- Blood test: The primary element of newborn screening involves a blood test to detect uncommon yet severe health issues. These conditions, such as PKU (phenylketonuria) , are rare and are mostly treatable. The nurse or other health-care provider will prick the baby’s heel to obtain a small blood sample, which is then collected on specialized paper and dispatched to a laboratory for analysis. Typically, the results are available by the time the baby reaches 5 to 7 days of age. If parents are curious about the need for newborn screening, the nurse can provide the example of PKU, which is treatable but, if not diagnosed early, leads to severe cognitive impairment.
- Hearing screening: This examination aims to evaluate the baby’s hearing capabilities and to identify potential hearing loss. Specialized computer equipment assesses the baby’s response to auditory stimuli. If the initial results show no response, more in-depth hearing evaluations are done later in coordination with the primary care provider.
- Heart screening: This screening is intended to identify specific heart conditions referred to as critical congenital heart defect s (also known as critical CHDs or CCHDs). It employs pulse oximetry, which measures the oxygen levels in the baby’s blood using a pulse oximeter machine and sensors placed on the baby’s skin.
To learn more about Critical Congenital Heart Defects Screening Methods available, see the algorithm and explanations of results at the Centers for Disease Control and Prevention (CDC) website.
All newborns in the United States get newborn screening, but the specific requirements differ from state to state. Some states require that babies have newborn screening for a second time at about 1 to 2 weeks after their first screening.
The National Newborn Screening and Genetics Resource Center (NNSGRC) lists conditions screened in newborns by U.S. states and territories.
Preventing Infant Abduction
Safety is an essential component of nursing instructions to new parents and is always a primary concern. The nurse is responsible for identifying the infant, even in emergent situations, at the time of delivery (even in the operating room, or OR), before the baby is removed from the room or taken to the nursery. This will occur even if the baby is transported to the neonatal intensive care unit (NICU). Identifying the newborn consists of placing two identification (ID) bands on the baby, usually one on each ankle, and one on the birthing parent’s wrist at the time of birth. Exact placement of ID bands is dictated by hospital policy. The ID bands contain the following information: sex, date and time of birth, parent’s last name, and doctor or midwife (Figure 24.3). An electronic security device with an imprinted number is placed on the infant, usually on the ankle. This device has the same identifying numbers as the other ID bands on the infant and parent, and it will sound an alarm at any of the unit exits for additional security. The device will be removed by the nurse at the time of discharge. Other methods for identifying the infant include footprints, usually taken at the time of delivery, along with the birthing parent’s fingerprint.
Hospitals around the world are prepared to protect against infant abductions by using security systems. This requires that special tamper-detecting bands are placed on the infant, usually on an ankle, but sometimes on the cord clamp, depending on the manufacturer. These bands have a number, which matches a band placed on the parents of the infant. All hospital staff are instructed to check the ID bands for matching numbers prior to leaving the baby with the parents. All parents are directed not to leave the baby with anyone who does not have a hospital picture ID. The security ID band will sound an alarm when the infant is brought within a certain distance of any of the unit exits. When this happens, all exits lock immediately; security cameras activate on the unit, in stairwells, and at all exits. In addition, an immediate search to account for all newborns on the unit is undertaken by nursing staff and security. When parents are discharged to home with their baby, the ID bands are removed by the nurse with a special tool so that alarms do not sound when babies leave the unit.
Common hospital safety instructions to parents include the following:
- Never release your baby to anyone who does not have a hospital picture ID badge.
- If you see anyone acting suspiciously on the unit, report them to the nursing staff or call hospital security with the phone in your room.
- Never leave your baby unattended in your room. You can take your baby’s crib into the bathroom with you or in the hallway with you.
- If you are going to take a nap, ask the nurses to take your baby to the nursery if a family member is not in the room with you.
- When the baby is in the room with you, position the crib on the side of your bed furthest and opposite from the door.
- Do not sleep with the baby in the bed with you. Do not let your partner sleep with the baby in the bed with them.
- Do not leave the infant alone on the bed or propped up on a pillow or with pillows.
- Do not prop up the baby with a bottle of formula for feeding.
- Do not leave your baby unattended in the arms of a child or sibling.
- In the hospital and during your early weeks at home, wash your hands before handling your newborn. Your newborn is particularly susceptible to infection.
Immunizations
An immunization is the process by which someone becomes protected against a disease through injections into the skin, nasal spray, or by mouth. The term can be used interchangeably with vaccination or inoculation . The Centers for Disease Control and Prevention (CDC, 2023b) and the American Academy of Pediatrics (AAP; 2023c) work together each year to recommend the same carefully planned childhood vaccine schedule to protect infants and children from vaccine-preventable diseases. Newborns receive their first vaccine shortly after birth, often while still in the hospital. They will be given several vaccines during their first months. Following the recommended vaccine schedule in the first months and years of life will keep them on track for life-long immunity to childhood diseases. See Figure 24.4 for the current vaccine schedule from birth to 15 months of life.
The hepatitis B vaccine is the first vaccine the baby will receive, most likely within the first 24 hours of life. The vaccination will be held and provided later if the newborn weighs less than 2 kg (4.4 lb). They will receive a second dose of the hepatitis B vaccine during their 2-month well-baby checkup and a third dose at 4 or 6 months to complete the three-dose vaccination series. Hepatitis B infection can cause slow, persistent liver damage in a child. The virus is found in the blood and body fluids and can last on a surface for up to a month. This vaccine is recommended for all babies to protect against infection, which can lead to complications such as chronic liver disease, liver cancer, and even death (CDC, 2023b).
The Vaccine Information Sheet for the hepatitis B vaccine should be given to new parents to read before their baby receives the vaccine.
Nurses should share important facts with parents regarding vaccinations and prevention of diseases. These medications go through rigorous safety testing before they are introduced to the public, and they are constantly being monitored for side effects after they are introduced. Vaccines may cause mild side effects that will not last long. After the infant receives a vaccine, the site may be sore for a day or two, or the infant may be irritable, but vaccination is one of the most important things parents can do to protect their children against serious and preventable illness.
Parents consider their health-care provider and staff, particularly nurses, to be the most trusted source of information when it comes to the health of their newborns and vaccine information (U.S. Department of Health and Human Services, 2021c). When discussing vaccines with parents, it is important to assume that they plan to vaccinate their newborns. Discuss the vaccine schedule and which vaccines the baby is due to receive as if you presume the parents are ready to accept the recommended vaccines for their child during that visit. For example, rather than saying “Have you decided what you want to do about your baby’s shots today?” say “Your child’s DTaP, Hib, and Hepatitis B vaccinations are scheduled today.” Research shows that more parents accept vaccines for their children, especially when offered the first time, when care providers take a presumptive approach in discussions (U.S. Department of Health and Human Services, 2021c).
The CDC’s recommended vaccine schedule for children and adolescents ages 18 years and younger is updated often and should be referred to prior to any vaccination plan.
If parents express vaccine concerns, then providers should share their strong recommendation. Because the opinion of doctors and nurses is consistently valued highly, responses such as “This office strongly recommends that your child get these vaccines today” or “I strongly believe in following this vaccine recommendation and have vaccinated my own children with these vaccines at the same age” can be persuasive. You can also say, “Vaccines are very important to protect children from serious diseases.” When parents have vaccine-related concerns, the nurse should show their willingness to listen. This will play a major role in building a foundation of trust in you and your strong recommendations. Answer all their questions to the best of your ability.
Parents have the right to refuse vaccinations, and it is not appropriate for the nurse to argue with them. Try to end the conversation at that visit on a positive note. Continue the conversation about vaccines during the next visit and restate your strong recommendation. Discuss with the parents some clinical examples of vaccine-preventable diseases, including early symptoms of such diseases. Remind parents that if the child remains unvaccinated, they will need to call the office, clinic, or emergency department before visiting so that arrangements can be made to prevent contact with other patients who may be too young to be vaccinated or who may have weakened immune systems. Some providers have parents sign “ AAP ’s Refusal to Vaccinate” form (see the following Link to Learning) each time a vaccine is refused, to have a record of the refusal in the child’s medical record. Because a parent has refused a vaccine once does not mean that they will refuse every vaccine. Continue the conversation with vaccine-hesitant parents. Encourage them to read information that you provide them and continue to remind them about the importance of keeping their child up to date on vaccines during future visits.
Many pediatric providers have parents sign the AAP’s form Documenting Parental Refusal to Have Their Children Vaccinated for each vaccination refused.
Umbilical Cord Care
During pregnancy, the umbilical cord supplies the developing fetus with nutrients and oxygen. After birth, the umbilical cord is no longer needed, so it is clamped and cut, leaving a short stump and a clamp. The clamp is removed when the cord stump dries out and before the baby leaves the hospital. The umbilical cord stump will eventually dry up and fall off, usually within 1 to 3 weeks after birth. In the meantime, parents need to be taught how to care for the umbilical cord stump at home. Keeping the cord stump and surrounding skin clean and dry, which prevents infection and helps the stump to fall off and the navel to heal more quickly, is called cord care .
QSEN Competency: Patient-Centered Care: Parental Instructions for Umbilical Cord Care
Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient's preferences, values, and needs.
Knowledge: Describe strategies to empower patients or families in all aspects of the health-care process.
Skill: Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management.
Do not pull the stump off, even if it appears to be hanging on. Let the cord fall off naturally.
- Sponge bathe the baby. No tub baths until the cord has fallen off on its own.
- Keep the stump dry. Expose to air to help the cord dry at the base and separate.
- Fold down the front of the baby’s diaper to avoid covering the stump. If the stump gets soiled between diaper changes, wash with gauze and water only and air dry.
-
Watch for signs of a local infection at the stump site:
- foul-smelling, yellow drainage from the stump
- redness, swelling, or tenderness of the skin around the stump
- oozing pus
- development of a pink, moist bump in the surrounding area
-
Be aware of more serious signs of infection:
- poor feeding
- fever of 100.4° F (38° C) or higher
- lethargy
- floppy, poor muscle tone
- When healing, the cord may scab at the stump, and it may bleed a little when it falls off. Both are normal. Any continuous oozing of blood is not normal, and the baby’s health-care provider should be notified.
- Sometimes instead of completely drying, the cord forms a pink scar tissue called a granuloma, or the granuloma drains a light-yellowish fluid. This will usually go away on its own in about a week. If it does not, the baby’s health-care provider should be notified.
- If the stump has NOT fallen off in 3 weeks, call the baby’s health-care provider. This may be an indication of a problem such as an infection or an immune system disorder.
(Pruthi, 2023)
Knowledge: Value active partnerships with patients or designated surrogates in planning, implementation, and evaluation of care.
Umbilical Cord Problems
The umbilical cord should dry and fall off between 10 days and 2 weeks after birth. Parents may notice a few drops of serous drainage or blood on the diaper around the time that the umbilical stump falls off. This is normal. If at any time the umbilical cord or stump is actively bleeding, parents should be instructed to call their health-care provider immediately, as it will require medical treatment. Cord infections are uncommon, but if caregivers notice any of the following, they should notify their health-care provider:
- foul-smelling yellowish discharge from the cord or stump
- red skin around the base of the stump
- crying when the cord or the skin around it is touched
Feeding the Newborn
The newborn period is a time of great nutritional need, greater than any other time in a person’s life. The infant will be entering a time of exponential growth and maturation in the upcoming year and will need the best nutritional composition and health-promoting feedings possible to support and sustain them. Breast milk, or human milk, is the ideal food for human infants (American Academy of Pediatrics [AAP], 2021c). For those birthing parents who cannot or do not wish to breast-feed their newborns, infant formula is an acceptable and nutritious alternative to breast milk (AAP, 2021c). Most commercially prepared infant formulas are based on cow’s milk and have been modified to closely resemble the nutritional composition of human milk. Both provide 20 kcal/ounce (30 mL) but vary in other metrics of nutritional content.
Formula-Feeding
Parents and the infant’s health-care provider will need to pay attention to the baby’s pattern of feedings to make sure they are getting enough to eat and are growing properly. Regular checkups and growth monitoring are the best way to do this. Formula provides parents with an option to supplement maternal breast milk, as an additional feeding method for the newborn if they desire. It allows others the opportunity to feed the newborn and provides the nursing parent with respite from breast-feeding. Formula can be prepared ahead of time and can remain in a refrigerator for up to 48 hours. If an infant is fed formula exclusively, there is no need for maternal breast pumping or emptying if breast-feeding is missed. When formula-feeding, bottles, nipples, and clean water will be needed, as will a place to store the equipment. If the caregiver is traveling, they will need to make bottles in advance. Formula can be fed at room temperature, but it depends on what the individual infant is used to. Pacifiers may be introduced immediately after the baby is born, which will provide nonnutritive sucking, decrease the risk of sudden infant death syndrome (SIDS), and provide comfort to the crying baby.
Formula Characteristics
Infant formula is easily accessible for purchase in the United States in pharmacies, grocery stores, warehouse clubs, and via the Internet. One can purchase ready-to-use formula in bottles or in cans, and concentrated formula is also available in liquid or powdered form. Concentrated liquid formula requires water to be added to it before it can be fed to the baby. Powdered formula, also referred to as dry formula, must also be mixed with water before feeding it to the baby. The scoop that comes with the formula must be used to measure the right amount of powder. Then, the powder must be mixed with the correct amount of water.
No brand of formula is best for all babies, and not all babies have the same nutritional needs. The U.S. Food and Drug Administration ( FDA ) regulates commercial infant formulas to make sure formulas meet minimum nutritional and safety requirements. The CDC and the AAP strongly recommend using only infant formulas purchased in the United States and those that are iron-fortified (CDC, 2022b; AAP, 2021c). Enfamil, Similac, and Gerber’s Good Start are three common formula brand names found in the United States, each offering many different varieties to meet the individual nutritional needs of normal newborns as well as premature, special, or prescription formulas.
Parents can work with their infant’s health-care provider to determine if these or other formulas are best for their baby. When they find a formula that their baby tolerates well, it is best to use that brand only, without switching between brands. Parents should notify their baby’s health-care provider if the baby develops gas, a rash, diarrhea, or vomiting. These may be signs that the formula is not right for their baby and that they may have to change to another. This should be done with the guidance of the health-care provider. Their baby may have developed an allergy to one of the ingredients of the formula. Neither homemade infant formulas nor formulas from outside the United States are recommended by the CDC or the AAP because these formulas are not regulated by the FDA, and their ingredients may not be trustworthy. These formulas also do not usually contain iron. Both homemade and foreign formulas have an increased risk of contamination, and thus are more likely to make babies ill with infection.
There are three kinds of infant formula (AAP, 2022b; March of Dimes, 2019):
- Ready-to-use liquid formula . This formula is ready for infant consumption and can be poured directly into the baby’s bottle. This is the “no-mix, no-measuring, no-fuss” method, but it is also the costliest.
- Concentrated liquid formula . This formula requires the addition of water, according to specific directions on the container before it can be fed to the baby. This is the “just add water and shake” option for formula. All brands of concentrate call for equal amounts of water and concentrate to reduce error in preparation (AAP, 2022b). To make 4 ounces of prepared formula, you will need to mix 2 fluid ounces of concentrate with 2 fluid ounces of water . Concentrated formula is not as costly as ready-to-feed formula but is more costly than powdered formula. Once mixed, this formula can be refrigerated for up to 48 hours.
- Powdered formula (may also be referred to as dry formula). Most powdered formulas need to be used within 1 month of opening the container (check label). Once a container has been opened, write the date on the lid as a reminder. Never use formula after the “use by” date on the container.
Once mixed, formula needs to be used within 1 hour from the start of feeding and within 2 hours of preparation (AAP, 2022b; March of Dimes, 2019). If it is not going to be used within 2 hours, immediately store it in the refrigerator for up to 48 hours (AAP, 2022b). Any formula left in the bottle after a feeding should be discarded. The combination of formula and infant’s saliva can cause bacteria to grow; therefore, “leftovers” should not be refrigerated or saved for another feeding.
Safe Preparation of Formula in the Hospital
In the United States, most hospitals use ready-to-feed formula when feeding infants. This formula requires no preparation, no unique storage, and is, as its name implies, “ready-to-feed.” Infant formula is frequently supplied to hospitals and birthing centers free of charge by formula companies. This is a form of advertisement and promotion of their products to new parents. Care providers make the final decision about what formula an infant will receive while in the hospital, regardless of what formula has been donated or purchased.
When an infant requires special formula—for example, lactose-free, hypoallergenic, or high-iron—the nurse may need to mix it from a powdered formula if it is not available in ready-to-feed bottles. If that is the case, hospitals strictly follow the protocol for mixing powdered formula, using sterilized (disposable) bottles and nipples as well as bottles of sterilized water. Bottles are filled with the correct amount of water before adding the powdered formula. An incorrect amount of water mixed with formula can be harmful to the infant. Formula mixed from powder must be disposed of within 1 hour of the start of the feeding. It can be stored in the refrigerator for only 24 hours after being mixed; therefore, bottles are marked with the name, date, and time before being refrigerated. Families that do not have access to clean running water or electricity must have alternative ways to safely mix and store formula.
Competency: Safety: Preparing Powdered Infant Formula
Definition: The preparation minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Knowledge: Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as workarounds and dangerous abbreviations).
Skill: Use appropriate strategies to reduce reliance on memory (such as forcing functions, checklists).
| Step 1 | Make sure the container is not expired and is in good condition (no dents, puffy ends, or rust spots). Ensure that the container is labeled for infants, not toddlers. Toddler formulas are not safe for infants until they are 1 year of age. Store unopened formula containers in a cool, dry, indoor location—not in vehicles, garages, or outdoors. |
| Step 2 | Clean the countertops and wash hands with soap and warm water before preparing bottles. Use a clean bottle and nipple. |
| Step 3 | Use water from a safe source to mix with the formula. Tap water is usually safe but contact the local health department if unsure. |
| Step 4 |
Use the exact amount of water and formula listed on the instructions of the infant formula container.
*
Always
measure the water first and then add the infant formula powder.
Never
dilute formula by adding extra water. This can make the baby sick.
* NOTE: Most powdered formula is mixed according to the same recipe: 1 scoop of formula mixed with 2 fluid ounces of water to make 2 ounces of formula (AAP, 2022b) unless otherwise specified by the provider. |
| Step 5 | Shake infant formula in the bottle to mix. Do not stir. |
| Step 6 |
Infant formula does
not
need to be heated before feeding. If you decide to warm the formula, place the bottle under running warm water or into a bowl of warm water for a few minutes. Avoid getting water into the bottle or nipple. This could contaminate the prepared formula. Test the temperature of the formula before feeding it to the baby by putting a few drops on the inside of your wrist. It should feel warm,
not
hot.
Never warm infant formula in a microwave! Microwaving creates hot spots, which can burn a baby’s mouth! |
| Step 7 | After feeding, be sure to thoroughly clean the bottle and nipple before the next use. |
Attitude : Value the contributions of standardization/reliability to safety.
Patient Education for Parents Who Are Formula-Feeding
Teach parents to watch for signs that their baby is ready to eat and, whenever possible, to begin their feeding before the baby becomes agitated or begins to cry. Instruct parents to let the baby take breaks to catch their breath, drinking when the baby seems to want to. The baby does not need to suck continuously.
Demonstrate how to hold the baby close when feeding them a bottle. Encourage parents to make eye contact with and talk softly to the infant. This contact is important to bonding and the baby’s overall socialization. Explain to parents the importance of always holding the bottle for the baby while feeding. Propping the bottle in the baby’s mouth can increase the baby’s risk of choking, ear infections, and later tooth decay. Teach parents not to put their baby to bed with a bottle. Infant formula can pool in the baby’s mouth and cause choking. Later, it can pool around the baby’s teeth and cause tooth decay. Instruct parents not to force the baby to finish their bottle. Let the baby be the judge of when the feeding is over. See Table 24.1 for signs that an infant is full. Teach these signs to the parents so that they know to stop the feeding, even if the bottle is not empty.
If an infant is younger than 2 months old, was born prematurely, or has a weakened immune system, caregivers may want to take extra precautions when preparing infant formula. The CDC provides guidance on how to keep infants safe from Cronobacter sakazakii which may be found in powdered infant formula.
| Cues | |
|---|---|
| Hunger |
Rooting: when baby turns head toward anything that touches the cheek or mouth
Sucking movements or sounds Putting hand to mouth Crying, a late feeding cue; best to feed before baby starts crying, particularly if breast-feeding |
| Fullness |
Starts and stops feeding
Spits out the bottle or breast Slows down or falls asleep Is difficult to wake Gets easily distracted |
Newborns eat approximately 2 to 3 ounces of formula every 3 to 4 hours. If the infant sleeps longer than 4 to 5 hours at a time, they need to be awakened for a feeding. By the end of the second month, they will eat at least 4 ounces every 4 hours. By the time they are 6 months of age, they will be eating approximately 6 to 8 ounces 4 or 5 times a day (March of Dimes, 2019).
In the baby’s first few days of life, many parents are concerned that their infant is consuming too little during feedings. Breast-feeding parents often feel they need to supplement with formula at this stage. However, the natural content of colostrum , the first breast milk produced in breast-feeding, paired with the anatomic size of a newborn’s stomach is such that only a very small amount of colostrum is needed to satisfy the infant’s nutritional needs (Figure 24.5).
Breast-Feeding
The AAP (2021c) and CDC (2023a) recommend exclusive breast-feeding for the first 6 months of an infant’s life. For the benefits of breast-feeding, see Table 24.2. Updated AAP breast-feeding guidelines emphasize an urgent need for nurses and other health-care workers to provide a patient-centered approach to broaden awareness of the benefits of breast-feeding and to promote equitable care (Meek et al., 2022). Knowledge imparted by the nurse in the immediate newborn period has a powerful influence on the breast-feeding parent and infant.
Successful lactation practices developed at this time can help prevent infant readmissions for dehydration or hyperbilirubinemia and can promote overall infant health. They can also serve as an important promotion of self-efficacy for the nursing parent, thereby improving breast-feeding success and duration. The establishment of frequent and efficient infant feedings (8 to 12 feedings in 24 hours) of unlimited length, where the infant is positioned properly and latched on, will promote an adequate supply of breast milk and prevent many common breast-feeding problems (U.S. Department of Health and Human Services, 2022b). Beyond the initial 6 months, the AAP recommends that breast-feeding continue for as long as desired by parent and infant and be supplemented with nutritious complementary foods as needed (AAP, 2022b; Scott & Kirkland, 2023). The most significant change in the revised guideline is the length of breast-feeding time recommended by the AAP, which has increased from 1 year to 2 years and beyond on the condition that it remains desired by both parent and infant.
| Benefits | |
|---|---|
| Infant |
|
| Nursing parent |
|
Breast Milk Characteristics
Breast milk is complex and specific. As the infant grows, the consistency and nutritional content of the milk change to meet the ever-changing needs of the baby. Breast-feeding is the best nutritional choice to feed a newborn, but not all parents choose to or can breast-feed their infants for a variety of reasons. In the United States, prepared formulas are developed to meet the nutritional needs of infants and to be as close to breast milk as possible. When breast-feeding is not possible or not chosen as a feeding choice, nurses and physicians should be supportive of a family’s choice to formula-feed their infant.
Breast-Feeding Practices
Breast-feeding practices differ from one culture to another around the world. The World Health Organization (WHO) breast-feeding statistics show that 41 percent of babies below 6 months of age experience exclusive breast-feeding (EBF). One major difference is the length of time that nursing parents breast-feed their infants. Culture often has an influence on this practice (Table 24.3).
| Country | Length of Breast-Feeding | Notes |
|---|---|---|
| Turkey | 12–24 months | Only 1% of babies are NOT breast-fed. Paid parental leave of 46–56 weeks encourages high breast-feeding rates. |
| France | 3–6 months | 41% of mothers find it awkward to breast-feed in public. |
| United States | 6–12 months | The United States has many support groups available to promote breast-feeding for new mothers, but most hospitals provide free formula to parents at discharge. |
| China | 6–12 months | Research demonstrates that exclusive breast-feeding determinants include urban residence, mode and place of delivery, and where early initiation of breast-feeding took place, more so than the mother’s wishes alone. |
| Brazil | 6–12 months | Brazil has the most milk banks globally, numbering over 200. The government bans advertising of infant formula. |
| Hungary | 6–12 months | 7% of mothers find it awkward to breast-feed in public. |
| Mexico | 6–12 months | 13% of mothers find it awkward to breast-feed in public. |
| Canada | 6–12 months | 91% initiate breast-feeding after birth, but 40%–50% stop after 6 months. |
| India | Varies | There is a widespread belief that colostrum is impure and dirty, and it is thus discarded. Infants are given formula the first few days of life. Some give infants hot water, tea, goat/cow milk, or honey, etc. Unpasteurized honey is unsafe for newborns. |
| Guatemala | 8–12 months(exclusive breast-feeding may be due to financial constraints) | Many believe colostrum is not clean and discard it, giving babies coffee, soda, and sugar water in the first days of life. Some breast-feed until solids for financial reasons. |
| Philippines | A high percentage will practice mixed feeding (breast and formula). | The government encourages breast-feeding for up to 6 months. It is illegal to advertise infant formula. |
| Muslim countries | Approximately 2 years | Parents often see breast-feeding as a religious duty. The Qu’ran states that babies should be breast-fed by their mothers or a wet nurse for approximately 2 years. |
It is important to let nursing parents know that longer feedings do not usually lead to sore nipples or breast-feeding problems if the baby is latched-on properly. If nursing parents feel feedings are lasting too long or if nipples are becoming sore, encourage evaluation by a lactation consultant.
Donor Breast Milk
With breast-feeding recommended exclusively for the first 6 months of life and with the possibility that it may remain part of the nutritious diet for the first 2 years of age and beyond, it is important that breast milk be available as a first alternative feeding choice for those infants who cannot or will not be breast-fed. Breast milk provides a wide range of benefits for the infant, as mentioned in Table 24.2, that simply cannot be replicated by any other source of nutrition. When the nursing parent has an insufficient volume of breast milk, pasteurized breast milk is a viable option as an alternative feeding. Human milk banks exist throughout the United States and around the world. It is important to note that human milk is species specific and considered superior to all other supplements or alternatives.
Although cow-, goat-, and soy-based formulas have been made that approach the fat, protein, and carbohydrate composition of breast milk, they do not replicate the complexity or purpose of the bioactive factors found in breast milk (Canadian Paediatric Society, 2020; Quigley et al., 2019). Breast milk helps ensure optimal growth, immune function, and neurodevelopment at minimal financial costs to families. Benefits are seen in both the short and long term, with positive effects seen in both maternal and child health.
Preterm and ill infants may not be able to nurse directly at the breast from birth, but with appropriate and continued support, they can begin to breast-feed when they become developmentally ready or stable enough. When breast-feeding itself is not possible, the first choice is to feed expressed milk from the infant’s own birthing parent. When that parent’s milk is not recommended, is unavailable, or is limited in volume, pasteurized donor human milk (PDHM) from a regulated milk bank is recommended for supplementary, bridging, or replacement feedings (Quigley et al., 2019). Most hospitals are connected to milk banks in the area in the event that pasteurized donor human milk is requested for premature or ill infants or for mothers who are unable to breast-feed due to illness. Milk from lactating persons who pump or express breast milk and donate it to a regulated breast milk bank following their policies and procedures is called donor breast milk .
To donate to a breast milk bank, donors are first screened extensively. Guidelines vary by center, but in general, donations are accepted only from donors who are seronegative for hepatitis B and C, human immunodeficiency virus ( HIV ), human T-cell leukemia virus (HTLV), SARS (COVID-19), and syphilis; do not take medications (with some exceptions); and do not consume alcohol, tobacco, or cannabis or use illicit drugs (Canadian Paediatric Society, 2020). If a donor experiences illness or uses medication, they are temporarily excluded from donation. The centers educate all accepted donors to ensure they follow safe breast milk handling techniques and storage.
“Breast is Best” is a global mantra started in 1991 by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) after breast-feeding rates decreased in the 1980s, to help increase breast-feeding rates worldwide. “Fed is Best” is the new mantra, launched in 2016. It is not meant to diminish the message that breast-feeding is still considered the best feeding choice but is meant to ensure that babies do not experience any complications due to a facility’s protocols, and that parents do not feel shame for choosing other feeding options.
Successful Breast-Feeding Patterns of the Newborn
To ascertain successful breast-feeding, the nurse needs to assess the breast-feeding process. There are five common maternal-infant positions for breast-feeding (Murray, 2021); however, others may be used effectively based on the needs and preference of the person. The nurse’s assessment of the infant at the breast focuses on the infant’s latch, coordinated suck, and swallow during breast-feeding. The nurse first checks the placement of the infant’s lips, gums, and tongue.
Then, the nurse listens for the infant’s swallowing pattern. After several sucks in a row, a soft “k” sound should be heard. This is easier to hear once the parent’s milk is in and has let down, with copious milk secretion. Therefore, this may not be observed in the first 24 hours of life or prior to discharge of parent and infant.
Finally, the nurse should observe the nipple shape immediately after the infant is removed from the breast. The nipple should be round. If a nipple is extended, with a shape resembling that of lipstick, that suggests a shallow latch and will lead to sore or damaged nipples.
The general guidelines for latching on involve correct placement of the infant’s mouth to ensure good stimulation for milk supply, promote good milk transfer to the infant, and decrease and/or prevent maternal nipple soreness. The steps of the procedure are as follows:
- Have the nursing parent stroke the center of the infant’s top lip with the nipple to elicit a rooting reflex and wait for the infant to open mouth wide.
- With the infant’s mouth wide open, the parent should pull the infant in close (using pressure on the infant’s upper back and neck). Note that the breast should not be brought to the baby, but rather the baby should be brought to the breast.
- The nipple should be deep in the infant’s mouth; more of the areola should be covered by the lower lip than by the top lip; both lips are flanged; chin is positioned deep into the breast, with infant’s head tipped back slightly to clear the nose.
- The nursing parent can remove the infant from the breast by breaking the suction; insert a clean finger into the corner of the infant’s mouth, between the infant’s gums.
The expected outcomes are as follows:
- Infant’s mouth is open wide, lips are not tucked or curled.
- Infant’s tongue is positioned under the breast.
- Infant does not slip off the breast.
- Infant demonstrates rhythmic sucking and swallowing.
- The nursing parent has few or no complaints of sore nipples. Infant is satiated after feedings.
To assist with and teach breast-feeding techniques, the nurse ensures that both the nursing parent and the infant are positioned comfortably. The parent should be made as comfortable as possible before the feeding begins. If they have recently delivered, particularly if they have had an operative delivery, provide pain medication as needed. Pain or an awkward position can interfere with the letdown reflex and cause the parent to tire easily. Be sure to provide privacy and prevent unnecessary interruptions. It is best to begin the feeding process when the infant shows feeding cues and before they are crying (which is a late cue to hunger). A crying infant is often difficult to settle, particularly because nursing parents often become anxious and unsettled themselves. The five commonly used maternal-infant breast-feeding positions (Murray, 2021) are described in detail here and shown in Figure 24.6. It is important to note that that these five positions are in no way inclusive, and many other positions can be utilized for breast-feeding as long as they are comfortable for both parent and infant and are conducive to the infant’s successful latch, suck, and swallow at the breast.
- Football-hold position: This may also be called the “clutch position.” This position is frequently recommended to nursing parents after cesarean birth or to those with a premature infant because it offers good control of the infant with little or no abdominal pressure for the parent. The infant is placed on a pillow at the parent’s side. The parent supports the infant’s upper back with their arm and supports the infant’s neck in their hand. The infant’s head is level with the breast. It is important that the infant’s body is turned toward the parent in a belly-to-body position, rather than looking upward, and that the infant’s head and body are in alignment (facing the same direction) facing the parent. If the head is facing the breast but the body is facing upward, it is difficult if not impossible to swallow, and feeding will not happen. Have the parent use their opposite hand to support the breast, fingers off the areola, with the index finger under the breast. The palm should remain facing the rib cage, and the nipple should gently tip down toward the infant’s mouth. Steps for successful latch-on can continue at this point forward.
- Cradle-hold position: For the cradle-hold position the parent positions the infant’s body across the front of their own, with the infant’s head at or near the antecubital space and level with their nipple. The parent’s arm is supporting the infant’s body, with the baby lying belly-to-belly with the parent and the infant’s bottom shoulder tucked in slightly closer to the parent’s stomach than the top shoulder. The parent grasps the infant’s bottom and tucks the infant’s lower arm next to the parent’s stomach. The parent’s other hand is free to support the breast in a “C” hold, fingers behind the areola, index finger under the breast. The parent lifts from under the breast until the nipple is directly in front of the infant’s mouth; the parent should continue to support the breast during the early weeks of breast-feeding.
- Cross-cradle hold position: This position is similar to the cradle-hold position in that the infant is placed across the nursing parent’s stomach as in the cradle hold but is held with the parent’s opposite hand placed at the infant’s upper back, supporting the back of the infant’s neck. Once again, the infant is belly-to-belly with the parent and is held close by tucking the parent’s forearm around the infant’s bottom and pulling the infant close. The other hand supports the breast with the thumb coming up from the bottom of the breast. The nipple should be gently tipped toward the infant’s mouth. At this point, the parent follows the tips for successful latch-on. The cross-cradle hold offers the parent more control over the infant’s position than the cradle-hold.
- Prone position: In this position, the nursing parent is semi-reclined with head, neck, and body supported by the bed or the chair. The infant is placed on the parent’s body in a way that allows the front of the infant’s body to be in full contact with the parent’s body. The infant’s head is at the nipple, and the infant is allowed to self-attach to the breast. The parent (or an assistant, as needed) supports the infant on the body to maintain the ideal position and for safety. The infant’s chin position is allowed to gently extend to allow proper mouth and chin placement with latch-on.
- Side-lying position: Nursing parents need to be well supported in this position. Infants are placed on their side, facing the parent (belly-to-belly) with their head and body in alignment. Parent and baby may require a pillow or blankets behind their backs to maintain this position during learning. Have the parent support the breast with the opposite hand (the top one), while the other hand (the bottom one) either supports the parent’s head or cradles the baby, depending on the parent’s preference. With the breast supported, the parent pursues a successful latch-on. For safety, it is important that the parent does not fall asleep in this position while feeding the baby. This position is often preferred for parents who have had an operative delivery.
To make the nursing parent more comfortable, pillows can be used behind the back, over the abdominal incision (if present), and to support the arms. It is important that the parent’s shoulders be relaxed, and they should not be in a hunched position. Pillows or blankets can be used to elevate the infant to the level of the nipple to prevent pulling and tension on the nipple, which will cause sore, cracked, and broken-down nipples.
Healthy infants are generally alert and active at the breast, particularly at the beginning of a feeding. If the baby is sleepy and has already gone 2 to 3 hours since the last nursing session, the nursing parent should be encouraged to frequently massage their breasts in a downward motion while feeding and arouse their baby to ensure adequate breast emptying. Providers should inquire about pain or discomfort during breast-feeding as well as observe a feeding when possible. This helps screen for ineffective latch, nipple trauma, and/or poor milk transfer. If there are any concerns regarding the infant’s status, the health-care provider should conduct a complete feeding evaluation and complete a comprehensive feeding plan, while also scheduling frequent follow-up visits until the issues have been resolved. Additionally, the provider should also gauge the parent’s overall well-being and the parent-infant bonding. Poor maternal-infant bonding may be an indication of perinatal mood or anxiety disorders (O’Dea et al., 2023).
Breast-feeding is most successful when infants are not subject to scheduled feedings but are allowed to nurse as frequently and for as long as they show feeding cues (see Table 24.3). Frequent feedings are required to establish and maintain milk supply. The AAP (Scott & Kirkland, 2023) states that a benchmark for breast-feeding is that infants should nurse between 8 and 12 times in a 24-hour period. But it is important to note that these feedings may not be evenly spaced, and the duration of each feeding may be different. Frequent feedings are particularly important in the first days of life when lactation is being established and the infant’s stomach capacity is small. The nurse should explain to parents that the hormone prolactin is being released in increased amounts while the infant is suckling, and this is responsible for milk production. This will help them understand the relationship between frequent feedings and milk supply. Long stretches of time between feedings increase the likelihood of breast engorgement.
Research demonstrates that early skin-to-skin contact between the nursing parent and the newborn may improve lactation confidence and help facilitate exclusive breast-feeding (Kellams, 2022; Scott & Kirkland, 2023). When milk supply diminishes for reasons of decreased stimulation, infant inability to nurse, maternal illness, or any other cause, breast milk volume can be supported and increased by the following:
- Have the nursing parent offer both breasts at each feeding, while increasing the frequency of feedings (or pumping) to more than 8 times per 24 hours.
- Instruct the nursing parent to allow the infant to feed on one breast until audible swallowing has decreased in frequency, and then switch to the other breast.
- Have the lactating parent apply warm compresses to the breast prior to feeding to assist in letdown. Instruct the parent to massage the breasts in a downward motion, toward the nipple, immediately before and during the feeding or pumping.
- Suggest to the nursing parent to consider breast-feeding for infant comfort or skin-to-skin contact between feedings.
- If the lactating parent is supplementing with breast milk or to increase supply, encourage pumping after feeding at the breast to stimulate supply, especially during the waking hours. Encourage maternal rest and sleep at night.
- Maternal intake of adequate fluids as well as continued consumption of a well-balanced nutritional diet is essential to produce healthy breast milk. As a basic guideline, encourage nursing parents to drink at least 8 ounces of water or fluids each time they breast-feed or pump (Ndikom et al., 2014).
For specific information on fluid amounts and dietary recommendations, parents should be directed to their health-care provider.
When an infant spaces several feedings closely together, with little time between the end of one feeding and the beginning of another, it is called a cluster feeding . These are often followed by a longer spacing between feedings. Infants may demonstrate cluster feedings on the second or third night home from the hospital after birth or in later weeks when experiencing a growth spurt (Kim et al, 2023). Cluster feeding is a way for the infant to increase the milk supply at each feeding. An infant’s need to nurse more frequently may lead a nursing parent to question whether they have an adequate milk supply for the baby when in fact they probably do and this behavior is normal. Nurses should give parents anticipatory guidance through this often difficult time, particularly when cluster feedings are at night, and encourage daytime resting whenever possible.
Because breast milk cannot be measured as it is consumed directly from the breast, parents must be given other tools to determine if their infant is getting enough to eat. Obviously, the number of feedings, frequency, and length of time on each breast are a measure, along with hearing auditory suck and swallow during feedings. But that still leaves a question regarding the volume consumed. The most accurate short-term sign of intake is the infant’s output (i.e., voids and stools). The nurse should note the time of the first void and stool on the infant’s chart because absence of either or both in the first days may indicate an anomaly. Another sure sign of successful breast-feeding is infant weight and hydration status. Weight gain below the 75th percentile on the newborn weight and height graph, failure to regain birth weight by day 14 of life, and/or gaining less than 0.5 ounce daily are all indicators that the provider should investigate the root cause(s), refer the nursing parent and baby to a lactation specialist, and potentially advise supplementation, depending upon individualized assessment and findings, according to the Academy of Breastfeeding Medicine (ABM) guidelines (Scott & Kirkland, 2023). The ABM encourages continued infant cueing and expressed breast milk as the first choice for supplementation, given after nursing and in limited volume. Donor human milk is the second choice, followed by formula when donor milk is not available (Scott & Kirkland, 2023). The ABM suggests specific volumes for supplementation based on the infant’s age. Supplementing with glucose water is not appropriate because it can cause hyponatremia.
Safe Handling, Storage, and Preparation of Expressed Breast Milk
Breast milk can be stored in several different ways for different lengths of time. It is important that specific preparation guidelines and storage protocols be followed to maintain the integrity and safety of the milk. The nurse teaches the nursing parent that before expressing or pumping breast milk, the parent must wash their hands well with soap and water. If soap and water are not available, they may use an alcohol-based hand sanitizer that contains at least 60 percent alcohol.
If pumping is required in the first 24 to 48 hours of life, a hospital-grade electric pump is most appropriate for establishing milk supply. Manual pumps, battery-operated or small electric pumps, or hand expression of milk should not be relied upon for establishing milk supply in the early days of breast-feeding. Many families are discharged with instructions on how to rent or borrow a pump from the birthing hospital or pharmacy. Nursing parents should inspect the pump kit and tubing to ascertain that it is clean, and they should immediately replace any tubing that is moldy. If using a shared pump, the parent should clean pump dials with a disinfecting wipe and clean the countertop.
To store breast milk after expressing, the nursing parent should use breast milk storage bags or clean food-grade containers with tight-fitting lids and avoid plastics containing bisphenol A (BPA) (recycle symbol #7).
Freshly expressed or pumped milk can be stored
-
- at room temperature (77° F/25° C or colder) for up to 4 hours,
- in the refrigerator for up to 4 days, and
- in the freezer. Up to 12 months is acceptable, but about 6 months is best. For specific storage temperatures, see Table 24.4. Although freezing keeps food safe almost indefinitely, recommended storage times are important to follow for best quality.
(CDC, 2023a)
| Storage Locations and Temperatures | |||
|---|---|---|---|
| Type of Breast Milk | Countertop, 77° F (25° C) or colder | Refrigerator, 40° F (4° C) | Freezer, 0° F (−18° C) or colder |
| Freshly expressed or pumped | Up to 4 hours | Up to 4 days |
Within 6 months is best.
Up to 12 months is acceptable. |
| Thawed, previously frozen | 1–2 hours | Up to 1 day (24 hours) | NEVER refreeze human milk after it has been thawed. |
| Leftover from a feeding (baby did not finish the bottle) | Use within 2 hours after the baby is finished feeding. |
Tips for safe breast milk storage include the following:
- Prior to storing, clearly label breast milk with the date it was expressed.
- Breast milk should not be stored on the door of the refrigerator or freezer, to avoid exposure to temperature changes from opening and closing the door.
- If breast milk will not be used within 4 days of expression, it should be frozen immediately to protect the quality of the milk.
- Store breast milk in small amounts to avoid wastage of milk not used at a feeding. Amounts of 2 to 4 ounces or the amount usually taken at a feeding is appropriate.
- Breast milk expands when frozen, so approximately 1 inch of space should be left at the top of the container to accommodate this.
- If breast milk is given to a childcare provider, it should be labeled clearly with the child’s name, and the provider should be given specific instructions about preparation and storage of breast milk.
- Breast milk can be stored in an insulated cooler with frozen ice packs for up to 24 hours when families are traveling. When they reach their destination, they should use the milk right away, store it in the refrigerator, or freeze it.
The CDC provides more information on the safe storage and preparation of breast milk. It includes tips for travel and home use of breast milk. After storage of breast milk, mixing will be required because of the fat, which may have separated. Remember, breast milk is not naturally homogenized. If the baby does not finish the bottle at a feeding, the leftover milk can be used to feed the baby within 2 hours after completion of the initial feeding. After the 2-hour period, the leftover breast milk should be discarded.
Bottle-Feeding the Breast-Fed Infant
Even when a baby is breast-fed, sometimes it is necessary to introduce a bottle as a feeding alternative, whether to feed expressed or pumped breast milk or formula. Depending on how long the breast-fed infant has been exclusively nursing, the type of bottle nipple used and what is in the bottle will impact how quickly and how easily the baby will transition to the bottle from the breast. In addition, infants vary in how easily they transition to the bottle. Some babies transition with more ease than others. All babies will eventually make that transition if the caregiver is persistent enough, but not all babies have to. Infants can successfully transition from the breast to the cup, regardless of age, if the caregiver is patient and persistent.
Positioning for Bottle-Feeding
When introducing the bottle to a breast-fed infant for the first time, it is best to have the baby in an upright position, keeping them comfortable and close, while giving them more control during the feeding. Similar to eliciting a latch-on, touch the baby’s bottom lip with the bottle nipple. This will encourage the infant to open their mouth wide. Place the nipple inside the mouth slowly and gently. Be sure not to force the mouth open, instead allowing the infant to open the mouth on their own. Try offering only ½ to 1 ounce of the bottle to the infant. This will allow them to learn to drink from the bottle without feeling too full. Increase the amount of the feeding only if the baby seems hungry and is giving cues for more. Introduce the bottle by giving it once a day between breast-feedings when the baby is neither full nor hungry. This may help them to accept the bottle (as a new feeding method) with less stress. About halfway through the bottle-feeding, switch the baby’s position by moving them from one arm to the other. This helps prevent the baby from developing a favorite side when feeding and allows for good eye contact with them as well, helping the parent to better read their cues. Let the baby take breaks if they want to, just as they do when breast-feeding. Never force them to finish the bottle (Kotowski et al., 2020).
If the baby refuses the bottle, several suggestions might help. It is best to offer the bottle when the baby is happy and calm, rather than when they are upset. Remember that crying is a late feeding cue for hunger. Try comforting the baby by holding them, singing to them, or playing with their favorite toy. Breast-feed the baby after they calm down and try the bottle again later in the day. Babies may refuse to feed when they do not feel well, so check the baby for signs of illness. Another suggestion is to hide the bottle with a blanket or washcloth during the feeding.
Frequency, Timing, and Quantity of Feedings
When breast-feeding an infant, it takes approximately 2 to 3 weeks to develop a good breast-feeding routine. Breast-feeding a baby on demand is full-time and exhausting work. The nursing parent’s body needs adequate energy to produce enough milk. They must eat well, get adequate rest and sleep, and drink sufficient fluids. Drinking at least 8 ounces of fluid each time they nurse helps address fluid needs. Nursing parents can expect that their breasts will become swollen, engorged, and painful 2 to 3 days after giving birth (Zakarija-Grkovic & Stewart, 2020). Their baby will need to be nursed often to relieve the discomfort and ease the engorgement. If a feeding is missed, nursing parents should pump their breasts or express them. This can also be done if a feeding does not relieve the pain of engorgement. During the first month, breast-fed infants will nurse every 1½ to 2½ hours during the day and night. Breast milk is digested more easily than formula, and thus breast-fed infants will need to eat more frequently than their formula-fed counterparts.
The American Academy of Pediatrics parenting website, healthychildren.org, provides a list of bottle-feeding tips for concerns about overfeeding or underfeeding a baby.
During growth spurts, babies increase the frequency with which they want to nurse. This frequent nursing works to increase the milk supply and allow for normal growth and development of the infant. The baby will breast-feed every 30 to 60 minutes and stay at the breast for longer periods. The frequent nursing for growth spurts is temporary, lasting only a few days, until the milk supply increases to provide enough milk at each feeding to meet the needs of the baby. At that time, the baby will eat less often and for shorter periods. Growth spurts usually occur at around 2 weeks, and then at 2, 4, and 6 months of age (Jacobson, 2022). To increase the milk supply, nursing parents need encouragement not to supplement with formula-feedings when their infant wants to feed frequently. Parents often feel that they are not making enough milk for their infant but need to know that this is normal and that their body will respond to their baby and make enough milk. Their baby is getting enough to eat if they: (Jacobson, 2022)
- nurse every 2 to 3 hours
- have 6 to 8 wet diapers each day
- gain weight (about 1 pound, or 450 grams, each month)
- make swallowing noises while nursing
- are satiated when feeding is over
Formula-fed infants also start out eating 8 to 12 times every 24 hours. As newborns, they might take in only ½ to 2 ounces per feeding for the first day or two of life, depending on their birth weight, but usually average 1 to 2 ounces at each feeding. This amount increases to 2 to 3 ounces by 2 weeks of age. By the end of 1 month, the baby will be up to at least 3 to 4 ounces (120 mL) per feeding, with a fairly predictable schedule of feedings about every 3 to 4 hours (AAP, 2022b). At about 2 months of age, babies usually take 4 to 5 ounces per feeding every 3 to 4 hours. At 4 months, babies usually take 4 to 6 ounces per feeding. By 6 months, babies will consume 6 to 8 ounces at each of 4 or 5 feedings in 24 hours (AAP, 2022b).
Babies generally take in about 2½ ounces (75 mL) of infant formula a day for every pound (453 g) of body weight (AAP, 2022b). All babies are different, but most will drink more and go longer between feedings as they grow and their stomachs can hold more milk. Also, babies suck not only for hunger but also for comfort. At 6 months, babies may be taking up to 8 ounces every 4 to 5 hours. As a general rule, infants will increase the amount of formula they drink by an average of 1 ounce each month before leveling off at 7 to 8 ounces per feeding (Jain & Bunik, 2022). Solid foods are usually introduced at about 6 months (Jain & Bunik, 2022).
The AAP also addresses parents’ concerns about pacifier use by providing guidelines for pacifier choice and use.
In general, babies do a good job of self-regulating how much they eat. Infants who are bottle-fed may be more likely to be overfed because drinking from a bottle takes less effort than being breast-fed. Overfed babies can experience stomach pains, gas, spit up, or vomit and be at higher risk for obesity as adults. Offering less is a better choice because you can always offer more if the infant remains hungry. For babies who like to suck for comfort rather than nutrition, pacifiers are a good substitute when used after feedings. While research on the timing of pacifier introduction to the breast-fed infant (Orovou et al., 2022) is highly variable, most of the literature agrees that avoiding a pacifier in the early days (first 1 to 3 weeks) while breast-feeding is being established is valuable.
Spitting up of stomach contents in infants, or reflux , that occurs when the lower esophageal sphincter muscle lets the stomach contents back into the esophagus because it is not fully developed is called physiologic regurgitation (AAP, 2022c). Spit up consists of milk flowing from the mouth during or after a feeding when the stomach is full and can be caused by overfeeding, air swallowed during feeding (therefore it may occur when burping), crying, or coughing. It is common for infants and children under 2 years of age to experience gastroesophageal reflux (GER) , which is the spitting up of liquid or food, when the stomach contents move back up from a baby’s stomach into the esophagus. Many infants who experience reflux have a normal physical exam and adequate weight gain, and present as healthy, happy newborns. This condition usually resolves itself by 12 months of age and does not require medical management (AAP, 2022c).
For concerns about infant reflux, read Gastroesophageal Reflux in Infants and Children from the American Academy of Family Physicians (AAFP).
How to Burp a Baby
Burping is necessary because babies take in air when they are feeding. They may take in more air with the bottle, but many babies take in air at the breast also. When a baby swallows air during a feeding, that air gets trapped in the stomach. The trapped air can become uncomfortable “gas pockets,” causing the baby to cry or fuss. Burping the baby helps to remove that trapped air and prevent the “gas” from becoming a problem.
Before burping the baby, place a burp cloth , bib, towel, or cloth diaper under the baby’s chin in case the baby spits up during the process. This protects the caregiver’s and the baby’s clothing. There are three commonly used burping positions that nurses can teach new parents (Figure 24.7):
- Over the caregiver’s shoulder: Hold the baby upright with their head over the caregiver’s shoulder.
- Sitting on the caregiver’s lap: Set the baby on the caregiver’s lap, facing away. Lean them forward and support their head (under the jaw) with the thumb and forefinger, while supporting their neck and chest with the hand and forearm.
- Lying on the caregiver’s lap: Place the baby on their belly, face down, across the caregiver’s lap, and support their head with the caregiver’s lap, arm, or hand.
When the baby is in one of the preceding positions, gently rub or pat them on their back to help elicit a burp. There is no need to pound harder on their back; this could cause injury and will not make them burp better or faster. If the baby does not burp after a few minutes of trying, change their position and try again. If you cannot elicit a burp and the baby does not appear to be in any discomfort, you do not need to worry about a burp. Babies do not need to burp every time you try.
How often should a baby be burped? That depends on the baby and the circumstances. If a nursing parent is breast-feeding and has a strong letdown reflex or an overabundant breast milk supply, the fast flow of breast milk can cause the baby to swallow more air; thus, that baby would need to be burped more often. Usually, it is enough to burp a breast-fed baby between breasts and at the end of the feeding. For bottle-fed infants, it depends on whether they are vigorous feeders and whether they gulp their feedings. Initially, they may need to be burped after every ½ ounce, then gradually increase to halfway through the feeding, and then as the infant sucks more continuously and efficiently, burp them when the feeding is finished. At any time during the feeding, if a breast-fed or bottle-fed infant begins to squirm or move around when they were previously still, they probably have gas and need to be burped (Deepti et al., 2024). If the newborn falls asleep at the breast or with the bottle, that is a good time to burp them. Burping may help to wake them up and keep them feeding a little longer. If the baby is feeding and actively sucking, you do not have to interrupt the feeding (breast or bottle) to burp them. Wait until they stop the feeding on their own and then burp them. Burping will help to get rid of the air that the baby naturally swallows as part of their feeding. The frequency of burping will ultimately be determined by the infant’s individual needs.
Voiding and Stooling Patterns in Newborns
When a newborn voids and stools and how often voiding and stooling occur after birth is an important assessment for the nurse to note in the newborn’s chart. Potential health concerns are raised when voiding or stooling does not occur. Educating the parents on the expected voiding and stooling pattern s and what to do if these expected norms are not met is a part of the nursing role in educating the newborn’s caregivers.
Expected Stooling Patterns in the Newborn
The newborn’s initial stool is the same for both breast-fed and bottle-fed infants and is present for the first few days after birth. It is called meconium and is a thick black or dark green, tar-like substance that filled the fetus’s intestines before birth (Figure 24.8). Meconium is passed within the first 24 to 48 hours of life; a delay in passing it may indicate an underlying health condition (Skelly et al., 2023). Babies have an immature digestive system, which accounts for the varying color and consistency of their stools. After the first day or two, the meconium starts to change in consistency, particularly after the baby starts to eat. After the meconium has passed, newborn stool changes to transitional stool , which is more yellowish-green. Then, stool becomes more consistently a “breast-fed stool” or “formula-fed” stool in appearance.
Regardless of feeding method, hard or very dry infant stools may be a sign that the infant is not getting enough fluids or that they are losing too much fluid due to illness, dehydration , fever, or heat (AAP, 2021b).
Stooling Pattern of Formula-Fed Infants
After meconium has passed, formula-fed infants have stools that are usually browner and firmer than those of breast-fed infants. Bowel movements in formula-fed infants are on the brown color spectrum, meaning that yellow-brown, tan-brown, and green-brown are all normal colors for stools. Consistency is like that of peanut butter. Although the odor is stronger than that of breast-fed infant stool, it remains mild until the infant begins solid foods.
Stooling Pattern of Breast-Fed Infants
The bowel movements of breast-fed babies are different from those of formula fed babies after meconium has passed. The stool is brownish-yellow, mustardy, or yellowish-green and often appears seedy (Figure 24.9). It is soft and occasionally runny. Being runny is not a problem as long as the baby is feeding well and does not have other issues, such as blood in the stool. Breast-fed babies may sometimes appear to have mucus in their stool. This is not a cause for concern. It is not normal for their stool to be very hard or similar to the consistency of adult stool. This would indicate constipation. Breast-fed babies rarely suffer from constipation, since breast milk contains a natural laxative-like component. Conversely, very watery stool might be a sign of diarrhea, for which a concern would be dehydration and illness. During the first 6 weeks of a baby’s life, frequent bowel movements are an indication that the baby is getting enough food. Most babies have two to five bowel movements per day and may stool after every feeding (AAP, 2021b). A baby who has significantly fewer bowel movements than this or does not stool on most days may not be getting enough breast milk. This may be an indicator that more frequent feedings are necessary or that an evaluation with a lactation consultant is indicated to increase breast milk supply. Other breast-fed infants, by 3 to 6 weeks of age, may have a stooling pattern of only one bowel movement a week and still be considered normal (AAP, 2021b). Breast milk leaves very little solid waste to be eliminated from the digestive system, but when these babies do have a bowel movement they go in very large quantities. As long as their infrequent stools are soft and the infant is otherwise healthy, it is not considered a problem. Caregivers need to be cognizant of any changes in their infant’s stooling patterns, as indicators of concerning issues.
Breast milk stool has a very mild odor. The stool of babies who are both breast-fed and bottle-fed has a stronger odor, as does the stool of those who have had solid foods introduced. These stools have more form to them and are a darker color than breast-fed stools.
Expected Voiding Patterns in the Newborn
Regardless of feeding method, in the first 4 days of life, a newborn is expected to have at least one void per day of age plus at least one stool per 24 hours; on day 5, the newborn should have at least six to eight voids and one yellow seedy stool daily (Scott & Kirkland, 2023). Newborns often void at the time of birth, and this can easily go unnoticed because of the small amount and because of the very pale color. The nurse should note the time of first voiding on the infant’s chart because absence of voiding in the first 2 days may indicate an anomaly. Usually, the first void occurs sometime during the first 12 to 24 hours of life. Disposable diapers are very absorbent, and the pale color of the infant’s urine may cause very little, if any, color change on the diaper itself. The nurse may need to put gloves on and examine the inner layer of the diaper for clumping or dampness. Cotton balls or tissues may be placed in the diaper to better visualize small amounts of urine. Newborn’s urine may contain uric acid crystals that cause a reddish or pink stain on the diaper, known as a brick staining, which might be frightening to parents who may mistake it for bleeding. It does not continue past the first few days as the kidneys mature. It is the nurse’s role to notify the primary care provider if the infant does not meet the voiding expectations in the first days of life. If the infant is breast-fed, an additional lactation consultation is indicated to assess latch, suck, and swallow with the ultimate goal of increasing breast milk production and ingestion. Infants who are content, have good skin turgor, produce an adequate number of wet diapers, and have normal weight gain are considered to be consuming an adequate amount of either breast milk or formula (Scott & Kirkland, 2023).
Circumcision of the Male Newborn
Male circumcision is the surgical removal of the foreskin, the layer of skin that covers the glans (head) of the penis. In the newborn, circumcision is typically done in the hospital on the first or second day of life, before the birthing parent and baby are discharged. Circumcision is performed only if the parents request it and if the baby is healthy. It can be postponed if necessary. For religious or cultural reasons, some babies may be circumcised later in a nonhospital setting. Overall, approximately 25 percent to 33 percent of the world’s male population is circumcised (Abdulwahab-Ahmed & Mungadi, 2013). Religious circumcision is practiced by those of the Jewish religion, while Muslims, Black Africans, Indigenous Australians, and other ethnic groups in different parts of the world practice religious and cultural circumcision (Gerharz & Haarmann, 2000). The United States is an outlier among other Western societies in its common circumcision of males who are not Jewish or Muslim (Abdulwahab-Ahmed & Mungadi, 2013).
The three techniques used for infant circumcision are the Plastibell technique, the Mogen clamp, and the Gomco clamp.
- Plastibell: A plastic bell-shaped tool is used for the procedure. The penis will have a plastic ring around it that will remain after surgery. The ring will fall off on its own in 5 to 7 days. There are no stitches with this procedure. Swelling may be present but will subside by approximately day 4. Change diapers often, rinsing the genitals and buttocks with water (do not use commercial diaper wipes). Give sponge baths until the umbilical cord has fallen off. If it is off, baths can be given daily beginning the day after circumcision until the ring comes off. Follow circumcision care instructions. There are no restrictions. The advantage to this method is reduced bleeding.
- Mogen clamp: With use of this clamp, the foreskin is crushed along a line that is 1 mm wide, and the foreskin is then removed distal to the clamp. When the clamp is removed, the glans is then liberated by opening the crush line. The procedure usually takes only 3 to 4 minutes and is virtually bloodless. The Mogen clamp has been associated with shorter procedure time and less pain when compared with the Gomco clamp (Taddio, 2001). This procedure was initially designed by Rabbi Harry Bronstein in 1954 and is one of the most commonly used techniques for ceremonial circumcisions outside hospital settings (Stanford Medicine, n.d.-b).
- Gomco clamp: This is one of the most commonly used devices for newborn circumcision (Stanford Medicine, 2023a). It has all the advantages of a steel bell, which protects the glans penis during the procedure, and the absence of a foreign body remaining on the penis after the circumcision (as it does with the Plastibell). It has been in continuous use for more than 70 years and gets its name from the company that originally manufactured it, the Goldstein Manufacturing Company (Stanford Medicine, 2023a).
Nurses are often involved in the consent procedure for infant circumcision. Before obtaining any consent, the nurse must have a thorough understanding of the indications, contraindications, complications, and the need for emergent intervention. When obtaining parental consent for circumcision, the nurse is responsible for explaining these elements to the parents, listening to their questions and/or concerns, and addressing them. The nurse then witnesses parental signature on the consent. If the parent does not wish to sign the consent, the nurse then notifies the physician prior to the procedure and any procedural preparation for the patient.
Circumcision is a quick procedure, and various surgical techniques can be used, but the basic steps are the same (Stanford Medicine, n.d.-a):
-
Local anesthetic is applied.
- A topical cream (put on the penis) may be used. It takes about 20 to 40 minutes to take full effect.
- An injectable anesthetic requires less time to take effect and may provide a slightly longer period of anesthesia.
- Sometimes acetaminophen (Tylenol) is also given with the anesthetic to help lessen pain during surgery and for several hours later. Acetaminophen is an analgesic , which is a drug or medication that reduces pain or discomfort.
- A bottle nipple filled with a sugar water substance (also called a “sweetie” or “sweet ease”) may also be given during the procedure to soothe the infant and lessen stress. A pacifier alone can also lessen stress and pain.
- The baby is placed on a special table for the procedure.
- The penis and foreskin are cleaned.
- A special clamp is attached to the penis, and the foreskin is cut and removed.
- After the procedure, special care is taken to protect the wound from rubbing against the diaper.
Circumcision may be done by the maternal health-care provider or by the newborn care provider. In some cases, when it is done in a nonmedical setting for religious or cultural reasons, circumcision may be performed by another person trained in how to do the procedure, how to relieve pain, and how to prevent infection in the baby. No single treatment has been demonstrated to offer complete pain relief for every newborn undergoing circumcision. Therefore, a combination of therapies is likely the most effective choice for pain management.
Medications Used in Male Circumcision
Lidocaine (Topical)
- The application of a 1-g dose of lidocaine -prilocaine cream to the penis, about 60 to 80 minutes before circumcision, has been determined to be both safe and efficacious for newborns. The effectiveness of pain relief decreases during circumcision stages that involve significant tissue damage.
- Additional research reports similar effectiveness when employing a 0.5-g dose of lidocaine-prilocaine cream applied beneath an occlusive dressing for 45 to 60 minutes before circumcision.
- When comparing the effects of lidocaine 30 percent cream (1 g) and lidocaine-prilocaine cream (1 g), it was observed that the latter more efficiently reduced crying time and attenuated the increases in heart rate and blood pressure in neonates during circumcision. Additionally, it was deemed safe to use lidocaine cream in newborns, as there were no significant reports of systemic absorption of lidocaine.
Lidocaine (Dorsal Penile Nerve Block—DPNB)
- Lidocaine 1 percent is administered through injection, with 0.2 to 0.5 mL injected into two dorsolateral sites located at the base of the penis, specifically positioned at 2 o'clock and 10 o'clock, approximately 3 to 8 minutes prior to the circumcision procedure.
- Research studies that used the Neonatal Infant Pain Scale (NIPS) scores as their endpoints reached the conclusion that neonates who received DPNB had significantly lower NIPS scores when compared to those who received lidocaine-prilocaine cream, demonstrating a more pronounced reduction in pain.
Subcutaneous Ring Block
- The ring block technique involves the injection of approximately 0.8 mL of lidocaine 1 percent in a circular manner around the penis, placed halfway along the shaft, with this procedure being performed approximately 8 minutes before the circumcision.
- Ring block was found to be the most effective in reducing pain during foreskin separation and incision, as demonstrated by reduced crying and a lower heart rate. Following ring block, DPNB was the second most effective anesthetic, while lidocaine-prilocaine cream was the least effective.
NOTE: With DPNB and ring block, epinephrine should not be mixed with lidocaine due to the vasoconstrictive nature of epinephrine, which can lead to the risk of ischemia and tissue necrosis.
Acetaminophen (Tylenol)
- Acetaminophen is commonly used to reduce fever or pain in infants but is not recommended as the sole pain reliever for circumcision. Research has shown no significant difference in terms of pain tolerance and pain control between a placebo group of newborns and a group that received acetaminophen preoperatively and intraoperatively. The group who had received acetaminophen showed an increase in comfort level at 6 hours post procedure, demonstrating that the acetaminophen may be more effective after the initial postoperative period.
Sucrose (oral)
- Research indicates that using pacifiers dipped in or filled with a sucrose solution is more effective than using water-dipped pacifiers in neonates, resulting in reduced crying during painful procedures like circumcision and heel stick s.
- Although sucrose is not as effective as lidocaine-prilocaine cream or DPNB for pain reduction, the combination of sucrose and other pain-relieving measures has been shown as more effective than either method on its own in alleviating neonatal pain during circumcision.
Care of the Uncircumcised Newborn
When parents choose not to have their baby boy circumcised, the uncircumcised penis does not require any specialized care. To keep it clean, simply wash the outside of the penis with a mild soap and water or use baby wipes when changing diapers. Do not attempt to pull back the infant’s foreskin. The foreskin may not pull back completely until the child is older. This is normal. The child’s pediatrician can tell parents when it is ready to be pulled back and cleaned (American College of Obstetricians and Gynecologists, 2022).
Care of the Circumcised Newborn
After a baby has been circumcised, care must be taken to keep the area clean. Initially after the circumcision, the area will be checked every 15 minutes for an hour to assess for excessive bleeding at the surgical site. In addition, the nurse will monitor for swelling at the site and for the first void post circumcision. A dressing on the surgical site will consist of a gauze pad with petroleum jelly placed on the tip of the penis. Petroleum jelly can also be placed on the diaper in the area where the penis will touch. A clean dressing should be applied at every diaper change for the first day or two to prevent the surgical site from sticking to the diaper and to help keep the site clean. The tip of the penis will initially appear bright red. Even after the dressing is no longer needed, parents should put a dab of petroleum jelly on the penis tip or on the front of the diaper. It usually takes between 7 and 10 days for the penis to heal. Initially, the tip of the penis may appear slightly swollen, and a small amount of blood may appear on the diaper. That is to be expected and is not a concern. A slight yellow discharge or crust may also appear after a couple of days. This is a normal part of healing. If immediately after the circumcision or at any time during the recovery the penis is actively bleeding, the nurse or caregiver needs to apply direct pressure for 1 to 2 minutes to control the bleeding and must notify the provider. The provider may decide to apply silver nitrate to stop the active bleeding.
When to Call the Health-Care Provider
As with any surgical procedure, circumcision comes with the possibility of risks and complications. With circumcision, complications are rare and are usually minor. Possible complications include bleeding, infection, and scarring. It is less likely for complications to occur if circumcision is done in a medical setting.
If any of the following problems are noticed, the doctor should be called immediately (American College of Obstetricians and Gynecologists, 2022):
- bleeding that is not stopping
- more than a quarter-sized amount of blood on the diaper
- redness getting worse or not going away after 7 to 10 days
- fever, rectal temperature > 100.4° F or 38° C
- other signs of infection, such as swelling or discharge getting worse, or pus-filled blisters
- not urinating normally within 12 hours after circumcision.
Nurse:
Erin, BSN
Years in practice:
5
Clinical setting:
Pediatric cardiology floor
Geographic location:
The inner city of a large metropolitan area in Ohio
A 6-day-old baby boy with a known ventricular septal defect (VSD) was not given the opportunity to have a circumcision done in the newborn nursery. After seeing his primary care provider and pediatric cardiologist, he was introduced to pediatric surgery and had a circumcision done in the OR with postcare provided by the pediatric cardiology floor.
Erin received a sign-out from the post-anesthesia care unit (PACU). Notably, the patient had had to have sutures placed due to bleeding.
When he arrived on the floor, Erin found that he was tachycardic, pale, and irritable. His mother was concerned that he was in pain. The floor provider prescribed Tylenol for pain.
Erin was also concerned as the patient continued to be inconsolable with a heart rate in the 170s to 180s. During the second diaper change that evening, she found a red-filled diaper and active bleeding at the circumcision site.
Pediatric surgery was alerted to the acute change in the surgical site. Erin followed the orders of both teams as she started infusing packed red blood cells (PRBCs) through a peripheral IV and utilized her change nurse to meet her other patients’ needs.
The pediatric surgery team was able to stop the bleeding without requiring further surgery, and the patient improved significantly after receiving blood.
With quick intervention, almost all circumcision-related problems are easily treated.
Postprocedural Pain in the Circumcised Newborn
Postcircumcision pain and initial discomfort are expected and can be lessened for the newborn by:
- providing a pacifier for sucking
- nursing if the baby is breast-fed
- swaddling , a traditional practice of wrapping up a baby gently in a light, breathable blanket to help them feel calm and sleepy (Figure 24.10)
- administering acetaminophen as an analgesic
- rocking the baby
Circumcision around the World
Table 24.5 lists the percentage of males who undergo circumcision at some point in their life, likely as a newborn. Cultural, religious, and ethical beliefs of the family result in the procedural choice.
| Country | Rate | Country | Rate |
|---|---|---|---|
| Afghanistan | 99.8% | Japan | 9% |
| Algeria | 97.9% | Jordan | 98.8% |
| Australia | 26.6% | North Korea | 0.1% |
| Austria | 5.8% | Libya | 96.6% |
| Bolivia | 0.11% | Mexico | 15.4% |
| Botswana | 15.1% | Morocco | 99.9% |
| Brazil | 1.3% | Netherlands | 5.7% |
| British Virgin Islands | 1.2% | Nigeria | 98.9% |
| Canada | 31.9% | Norway | 3.0% |
| China | 14% | Puerto Rico | 0.14% |
| Colombia | 4.2% | Romania | 0.34% |
| Egypt | 94.7% | Russia | 11.8% |
| France | 14% | Saudia Arabia | 97.1% |
| Gaza Strip | 99.9% | Turkey | 98.6% |
| Germany | 10.9% | United Kingdom | 20.7% |
| Iran | 99.7% | United States | 71.2% |
| Iraq | 98.9% | Vietnam | 0.2% |
| Israel | 91.7% | Yemen | 99.0% |