Vitamin K Administration

Shortly after birth, vitamin K is administered to prevent hemorrhagic disease of the newborn. (See Chapter 9.) Normally, the intestinal flora synthesizes vitamin K. However, because the infant’s intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K, the supply is inadequate for at least the first 3 to 4 days. The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver, which is needed for blood clotting. The vastus lateralis muscle is the traditionally recommended injection site, but the ventrogluteal (not dorsogluteal) muscle can be used.

Several countries have noted a resurgence in later onset of vitamin K deficiency bleeding (VKDB) after practicing orally administered prophylaxis (American Academy of Pediatrics, 2003c). Current recommendations are that vitamin K be given to all newborns as a single intramuscular dose of 0.5 to 1.0 mg (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2007). Additional study is needed on the efficacy, safety, and bioavailability of oral preparations and on the most effective dosing regimens to prevent VKDB (see Research Focus box).

Hepatitis B Vaccine Administration

To decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences (cirrhosis and liver cancer) in adulthood, the first of three doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)–negative mothers. The injection is given in the vastus lateralis muscle, since this site is associated with a better immune response than the dorsogluteal area (although the dorsogluteal muscle typically is not used in infants in the United States) (American Academy of Pediatrics, 2009b). (See Immunizations, Chapter 12.) Giving the infant concentrated oral sucrose can reduce the pain of the injection (Stevens, Yamada, and Ohlsson, 2004). Preterm infants born to HBsAg-negative mothers should be vaccinated as early as 30 days of age regardless of gestational age or birth weight. Preterm infants weighing less than 2000 g (4.4 lb) who are ready to be released from hospital should receive hepatitis B vaccine just before hospital discharge. Infants born to HBsAg-positive mothers should be immunized within 12 hours after birth with HBV vaccine and hepatitis B immune globulin at separate sites, regardless of gestational age or birth weight (American Academy of Pediatrics, 2009b).

Newborn Screening for Disease

Blood sampling can detect a large number of congenital disorders in the newborn period so that early intervention can take place to decrease the long-term effects and cost of not treating such conditions. Currently no national policy regulates newborn screening; therefore the extent of screening has been largely determined by state laws and individual practice. All states now mandate screening tests for phenylketonuria (PKU) and congenital hypothyroidism (see Chapters 9 and 35); many states also have programs that include screening for sickle cell disease and galactosemia. Because of concern regarding the inconsistency among states in screening for such conditions based on cost, population demographics, resource availability, and political environment, the Task Force on Newborn Screening was formed by the American Academy of Pediatrics and other federal health care agencies and has developed a number of resolutions and policies to better address the issue of newborn screening (American Academy of Pediatrics, 2008b).

The advent of tandem mass spectrometry has expanded newborn screening to include detection of disorders of fatty acid oxidation, amino acids, and organic acids. This technology uses a minimum amount of blood and can identify more than 40 different disorders in 2 minutes (Bryant, Horns, Longo, et al, 2004). Tandem mass spectrometry has improved sensitivity and specificity for the detection of such conditions as hyperphenylalaninemia (PKU) and has a lower rate of false-positive results than other standardized testing methods.

The nurse’s responsibility is to educate parents regarding the importance of screening and to collect appropriate specimens at the recommended time (after 24 hours of age or after the introduction of feedings; hospitalized infants must be screened before 7 days of age). With early newborn discharge before 24 hours, adequate screening for PKU requires a follow-up test within 2 weeks (Kaye and American Academy of Pediatrics, 2006). Accurate screening depends on high-quality blood spots on approved filter paper forms. The blood should completely saturate the filter paper spot on one side only. The paper should not be handled, placed on wet surfaces, or contaminated with any substance (see Atraumatic Care box). The American Academy of Pediatrics (2008a) recommends routine prenatal and perinatal human immunodeficiency virus (HIV) counseling and testing for all pregnant women. Benefits of early identification of HIV-infected infants include:

Cesarean section, performed before the rupture of membranes or the onset of labor, may prevent mother-to-child transmission of HIV in optimally treated women and is associated with a 50% or more reduction in the risk of mother-to-child transmission among HIV-infected women who are either not receiving antiretroviral therapy or are receiving minimal therapy. For infants whose mother’s HIV status is unknown, rapid HIV antibody testing provides information within 12 hours of the infant’s birth. Antiretroviral prophylaxis is started as soon as possible, pending completion of confirmatory HIV testing. Breast-feeding is delayed until confirmatory testing is done. If the test is negative, prophylaxis is stopped and breast-feeding may start. If the test is positive, infants should be treated with antiretroviral prophylaxis for 6 weeks, and the mother should not breast-feed (American Academy of Pediatrics, 2008a). HIV-exposed infants who test negative initially should undergo further testing at 1 to 2 months and at 4 to 6 months of age to exclude or identify HIV infection (Havens, Mofenson, and Committee on Pediatric AIDS, 2009). For information on several diseases that may be included in newborn screening, see American Academy of Pediatrics’ Introduction to the Newborn Screening Fact Sheets (Kaye and American Academy of Pediatrics, 2006).

Universal Newborn Hearing Screening

It has been estimated that screening children for hearing loss by risk factors alone fails to identify approximately 50% of all newborns with a congenital hearing loss. Furthermore, infants who are hard of hearing or deaf, yet receive intervention before the age of 6 months, maintain appropriate language development matching their cognitive abilities through the age of 5 years (Yoshinaga-Itano, Sedey, Coulter, et al, 1998). For these reasons the American Academy of Pediatrics Joint Committee on Infant Hearing (2007b) recommends universal hearing screening of all newborns before discharge from the birthing hospital. Infants may be screened for hearing loss by auditory brainstem response or evoked otoacoustic emissions. Newborns who fail the initial screening require referral for outpatient retesting and intervention by 1 month of age; newborns who do not receive initial screening before discharge should also be tested by 1 month (American Academy of Pediatrics, 2007b; Connolly, Carron, and Roark, 2005). A subsequent audiologic assessment should be performed at least once by 24 to 36 months of age if the infant has any hearing risk factors despite passing the newborn hearing screening (American Academy of Pediatrics, 2009c).

Bathing

Bath time is an opportunity for the nurse to accomplish much more than general hygiene. It is an excellent time for observing the infant’s behavior, state of arousal, alertness, and muscular activity. Bathing is usually performed after the vital signs, especially the temperature, have stabilized.

With the possibility of transmission of HBV and HIV via maternal blood and blood-stained amniotic fluid, the traditional timing of the newborn’s bath has been questioned. Studies indicate that healthy full-term newborns with a stable body temperature can be bathed as early as 1 hour of age without experiencing problems, provided that effective thermoregulation measures are taken after the bath (Penny-MacGillivray, 1996; Behring, Vezeau, and Fink, 2003; Varda and Behnke, 2000; Medves and O’Brien, 2004). Take caution, however, to avoid instituting routine newborn bathing according to a rigid schedule; nursing interventions such as bathing should instead be based on individualized assessment and family interaction needs.

Because of the possibility of blood and body fluid contagions, as part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing.

The bath time provides an opportunity for the nurse to involve the parents in the care of their child, to teach correct hygiene procedures, and to help them learn about their infant’s individual characteristics (Fig. 8-11). The bath may also be used to help parents learn and better understand their newborn’s behavioral characteristics using the BNBAS. The nurse stresses appropriate bathing supplies and the need for safety in terms of water temperature and supervision of the infant at all times during the bath.

Encourage parents to examine every finger and toe of their infant during bathing. Frequently normal variations such as milia, erythema toxicum (rash), or “stork bites” worry parents who are unaware of the insignificance of such findings. Minor birth injuries may appear as major defects to them. Explaining how these occurred and when they will disappear reassures parents of their infant’s normalcy. Chapter 9 discusses common variations.

One of the most important considerations in skin cleansing is preservation of the skin’s “acid mantle,” which is formed by the uppermost horny layer of the epidermis; sweat; superficial fat; metabolic products; and external substances such as amniotic fluid, microorganisms, and chemicals. The infant’s skin surface has a pH of about 5 soon after birth, and the bacteriostatic effects of this pH are significant. In addition, newborn skin is covered with host-defense proteins, such as lysozyme and lactoferrin, which contribute importantly to a newborn’s defense against bacterial infections (Walker, Akinbi, Meinzen-Derr, et al, 2008). Consequently, use only plain warm water for routine bathing. If a cleanser is needed, Dove (fragrance free) has a neutral pH and is mild. Alkaline soaps, oils, powder, and lotions are not used because they alter the acid mantle, thus providing a medium for bacterial growth. Talcum powder has the added risk of aspiration if it is applied close to the infant’s face. Corn starch powder may also cause respiratory problems and aspiration. (See Diaper Dermatitis, Chapter 13.)

Parents should be involved in a discussion regarding the newborn’s bath at home. It is recommended that for the first 2 to 4 weeks the infant be bathed no more than two or three times per week with a plain warm sponge bath. This practice will help maintain the integrity of the newborn’s skin and allow time for the umbilical cord to dry completely. Routine daily bathing for newborns is no longer recommended.

Cleansing should proceed in the cephalocaudal (head-to-toe) direction. Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good. A diaper is applied after the bath, and the infant is clothed appropriately to prevent heat loss.

The nurse should discuss the choice of cloth or disposable diapers with parents. Disposable diapers are the most convenient, although a diaper service eliminates the need to shop for replacement diapers. Disposable diapers with absorbent gelling material have benefits related to preserving healthy skin; preventing diaper dermatitis, especially beyond the neonatal period (see Chapter 13); and controlling contamination of the environment because of their better containment of urine and feces.

Care of the Umbilicus

Because the umbilical stump is an excellent medium for bacterial growth, various methods of cord care have been practiced to prevent infection. Some methods popular in the past include the use of an antimicrobial agent such as bacitracin or triple dye, or agents such as alcohol or povidone. Many studies report that the use of antiseptic agents prolongs cord drying and separation (Zupan, Garner, and Omari, 2004; Dore, Buchan, Coulas, et al, 1998). Although studies regarding bacterial growth and colonization according to the cleansing method used have produced varied results (Janssen, Selwood, Dobson, et al, 2003; Golombek, Brill, and Salice, 2002; Dore, Buchan, Coulas, et al, 1998), a Cochrane Review of 21 studies found no significant difference between cords treated with antiseptics compared with dry cord care or placebo; there were no reported systemic infections or deaths, and a trend towards reduced colonization was found in cords treated with antiseptics (Zupan, Garner, and Omari, 2004). Current recommendations for cord care by the Association of Women’s Health, Obstetric and Neonatal Nurses (2007) includes cleaning the cord initially with sterile water or a neutral pH cleanser, then subsequently cleaning the cord with water.

Nurses working in neonatal care must carefully evaluate the available studies and compare the risks and benefits regarding the method of cord care within their own population of newborns and families. Particularly in the developing world, infants may encounter increased risk of potentially life-threatening sepsis; thus antimicrobial treatment may be appropriate in some settings (Mullany, Darmstadt, Katz, et al, 2009). A recent randomized controlled study showed that use of a newer antimicrobial for cord care, chlorhexidine powder, resulted in faster cord separation time and fewer complications than dry cord care (Kapellen, Gebauer, Brosteanu, et al, 2009). Regardless of the method used, nurses must teach parents about the importance of observation and monitoring of the cord, in addition to cord care methods, in discharge planning.

The diaper is placed below the cord to avoid irritation and wetness on the site. Parents are instructed regarding stump deterioration and proper umbilical care. The stump deteriorates through the process of dry gangrene. Cord separation time is influenced by a number of factors, including type of cord care, type of delivery, and other perinatal events. The average cord separation time is 5 to 15 days. It takes a few more weeks for the cord base to heal completely after cord separation. During this time, care consists of keeping the base clean and dry and observing for any signs of infection.

With early hospital discharge, newborns may be discharged before it is safe to remove the cord clamp. Teach the parent how to safely remove the clamp once the newborn is at least 24 hours old and no oozing from the cord is evident.

Circumcision

Circumcision, the surgical removal of the foreskin on the glans penis, is usually done in the hospital, although it is not a common practice in most countries. In the United States, however, circumcision rates have increased significantly over time: 61.1% of U.S. boys born from 1997 to 2000 were circumcised, compared with 48.3% of U.S. boys born from 1988 to 1991 (Nelson, Dunn, Wan, et al, 2005). Despite the frequency of the procedure in the United States, there is still much controversy regarding the benefits and risks (Box 8-5). One study that received considerable criticism demonstrated a ninefold increase in urinary tract infections in uncircumcised boys during the first year of life (Bartman, 2001; Schoen, Colby, and Ray, 2000). Other researchers have responded that such infections are best prevented by practicing good hygiene, rather than advocating an invasive procedure such as circumcision (Kinkade, Meadows, and Gracia-Trujillo, 2005).

Critical Thinking Exercise—Circumcision

Recently, research has explored the possible link between circumcision and reduced transmission of communicable illnesses such as human papillomavirus (HPV) and HIV in later life. Several researchers report that circumcision is associated with reduced likelihood of transmission of HPV in men known to be exposed (Lu, Wu, Nielson, et al, 2009; Nielson, Schiaffino, Dunne, et al, 2009). Warner, Ghanem, Newman, and colleagues (2009) report that circumcision is associated with substantially reduced transmission of HIV in men known to be exposed. There is concern, however, regarding findings from such observational studies, since there is no opportunity for control of confounding variables (factors other than circumcision that explain the results). A Cochrane Review cautioned against adoption of circumcision as a public health measure until stronger prospective studies demonstrate a clear link between lack of circumcision and disease transmission (Siegfried, Muller, Volmink, et al, 2003). Since that caution, some prospective studies have reported reduced risk of HIV transmission after adult circumcision in high-risk groups (Bailey, Moses, Parker, et al, 2007; Gray, Kigozi, Serwadda, et al, 2007). More research is needed to better understand any possible link between neonatal circumcision and subsequent risk of sexually transmitted infection.

The American Academy of Pediatrics (1999) issued a circumcision policy statement stating that the medical benefits of male newborn circumcision are not sufficiently significant to recommend it as a routine procedure. The academy statement emphasizes parental autonomy to determine what is in the best interest of their newborn boy. The policy encourages the physician to ensure that parents have been given accurate and unbiased information about the risks, benefits, and alternatives before making an informed choice and that they understand that circumcision is an elective procedure. In addition to examining the medical benefits of newborn circumcision, the academy recommended that if parents decide to have their male infant circumcised, procedural analgesia should be provided.

This policy statement has direct implications for nurses caring for newborns and their families. First, because nurses are in a unique position to educate parents regarding the care of their newborns, they must take responsibility for ensuring that each parent has accurate and unbiased information on which to make an informed decision. Parents need to know the options for pain control, especially the choice of topical or injected anesthesia, and their option of observing the procedure.*

Second, the nurse should use nonpharmacologic interventions as an adjunct to reduce the pain of this operative procedure (see Atraumatic Care box). Despite adequate scientific evidence that newborns feel and respond to pain, circumcisions are still performed in the United States with either insufficient analgesia or no analgesia at all. Nurses can use the academy’s policy statement to advocate more effectively for the use of optimum pain relief during circumcision.

Four types of anesthesia and analgesia are used in newborns undergoing circumcision: ring block, dorsal penile nerve block (DPNB), topical anesthetic such as EMLA (prilocaine-lidocaine), and oral sucrose. Oral acetaminophen and comfort measures such as music, sucking on a pacifier, and soothing voices have not proved to be effective in reducing the pain of circumcision when used alone (Williamson, 1997).

A Cochrane Review (Brady-Fryer, Wiebe, and Lander, 2004) reports that DPNB is the most frequently studied intervention and the most effective method of preventing circumcision pain. Ring block is also effective in reducing pain and is reported to be technically easier and potentially safer because it eliminates the risk of injecting lidocaine into the dorsal vessels. The topical application of EMLA to the penis before circumcision has also been helpful in reducing operative pain (Taddio, Ohlsson, and Ohlsson, 2000). An occlusive dressing must be placed over the cream, which must be applied approximately 1 hour before the procedure. Although this preparation may be perceived as complicated and requiring too much advance notice, it is important to remember that most newborns are kept NPO (nothing by mouth) for 1 to 2 hours before the procedure to prevent aspiration. In clinical practice, however, the issues of difficulty in application and time required to reach maximum effect may result in EMLA being used less often as an anesthetic (Brady-Fryer, Wiebe, and Lander, 2004). The use of EMLA cream for neonatal circumcision has not been associated with methemoglobinemia, a serious but rare complication associated with prilocaine. A localized rash has been associated with EMLA when used for circumcision.

A nonpharmacologic strategy for providing pain relief for circumcision is the use of intraoral sucrose. The administration of a concentrated dose of oral sucrose and nonnutritive sucking have proved more effective than no treatment in decreasing procedural pain (venipuncture, heel stick, circumcision) in full-term and preterm infants in many studies (Herschel, Khoshnood, Ellman, et al, 1998; Stevens, Taddio, Ohlsson, et al, 1997; Stevens, Johnston, Franck, et al, 1999). A Cochrane Review (Stevens, Yamada, and Ohlsson, 2004) concludes that oral sucrose is safe and effective for reducing procedural pain for single painful events, although the optimum dose for maximum pain relief is not yet known. Research addressing the use of sucrose as an adjunct to other nonpharmacologic and pharmacologic pain management methods is needed. Many nurses use intraoral sucrose to reduce the pain associated with procedures such as circumcision, venipuncture, and heel stick.

The Cochrane group exploring pain relief for neonatal circumcision (Brady-Fryer, Wiebe, and Lander, 2004) recommends that future research focus on benefits of infants receiving two or more active interventions for pain relief, and states that a placebo or no-treatment group is no longer acceptable. Studies exploring the use of several strategies concurrently, such as that conducted by Razmus, Dalton, and Wilson (2004), which included groups receiving both sucrose and ring block compared with ring block alone, have the most potential to clarify optimum strategies.

A recent Cochrane Review on pain relief for boys undergoing circumcision emphasized the need for postoperative pain relief (Cyna and Middleton, 2008). The authors advocate anticipating and controlling postoperative pain both to enhance patient comfort and to decrease crying and agitation that may increase the risk of postoperative bleeding.

Circumcision is usually performed in the nursery. It should not be performed immediately after delivery because of the neonate’s unstable physiologic status and increased susceptibility to stress. Preoperative nursing care includes allowing the infant nothing by mouth before the procedure to prevent aspiration of vomitus (about 1 to 2 hours); however, the necessity of this practice has been challenged (Kraft, 2003). Additional measures include the surgical time-out, checking for a signed consent form, and adequately restraining the infant, usually on a special board (Fig. 8-12) or physiologic circumcision restraint chair. The circumcision chair is padded and allows free movement of the newborn’s extremities without compromising the surgical field. In addition, the chair allows the infant to sit at a 30- to 45-degree angle, and it is adjustable to accommodate smaller newborns (Stang, Snellman, Condon, et al, 1997). All the equipment used for the procedure, such as gloves, instruments, dressings, and draping towels, must be sterile.

The procedure involves freeing the foreskin from the glans penis by using a scalpel, Gomco or Mogen clamp (see Cultural Competence box), or Plastibell. In the Gomco technique the foreskin is clamped, cut with a scalpel, and removed; the clamp crushes the nerve endings and blood vessels, promoting hemostasis. In the Plastibell procedure the foreskin is removed using a plastic ring and a string tied around the foreskin like a tourniquet. The excess foreskin is trimmed. In about 5 to 8 days the plastic ring separates and falls off.

Once the procedure is completed, the infant is released from the restraints and comforted. If the parents were not present during the procedure, they are informed of the infant’s status and reunited with their son.

Care of the circumcision depends on the type of procedure. If a clamp (Gomco or Mogen) was used, a petrolatum gauze dressing may be applied loosely to prevent adherence to the diaper. If the Plastibell was applied, no special dressing is required. Because the area is tender, the diaper is applied loosely to prevent friction against the penis. The circumcision is evaluated for excessive bleeding in the first few hours after the procedure, and the first void is recorded. A recommended standard is to evaluate the site every 30 minutes for at least 2 hours and then at least every 2 hours thereafter (Williamson, 1997).

Normally, on the second day a yellowish white exudate forms as part of the granulation process. This is not a sign of infection and is not forcibly removed. As healing progresses, the exudate disappears. Parents are educated to report any evidence of bleeding, unusual swelling, or absence of voiding to the practitioner.

Cultural Influences on Infant Feeding

Cultural beliefs and practices are significant influences on infant feeding methods. As many as 50 of 120 cultures studied typically do not give colostrum to newborns and only begin breast-feeding after the milk has “come in.” These groups include some Filipinos, Hispanics, Vietnamese, Hmong, Koreans, and Nigerians. When breast-feeding is delayed until the milk is in, babies are given prelacteal food. In India, infants may be fed liquids such as honey, tea, water, or sugar water before the initiation of breast-feeding (Choudhry, 1997). Other cultures begin breast-feeding immediately and offer the breast each time the infant cries. Cultural attitudes regarding modesty and breast-feeding are important considerations. Language barriers may also prevent successful breast-feeding and counseling in some situations. Even among Hispanic Spanish-speaking people, terminology used in one country for the act of breast-feeding or describing the breasts may be offensive in another Spanish-speaking country.

Hernandez (2006) suggests that knowledge of the Hispanic woman’s immigration status is important when discussing breast-feeding; U.S.-born Hispanic women are less likely to initiate breast-feeding, whereas those recently immigrated are more likely to continue the social norm of breast-feeding. Breast-feeding classes in Spanish for the new mother and grandmother may enhance discussion of practices related to exclusive breast-feeding in the first few months (Hernandez, 2006). Mexican women have a custom called la cuarentena, which means the woman has 40 days of rest after giving birth; during this time the mother is relieved of housekeeping duties and may focus on the new infant. The maternal grandmother traditionally assists the mother during this time. Other Hispanic customs related to infant feeding include the belief in herbal teas consumed by the breast-feeding mother to settle the infant’s stomach; commonly given teas include manzanilla (chamomile) and anise. In Hispanic families the breast-feeding mother commonly consumes traditional cultural foods to acculturate the infant to such foods (Hernandez, 2006).

The Muslim and Jewish cultures value breast-feeding of infants. Muslim women also have the tradition of the 40-day rest period in which the woman is relieved of housekeeping duties and other women help care for her. During this time the mother may exclusively breast-feed; however, Muslim women typically terminate exclusive breast-feeding early in infancy (Chertok, Shoham-Vardi, and Hallak, 2004). Breast-feeding for Jewish women is perceived as being important but is highly influenced by maternal education level, assimilated cultural values depending on geographic region of origin, and previous breast-feeding experience (Chertok, Shoham-Vardi, and Hallak, 2004).

With the large percentage of immigrants in the United States, it is incumbent on nurses to discuss cultural values related to breast-feeding and the benefits of breast-feeding so the mother can make an informed decision. Hernandez (2006) relates the story of a young Mexican woman who delivered an infant in the United States but started bottle-feeding instead of breast-feeding. When asked about this, she told the nurse that since there was a packet of formula in the infant’s crib at discharge, she interpreted this as the cultural norm in the United States and did not breast-feed. The nursing implications are clear: clarify with the mother what her expectations are regarding infant feeding and assist her in meeting those goals.

Sociocultural values may preclude the mother receiving adequate information regarding breast-feeding; for example, if the family is strongly patriarchal and the father is the only English-speaking person in the family, the necessary information being conveyed to the mother by the health care provider may not be correctly translated. Persons immigrating to the United States often tend to acquire the local customs, and, although breast-feeding may have been common in their own country, they may abandon the practice in the United States, considering it “outdated” (Riordan and Gill-Hopple, 2001) (see Cultural Competence box).

Human Milk

Human milk is the best option for infant nutrition up to 1 year of age. Breast milk consists of a number of micronutrients that are bioavailable, meaning these nutrients are available in quantities and qualities that make them easily digestible by the newborn and absorbed for energy and growth. A variety of immunologic properties are found exclusively in human milk. Human milk has been shown to be effective in protecting the newborn against respiratory tract infections and decreasing the incidence of hospital admissions for respiratory tract illnesses in generally healthy infants (Bachrach, Schwarz, and Bachrach, 2003); gastrointestinal infections caused by enterococci; otitis media, numerous allergies, and atopy; and type 2 diabetes (Beaudry, Dufour, and Marcoux, 1995; Dewey, Heinig, and Nommsen-Rivers, 1995; Scariati, Grummer-Strawn, and Fein, 1997; Young, Martens, Taback, et al, 2002). Some studies have demonstrated that breast-feeding has an analgesic effect on newborns during painful procedures such as heel puncture (Gray, Miller, Phillip, et al, 2002; Carbajal, Veerapen, Couderc, et al, 2003).

The fat content of human milk is composed of lipids, triglycerides, and cholesterol; cholesterol is an essential element for brain growth. The function of these lipids is to allow optimum intestinal absorption of fatty acids and provide essential fatty acids and polyunsaturated fatty acids. Furthermore lipids contribute approximately 50% of the total calories in human milk (Lawrence and Lawrence, 2005). Although the overall fat content in human milk is higher than that of cow’s milk–based formula, it is used more efficiently by the infant.

The primary source of carbohydrate in human milk is lactose, which is present in higher concentrations (6.8 g/dl) than in cow’s milk–based formula (4.9 g/dl). Other carbohydrates found in human milk include glucose, galactose, and glucosamine. The carbohydrates serve not only as a large percentage of the total calories in human milk, but also have a protective function; the oligosaccharides (prebiotic) in human milk stimulate the growth of Lactobacillus bifidus (a probiotic) and prevent bacteria from adhering to epithelial surfaces (Lawrence and Lawrence, 2005).

Human milk contains the two proteins, whey (lactalbumin) and casein (curd), in a ratio of approximately 60:40 (versus 20:80 to 100% whey in different brands of cow’s milk–based formula). This ratio in human milk makes it more digestible and produces the soft stools seen in infants who breast-feed. Thus human milk has a laxative effect and constipation is uncommon. The whey protein, lactoferrin, in human milk has iron-binding characteristics with bacteriostatic capabilities, particularly against gram-positive and gram-negative aerobes, anaerobes, and yeasts (Lawrence and Lawrence, 2005).

Lysozyme is found in large quantities in human milk with bacteriostatic functions against gram-positive bacteria and Enterobacteriaceae organisms. Human milk also contains numerous other host defense factors such as macrophages, granulocytes, and T and B lymphocytes. Casein in human milk greatly enhances the absorption of iron, thus preventing iron-dependent bacteria from proliferating in the gastrointestinal tract (Biancuzzo, 2003). Secretory immunoglobulin A (IgA) is found in high levels in colostrum, but levels gradually decrease over the first 14 days of life. Secretory IgA is an immunoglobulin that prevents viruses and bacteria from invading the intestinal mucosa in breast-fed newborns, thus protecting them from infection (Hanson and Korotkova, 2002). This whey protein is also believed to play an important role in preventing the development of allergies (Biancuzzo, 2003).

Several digestive enzymes also present in human milk include amylases, lipases, proteases, and ribonucleases, which enhance digestion and absorption of various nutrients (Lawrence and Lawrence, 2005). The amounts of lipid- and water-soluble vitamins, as well as electrolytes, minerals, and trace elements, in human milk are sufficient for infant growth, development, and energy needs during the first 6 months of life. The one possible exception is vitamin D, which is found in varying amounts depending on the mother’s intake of vitamin D–fortified food and exposure to ultraviolet light. Therefore, to prevent vitamin D deficiency rickets, the American Academy of Pediatrics (Wagner, Greer, and American Academy of Pediatrics, 2008) now recommends that infants who are exclusively breast-fed, who are breast-fed and consuming less than 1000 ml of vitamin D–fortified formula or milk per day, or who are ingesting less than 1000 ml/day of vitamin D–fortified formula or milk be supplemented with 400 international units of vitamin D (oral) per day. In addition, older children who do not consume at least 400 international units of vitamin D–fortified milk or vitamin D–fortified foods should receive a supplement of 400 international units of vitamin D daily. The Canadian Paediatric Society (2007) suggests that for children living in its northernmost climates, it may be reasonable to double this recommendation to 800 international units per day, to compensate for extremely limited exposure to sunlight.

Studies have also shown that feeding infants human milk produces children with higher intelligence than their counterparts fed on cow’s milk–based formula (Anderson, Johnstone, and Remley, 1999; Lanting, Fidler, Huisman, et al, 1994). Additional beneficial components of human milk include prostaglandins; epidermal growth factor; docosahexaenoic acid (DHA); arachidonic acid (AA); taurine; carnitine; cytokine; interleukins; and natural hormones such as thyroid-releasing hormone, gonadotropin-releasing hormone, and prolactin.

Human milk also has variations related to the timing of the lactation cycle. Colostrum, for example, is rich in immunoglobulins and vitamin K and has a higher protein content than mature milk; however, it has a lower fat content. Transitional milk replaces colostrum when the mother’s milk supply starts increasing, and eventually mature milk becomes the primary milk source. There is also diurnal variation in the biochemistry of mature human milk. Human milk also varies with respect to gestational age; preterm human milk differs from mature milk in its biochemical composition (Lawrence and Lawrence, 2005). Nonphysiologic advantages of human milk are discussed in the next section.

Breast-Feeding

Human milk is the preferred form of nutrition for the full-term infant. Healthy People 2020 has a goal to increase breast-feeding rates in the United States to 75% in early postpartum and to 50% for mothers who continue to breast-feed for at least 6 months US Department of Health and Human Services, 2009). Data from the 2003 Ross Mothers Survey indicate that the overall rate of breast-feeding in the hospital was 66%, down four points from 2002 (70.1%); breast-feeding at 6 months of age in 2003 was reported to be 32.8%, down slightly from the previous year (33.2%) (Ross Mothers Survey, 2003). The Centers for Disease Control and Prevention (2007) analyzed data from the National Immunization Survey and found that, among infants born in 2004, 30.5% and 11.3% were exclusively breast-feeding at 3 and 6 months, respectively. Both surveys found similar disparities in breast-feeding rates: lower breast-feeding rates at 6 months occurred in African-American women and in women without a college degree. Full-time employment at 6 months was a strong contributing factor to the decrease in breast-feeding, and enrollment in the Women, Infants, and Children (WIC) program was also found to have a negative impact on the initiation of breast-feeding in the hospital (55.2% for non-WIC versus 32.3% for WIC participants) (Ross Mothers Survey, 2003).

Case Study—Breast-Feeding

In a survey breast-feeding mothers indicated that the determining factors for changing to bottle-feeding included the mother’s perception of the father’s attitude toward breast-feeding and the mother’s uncertainty regarding the amount of milk the infant would receive (Arora, McJunkin, Wehrer, et al, 2000). These findings have important implications for involving fathers in education and discussion regarding breast-feeding before and during the pregnancy. Fathers may feel left out during the newborn period if they have little involvement other than diapering and holding the infant. Encouraging fathers regarding their positive role in supporting the mother in her breast-feeding may help decrease feelings of isolation, benefit mother-infant interaction, and decrease a sense of helplessness and isolation.

The American Academy of Pediatrics (2005b) has reaffirmed its position recommending exclusive breast-feeding until 6 months of age, with continued breast-feeding to at least 1 year of age and beyond as long as is mutually desirable by mother and infant. The academy also supports programs that enable women to continue breast-feeding after returning to work. In its support of breast-feeding practices, the academy further discourages the advertisement of infant formula to breast-feeding mothers and distribution of formula discharge packs without the advice of a health care provider.

The Baby-Friendly Hospital Initiative (BFHI) is a joint effort of the World Health Organization and UNICEF to promote and support breast-feeding as the model for optimum infant nutrition. BFHI developed 10 research-supported practices as guidelines for maternity facilities worldwide to promote breast-feeding (Kyenkya-Isabirye, 1992; Wright, Rice, and Wells, 1996) (Box 8-7).

In addition to the physiologic qualities of human milk, the most outstanding psychologic benefit of breast-feeding is the close maternal-child relationship. The infant is nestled close to the mother’s skin, can hear the rhythm of her heartbeat, can feel the warmth of her body, and has a sense of peaceful security. The mother has a close feeling of union with her child and feels a sense of accomplishment and satisfaction as the infant suckles milk from her.

Human milk is the most economical form of feeding. It is always available, ready to serve at room temperature, and free of contamination. The projected monetary savings for a population of breast-feeding infants in relation to preventive medicine are considered significant (Ball and Wright, 1999; Montgomery and Splett, 1997). Although human milk is not sterile, healthy full-term infants can tolerate varying amounts of nonpathogenic and pathogenic organisms. The protection against infection can provide additional cost savings in terms of fewer medical visits and less time lost from work for the employed mother.

Breast-fed infants, especially beyond 2 to 3 months of age, tend to grow at a satisfactory but slower rate than bottle-fed infants (Dewey, Heinig, Nommsen, et al, 1991; de Onis and Onyango, 2003). Infants who are exclusively breast-fed have decreased amount of free fat and thus tend to appear leaner than their formula-fed counterparts (Butte, Wong, Hopkinson, et al, 2000; Dewey, Heinig, Nommsen, et al, 1993). The National Center for Health Statistics’ growth charts (see Appendix B) have been adjusted to reflect exclusively breast-fed infants, who have a slower growth rate during the first several months of life. By the age of 12 to 15 months breast-fed infants weigh approximately the same as their bottle-fed counterparts.

Contraindications to breast-feeding include (Lawrence and Lawrence, 2005; American Academy of Pediatrics, 2005b):

A small number of medications are contraindicated for breast-feeding mothers. Consult a reference text such as Hale (2008). Mastitis is usually not a contraindication if the discomfort is tolerable.

Some herbal products are presented as safe and effective alternatives to prescription or over-the-counter medications. Certain herbal agents, namely the galactogogues, are reported to increase breast milk production. Data are still insufficient to confirm or deny the assertion of increased milk production using galactogogues, and nurses should caution mothers to seek advice from a practitioner to ensure that the herbal preparations will not harm the breast-feeding infant (Conover and Buehler, 2004).

Breast-feeding can be done with twin births and other multiples. If the infants are full term, they can begin feedings immediately after birth (Fig. 8-13). Simultaneous feeding promotes the rapid production of milk needed for both infants and makes the milk that would normally be lost in the let-down reflex available to one of the twins. When only one infant is hungry, the mother should feed singly. She should also alternate breasts when feeding each infant and avoid favoring one breast for one infant. The sucking patterns of infants vary, and each infant needs the visual stimulation and exercise that alternating breasts provides.

A concern many mothers have is the perceived inconvenience of loss of freedom and independence. Being committed to feeding the infant every 2 to 3 hours can be overwhelming, especially to women with multiple responsibilities. Many women resume their careers shortly after their pregnancy and prefer to bottle-feed. Combining breast-feeding and employment is possible, and Chapter 12 discusses suggestions for the mother. Although breast-feeding is the preferred form of infant feeding, mothers’ decisions regarding their preferences must be supported and respected.

Successful breast-feeding probably depends more on the mother’s desire to breast-feed, satisfaction with breast-feeding, and available support systems than on any other factors. Mothers need support, encouragement, and assistance during their postpartum hospital stay and at home to enhance their opportunities for success and satisfaction.

Three main criteria have been proposed as essential in promoting breast-feeding: absence of a rigid feeding schedule, correct positioning of the infant at the breast to achieve a deep alveolar latch, and correct suckling technique. Correct suckling for breast-feeding is defined as a wide-open mouth, tongue under the areola, and expression of milk by effective alveolar compression (Fig. 8-14).

The following interventions promote breast-feeding:

Nurses play a significant role in the breast-feeding decision and must make themselves available to families for guidance and support. Several excellent books and organizations, such as La Leche League International,* are available as resources for professionals and breast-feeding mothers.

Bottle-Feeding

Bottle-feeding generally refers to the use of bottles for feeding commercial or evaporated milk formula rather than using the breast, although in some instances human milk may be expressed and fed with a bottle. Bottle-feeding is an acceptable method of feeding. However, nurses should not assume that new parents automatically know how to bottle-feed their infant. Parents who choose bottle-feeding also need support and assistance in meeting their infant’s needs.

Providing newborns with nutrition is only one aspect of the feeding. Holding them close to the body while rocking or cuddling them helps ensure the emotional component of feeding. Like breast-fed infants, bottle-fed infants need to be held on alternate sides of the lap to expose them to different stimuli. The feeding should not be hurried. Even though they may suck vigorously for the first 5 minutes and seem to be satisfied, they should be allowed to continue sucking. Infants need at least 2 hours of sucking a day. If there are six feedings per day, then about 20 minutes of sucking at each feeding provides for oral gratification.

Propping the bottle is discouraged because:

Feeding Schedules

Ideally, feeding schedules should be determined by the infant’s hunger. Demand feedings are given when the infant signals readiness. Scheduled feedings are arranged at predetermined intervals. Some hospitals routinely feed infants every 3 to 4 hours. Although this may be satisfactory for bottle-fed infants, it hinders the breast-feeding process. Since breast-fed infants tend to be hungry every 2 to 3 hours because of the easy digestibility of the milk, they should be fed on demand.

Supplemental feedings should not be offered to breast-fed infants before lactation is well established because they may satiate the infant and may cause nipple preference. Supplemental water is not needed by breast- or bottle-fed infants, even in hot climates (American Academy of Pediatrics, 2009a). Satiated infants suck less vigorously at the breast, and milk production depends on the breast being emptied at each feeding. If milk is allowed to accumulate in the ducts, causing breast engorgement, ischemia results, suppressing the activity of the acini, or milk-secreting cells. Consequently, milk production is reduced. In addition, the process of sucking from a bottle is different from breast nipple compression. The relatively inflexible rubber nipple prevents the tongue from its usual rhythmic action. Infants learn to put the tongue against the nipple holes to slow down the more rapid flow of fluid. When infants use these same tongue movements during breast-feeding, they may push the human nipple out of the mouth and may not grasp the areola properly.

Usually by 3 weeks of age, lactation is well established. Bottle-fed infants consume about 2 to 3 oz of formula at each feeding and are fed approximately six times a day. The quantity of formula consumed is based on the caloric need of 108 kcal/kg/day; therefore a newborn who weighs 3 kg (6.6 lb) requires 324 kcal/day. Because commercial formula for full-term infants has 20 kcal/oz, about 480 ml (16 oz) will provide the daily caloric requirement. Breast-fed infants may feed as frequently as 10 to 12 times a day.

Feeding Behavior

Five behavioral stages occur during successful feeding. Recognizing these steps can assist nurses in identifying potential feeding problems caused by improper feeding techniques (see discussion of NCAST Feeding Scale, p. 234). Prefeeding behavior, such as crying or fussing, demonstrates the infant’s level of arousal and degree of hunger. To encourage the infant to grasp the breast properly, it is preferable to begin feeding during the quiet alert state, before the infant becomes upset. Approach behavior is indicated by sucking movements or the rooting reflex.

Attachment behavior includes those activities that occur from the time the infant receives the nipple and sucks (sometimes more pronounced during initial attempts at breast-feeding). Consummatory behavior consists of coordinated sucking and swallowing. Persistent gagging might indicate unsuccessful consummatory behavior. Satiety behavior is observed when infants let the parent know that they are satisfied, usually by falling asleep.

Commercially Prepared Formulas

The analysis of human and whole cow’s milk indicates that the latter is unsuitable for infant nutrition. Whole cow’s milk has a high protein content, has low fat and lipid content, and may cause intestinal bleeding and lead to iron deficiency anemia in infants. There has also been some question regarding the unmodified protein content of whole cow’s milk, which may trigger an undesired immune response and thus increase the incidence of allergies in children at an early age.

Commercially prepared formulas are cow’s milk–based formulas that have been modified to resemble the nutritional content of human milk. These formulas are altered from cow’s milk by removing butterfat, decreasing the protein content, and adding vegetable oil and carbohydrate. Some cow’s milk–based formulas have demineralized whey added to yield a whey/casein ratio of 60:40. The standard cow’s milk–based formulas, regardless of the commercial brand, have similar compositions of vitamins, minerals, protein, carbohydrates, and essential amino acids, with minor variations such as the source of carbohydrate (Akers and Groh-Wargo, 2005), nucleotides to enhance immune function, and long-chain polyunsaturated fatty acids (LCPUFAs) DHA and AA, which are thought to improve brain function (Georgieff, 2001; Gil, Ramirez, and Gil, 2003). DHA and AA are both found in large quantities in human milk but until recently were not present in most infant formulas. Studies in full-term infants receiving supplements with DHA and AA have produced mixed results regarding brain function and visual acuity. Many studies report a variety of sources for LCPUFAs, including egg yolk lipid, phospholipids, and triglyceride. The evidence for supplementation of formula for preterm infants with LCPUFAs, however, has been more convincing; it produces some transient improvement in visual acuity and general development (American Academy of Pediatrics, 2009a). There do not appear to be any adverse effects associated with LCPUFA supplementation in preterm infants with respect to the incidence of bronchopulmonary disease, necrotizing enterocolitis, or other conditions of prematurity (American Academy of Pediatrics, 2009a). Standard cow’s milk–based formulas are also sold as low iron and iron fortified; however, only the iron-fortified formulas meet the iron requirements of infants (American Academy of Pediatrics, 2009a).

The presence of the probiotics Lactobacillus rhamnosus GG and Bifidobacterium lactis in breast milk has led to the addition of prebiotic components to cow’s milk–based formula. Prebiotic oligosaccharides are food ingredients that promote the growth and activity of bacteria such as Lactobacillus and Bifidobacterium, which benefit the host (Douglas and Sanders, 2008; Vandenplas, 2002). Some of the reported advantages include a decreased number of intestinal infections, otitis media, and acute respiratory tract infections (Rautava, Salminen, and Isolauri, 2009). The addition of a prebiotic oligosaccharide was reported to have modified formula-fed infants’ intestinal flora and aided in decreasing upper respiratory tract and gastrointestinal infections (Arslanoglu, Moro, and Boehm, 2007).

Commercially prepared infant formulas fall into four main categories: (1) cow’s milk–based formulas, available in 20 kcal/fl oz as liquid (ready to feed), as powder (requires dilution with water), or as a concentrated liquid (requires dilution with water); (2) soy-based formulas, available commercially in ready-to-feed 20 kcal/fl oz powder and concentrated liquid forms, commonly used for children who are lactose or cow’s milk protein intolerant; (3) casein- or whey-hydrolysate formulas, commercially available in ready-to-feed and powder forms and used primarily for children who cannot tolerate or digest cow’s milk or soy-based formulas; and (4) amino acid formulas.

The American Academy of Pediatrics Committee on Nutrition (2008c) recommends the use of soy protein–based formulas for infants with galactosemia and hereditary lactase deficiency, and in situations where a vegetarian diet is preferred. For infants with documented allergies caused by cow’s milk, extensively hydrolyzed protein formula should be considered, since up to 14% of these infants will also have a soy protein allergy. Some researchers have speculated that exclusive use of soy formula in infants may adversely affect their endocrine, reproductive, and immune systems. This concern is related to isoflavones in soy and possible alteration in sexual maturity, immune response, and thyroid function (Greim, 2004; Chen and Rogan, 2004). Chen and Rogan (2004) note an urgent need to evaluate the effects of isoflavones in soy infant formula clinically, prospectively, and longitudinally. Others report no long-term untoward effects from the ingestion of isoflavones in soy formula (Merritt and Jenks, 2004; Giampietro, Bruno, Furcolo, et al, 2004). The American Academy of Pediatrics (2008c) states that there is currently no conclusive evidence that dietary soy products adversely affect human development, reproduction, or endocrine function.

The casein- or whey-hydrolysate formulas are considered to be less antigenic than either cow’s milk– or soy-based formulas. The protein hydrolysate formulas (casein and whey) are derived from cow’s milk–based formula by a process of heat, filtration, and enzyme treatment designed to break the peptide chains into more digestible proteins. The hydrolysate formulas have the reported disadvantage of tasting bad; some have commercially added flavoring. Neocate and EleCare are amino acid formulas, designed for infants who are extremely sensitive to cow’s milk–based, soy-based, and partially or extensively hydrolyzed casein- and whey-based formulas. Both Neocate and EleCare are available in powder form. A variety of formulas are manufactured for infants and children with special needs (Table 8-6).

Follow-up formulas are marketed as a transitional formula for infants older than 6 months who are also eating solid foods. These generally contain a higher percentage of calories from protein and carbohydrate sources, a higher amount of iron and vitamins, and a lower amount of fat than standard cow’s milk–based formulas. Many nutrition experts and the American Academy of Pediatrics (2009c), however, discount the necessity of follow-up formulas if the infant is receiving an adequate amount of solid food containing sufficient iron, vitamins, and minerals.

Alternate Milk Products

In the United States few infants are fed evaporated milk formula, and its use is not recommended by the American Academy of Pediatrics (2009c). However, it has many advantages over whole milk. It is readily available in cans; needs no refrigeration if unopened; is less expensive than commercial formula; provides a softer, more digestible curd; and contains more lactalbumin and a higher calcium/phosphorus ratio. Disadvantages of evaporated milk for infant nutrition include low iron and vitamin C concentrations, excessive sodium and phosphorus, decreased vitamin A and D (except in fortified forms), and poorly digested fat (Akers and Groh-Wargo, 2005). A common method for preparing evaporated milk formula is diluting the 13-oz can of milk with oz of water and adding 3 tbsp of sugar or commercially processed corn syrup.

Evaporated milk must not be confused with condensed milk, which is a form of evaporated milk with 45% more sugar. Because of its high carbohydrate concentration and disproportionately low fat and protein content, condensed milk is not used for infant feeding. Likewise, skim milk and low-fat milk must not be used because they are deficient in caloric concentration, significantly increase the renal solute load and water demands, and deprive the body of essential fatty acids.

Goat’s milk is a poor source of iron and folic acid. It has an excessively high renal solute load as a result of its high protein content and can cause metabolic acidosis, making it unsuitable for infant nutrition (American Academy of Pediatrics, 2009c; Hendriksz and Walter, 2004). Some parents believe that goat’s milk is less allergenic than other available milk sources and may feed it to their infants to reduce allergic milk reactions. However, infants allergic to cow’s milk have experienced anaphylaxis with their first exposure to goat’s milk (Pessler and Nejat, 2004).

Raw, unpasteurized milk from any animal source is unacceptable for infant nutrition.

Infant Behavior

Nurses must appreciate the individuality and uniqueness of each infant. According to the individual temperament, the infant will change and shape the environment, which will undoubtedly influence future development. An infant who sleeps 20 hours a day will be exposed to fewer stimuli than one who sleeps 16 hours a day. In turn, each infant will likely elicit a different response from parents. The infant who is quiet, undemanding, and passive may receive much less attention than the infant who is responsive, alert, and active. Behavioral characteristics such as irritability and consolability can influence the ease of transition to parenthood and the parent’s perception of the infant.

Nurses can positively influence the attachment of parent and child. The first step is recognizing individual differences and explaining to parents that such characteristics are normal. For example, some people believe that infants sleep throughout the day, except for feedings. For some newborns this may be true, but for many it is not. Understanding that the infant’s wakefulness is part of biologic rhythm and not a reflection of inadequate parenting can be crucial in promoting healthy parent-child relationships. Another aspect of helping parents involves supplying guidelines on how to enhance the infant’s development during awake periods. Placing the child in a crib to stare at the same mobile every day is not exciting, but carrying the infant into each room as one does daily chores can be fascinating. A few suggestions can make life more stimulating for the infant and gratifying for the parents (Box 8-8).

Maternal Attachment

Research has suggested that there is a maternal sensitive period immediately and for a short time after birth when mothers have a unique ability to attach to their infants (Klaus, Kennell, and Klaus, 1995). Mothers demonstrate a predictable and orderly pattern of behavior during the attachment process. When mothers are presented with their nude infants, they begin to examine the infant with their fingertips, concentrating on touching the extremities, and then proceed to massage and encompass the trunk with their entire hands. Assuming the en face position, in which the mother’s and infant’s eyes meet in visual contact in the same vertical plane, is significant in the formation of affectional ties (Fig. 8-15). Although similar patterns of touching have been observed, additional studies demonstrate different patterns for mothers, as well as the same pattern for nonmaternal persons, such as male and female nurses. Consequently, nurses must exercise caution in interpreting behaviors such as touching.

Several studies have attempted to substantiate the long-term benefits of providing parents with opportunities to optimally bond with their infant during the initial postpartum period. Although there is some evidence that increased parent-child contact encourages prolonged breast-feeding and may minimize the risks of parenting disorders, conclusions about the long-term effects of such early intervention on parenting and child development must be viewed cautiously. In addition, some authorities claim that the emphasis on bonding has been unjustified and may lead to guilt and fear in parents who did not have early contact with their infant. There is concern that literal interpretation of “sensitive” or “critical” might imply that, without early contact, optimum bonding cannot occur or, conversely, that early contact alone is sufficient to ensure competent parenting.

The nurse should stress to parents that, although early bonding may be valuable, it does not represent an “all or none” phenomenon. Throughout the child’s life there will be multiple opportunities for the development of parent-child attachment. Bonding is a complex process that develops gradually and is influenced by numerous factors, only one of which is the type of initial contact between the newborn and parent. In a concept analysis of parent-infant attachment, Goulet, Bell, St-Cyr, and colleagues (1998) describe attributes of parent-infant attachment as proximity, reciprocity, and commitment. Within these attributes are further dimensions, which include contact, emotional state, individualization, complementarity, sensitivity, centrality, and parent role exploration. The researchers describe the parent-infant attachment process as one that is complex and therefore cannot be evaluated simply by the observations of attitudes and behaviors of parents toward their infants. Further research into the reciprocal relationships between infant and parent and the situational factors that influence such relationships are recommended.

One component of successful maternal attachment is reciprocity (Brazelton, 1974). As the mother responds to the infant, the infant must respond to the mother by some signal, such as sucking, cooing, eye contact, grasping, or molding (conforming to other’s body during close physical contact). The first step is initiation, in which interaction between infant and parent begins. Next is orientation, which establishes the partners’ expectations of each other during the interaction. Following orientation is acceleration of the attention cycle to a peak of excitement. The infant reaches out and coos, both arms jerk forward, the head moves backward, the eyes dilate, and the face brightens. After a short time, deceleration of the excitement and turning away occur, in which the infant’s eyes shift away from the mother’s and the child may grasp his or her own shirt. During this cycle of nonattention, repeated verbal or visual attempts to reinitiate the infant’s attention are ineffective. This deceleration and turning away probably prevent the infant from being overwhelmed by excessive stimuli. In a good interaction both partners have synchronized their attention-nonattention cycles. Parents or other caregivers who do not allow the infant to turn away and who continually attempt to maintain visual contact may encourage the infant to turn off the attention cycle and thus prolong the nonattention phase.

Although this description of reciprocal interacting behavior is usually observed in the infant by 2 to 3 weeks of age, nurses can use this information to teach parents how to interact with their infant. Recognizing the attention versus nonattention cycles and understanding that the latter is not a rejection of the parent helps parents develop competence in parenting. A recent study reported that co-regulation, where mothers and infants understood and responded appropriately to such cues as attention and inattention, was linked with increased attachment and better infant mental and psychomotor development (Evans and Porter, 2009). There are reports that maternal postpartum depression negatively affects attachment to the infant unless specific interventions are implemented. In one study mothers who were depressed showed a decreased sensitivity to the infants’ needs and expressed fewer affirmations of their infants’ behaviors and more negations when compared with nondepressed mothers (Murray, Fiori-Cowley, Hopper, et al, 1996). Insecure infant attachments were more likely to occur in depressed mothers when measured at 18 months postpartum. Overall, infants of depressed mothers showed no more pervasive distress or avoidance than the nondepressed control group, but did demonstrate more instances of disruptive behavior, which were precipitated by maternal negating. Conversely, a recent study of pregnant women demonstrated that concerns about attachment prenatally contribute to an increased risk for postpartum depression (Monk, Leight, and Fang, 2008).

Paternal Engrossment

Fathers also show specific attachment behaviors to the newborn. This process of paternal engrossment, forming a sense of absorption, preoccupation, and interest in the infant, includes (1) visual awareness of the newborn, especially focusing on the child’s beauty; (2) tactile awareness, often expressed in a desire to hold the infant; (3) awareness of distinct characteristics with emphasis on those features of the infant that resemble the father; (4) perception of the infant as perfect; (5) development of a strong feeling of attraction to the child that leads to intense focusing of attention on the infant; (6) extreme elation; and (7) a sense of deep self-esteem and satisfaction. These responses are greatest during the early contacts with the infant and are intensified by the neonate’s normal reflex activity, especially the grasp reflex and visual alertness. In addition to behavioral reactions, fathers also demonstrate physiologic responses such as increased heart rate and blood pressure during interactions with their newborns. In one study the attachment scores of inexperienced or first-time fathers were not significantly different from the attachment scores of experienced fathers. The researchers found support for the concept that the love relationship a father develops for a second or subsequent child is as strong and unique as for the first child (Ferketich and Mercer, 1995).

Fathers of preterm infants reported they first felt a bond or love with their high-risk newborn when they held the infant for the first time; the earlier the father was able to hold his infant, the earlier the father reported feelings of warmth and love for the newborn (Sullivan, 1999).

The process of engrossment has significant implications for nurses. It is imperative to recognize the importance of early father-infant contact in this process. Fathers need to be encouraged to express their positive feelings, especially if such emotions are contrary to any belief that fathers should remain stoic. If this is not clarified, fathers may feel confused and attempt to suppress the natural sensations of absorption, preoccupation, and interest to conform with societal expectations.

Mothers also need to be aware of the responses of the father toward the newborn, since one of the consequences of paternal preoccupation with the infant is less overt attention toward the mother. If both parents are able to share their feelings, each can appreciate the process of attachment toward their child and will avoid the unfortunate conflict of being insensitive and unaware of the other’s needs. In addition, a father who is encouraged to form a relationship with his newborn is less likely to feel excluded and abandoned once the family returns home and the mother directs her attention toward caring for the infant.

Ideally, the process of engrossment should be discussed with parents before the delivery, such as in prenatal classes, to reinforce the father’s awareness of his natural feelings toward the expected child. Focusing on the future experience of seeing, touching, and holding one’s newborn may also help expectant fathers become more comfortable in accepting their paternal feelings. This in turn can assist them in being more supportive toward the mother, especially as labor and delivery draw near.

At the infant’s birth the nurse can play a vital role in helping the father express engrossment by assessing the neonate in front of the couple; pointing out normal characteristics; encouraging identification through consistent referral to the child by name; encouraging the father to cuddle, hold, and talk to the infant; and demonstrating whenever necessary the soothing powers of caressing, stroking, and rocking the child (Fig. 8-16).

The father’s role in supporting the mother during this period cannot be overemphasized. Once the mother has held the newborn skin-to-skin the father may also be encouraged to hold the newborn skin-to-skin while the mother rests. Fathers are encouraged to be with the mother during labor and delivery, to spend time alone with the mother and newborn after delivery, and to “room in” with the mother and infant. Education programs should be made available to new fathers and include information on holding the newborn, bathing, assisting the mother with breast-feeding, problems associated with breast-feeding and potential solutions, and care of the newborn at home (including safety). The integration of the father into the existing dyad of mother-newborn to form a new family—a triad—will help solidify his role as parent and partner in the care and support of his family.

The nurse watches for the same indications of affection from the father as those expected in the mother, such as visual contact in the en face position and embracing the infant close to the body. When present, such behaviors are reinforced. If such responses are not obvious, the nurse needs to assess the father’s feelings regarding this birth, cultural beliefs that may prevent his expression of emotions, and other factors to facilitate his positive attachment during this critical period.

Siblings

Although the attachment process has been discussed almost exclusively in terms of the parents and infants, it is essential that nurses be aware of other family members, such as siblings, grandparents, and members of the extended family, who need preparation for the acceptance of this new child. Young children in particular need sensitive preparation for the birth to minimize sibling jealousy.

In support of family-centered care, there is an increasing trend to encourage siblings to visit the mother on the postpartum unit and to hold the newborn (Fig. 8-17). Another trend has been the presence of siblings at childbirth. Unlike sibling visitation, this practice has been controversial, yet truly family-centered care encompasses siblings, grandparents, and other significant persons from the extended family unit (Tomlinson, Bryan, and Esau, 1996). The American Academy of Pediatrics and American College of Obstetricians and Gynecologists (2007) support the presence of siblings at childbirth and visitation of the newborn and mother; basic guidelines for infection control and adult supervision are also recommended. Children exhibit different degrees of involvement in the birth process. Young children may fall asleep toward the end of delivery. Some reported benefits include children’s increased knowledge of the birth process, less regressive behavior after the birth, and more mothering and caregiving behavior toward the infant. Some practitioners add facilitated family bonding and assimilation of the newborn into the family as positive outcomes. Parents whose children attended the birth have echoed these same benefits and have expressed their desire to repeat the experience should another pregnancy occur. Despite these positive findings, opponents believe that allowing children to observe a delivery could lead to emotional difficulties, although no research supports this contention. As research mounts, birthing centers that allow siblings at the birth are developing more definitive guidelines, such as an age requirement of at least 4 to 5 years, the presence of a supportive person for the sibling only, and an adequate sequence of preparation in which parents explore all options for preparing their other children.

From observations during sibling visitation, there is evidence that sibling attachment occurs. However, the en face position is assumed much less often among the newborn and siblings than between mother and newborn, and when this position is used, it is brief. Siblings focus more on the head or face than on touching or talking to the infant. The siblings’ verbalizations are focused less on attracting the infant’s attention and more on addressing the mother about the newborn. Children who have established a prenatal relationship with the fetus have demonstrated more attachment behaviors, supporting the suggestion of encouraging prenatal acquaintance. Additional research is needed to establish theories on sibling bonding like those that have been constructed for parental bonding.

Multiple Births and Subsequent Children

A component of attachment that has special meaning for families with multiple births, monotropy refers to the principle that a person can become optimally attached to only one individual at a time. If a parent can form only one attachment at a time, how can all the siblings of a multiple birth receive optimum emotional care? Until recently a paucity of research had been done on bonding and multiple births, and even less is known about paternal engrossment and sibling attachment. In regard to maternal-twin bonding, the conclusions of different authors vary. Some report that mothers bond equally to each twin at the time of birth, even if one twin is ill. Others suggest that mothers of twins may take months or even years to form individual attachments and even longer if the twins are identical. Damato (2004) studied mothers of twins and found that postpartum depression had a negative impact on the maternal-infant relationship; when either one or both newborns (of twins) were admitted to the NICU, the mother’s feelings of attachment were decreased at the time of the admission and up to 9 weeks postpartum. The author highlights the need for mothers of twins to have multiple opportunities to interact with twins shortly after birth through breast-feeding, skin-to-skin contact, and complete access to and care of the infants.

In a qualitative metasynthesis, Beck (2002) reported that mothers of multiples have unique needs related to the following themes: the impact of the burden of constant care for the infants, the myriad emotions experienced in the process of childbirth and childrearing, support by the children’s father and mother’s close friends, provision of equal attention to each infant, and acknowledgment of each infant’s individuality.

Nurses can be instrumental in promoting bonding at multiple births. The most important principle is to assist the parents in recognizing the individuality of the children, especially monozygotic (identical) twins. The mother should visit with each newborn, including a sick infant, as much as possible after birth. Rooming-in and breast-feeding are encouraged. The nurse emphasizes any characteristics that are unique to each child and calls each infant by name, rather than calling them “the twins.” Asking the family questions such as “How do you tell Sally and Amy apart?” and “In what ways are Sally and Amy different and similar?” helps point out their individual characteristics. Behaviors on the BNBAS can be used to illustrate these differences and to stress effective strategies for dealing with multiple personalities at the same time. (Other strategies for promoting individualism are discussed under Multiple Births in Chapter 3.)

Cobedding of twins or other multiples may be done in the hospital to maintain the bond between siblings that was formed in utero (Della Porta, Aforismo, and Butler-O’Hara, 1998). However, the American Academy of Pediatrics (2007a) has recommended against families cobedding at home. Because neither the safety nor the benefits of cobedding for newborns has been documented in the literature, the academy recommends families be counseled to follow safe sleeping practices, which currently dictate that infants sleep alone for optimal safety.

Another area of attachment that has received minimum attention is maternal bonding of multiparous mothers. Research suggests that “taking on” a second child has several additional tasks:

Employed mothers who have a second child report fewer concerns than unemployed mothers regarding general aspects of separation from their child and the effect of separation on the child, but they have similar concerns regarding separation because of employment as they had with the first child. It appears that although experience may decrease some concerns, it may not minimize others.

• Transition from fetal or placental circulation to independent respiration is the most important physiologic change required of the newborn.

• Chemical and thermal factors help initiate the neonate’s first breaths.

• Circulatory changes in the neonate result from shifts in pressure in the heart and major vessels and from functional closures of the fetal shunts.

• The newborn’s relatively large surface area, thin layer of subcutaneous fat, and unique mechanism for producing heat predispose the newborn to excessive heat loss.

• The infant’s high rate of metabolism is closely correlated with the rate of fluid exchange, which is seven times greater in the infant than in the adult.

• The skin and mucous membranes and antibodies are the first and second lines of defense against infection.

• Apgar scoring, the initial assessment of the newborn, focuses on heart rate, respiratory effort, muscle tone, reflex irritability, and color.

• Physical assessment of the newborn includes clinical assessment of gestational age, general measurements, general appearance, head-to-toe assessment, and parent-infant attachment or bonding.

• Neurologic assessment focuses on reflexes and posture, muscle tone, head control, and movement and is best accomplished during the general physical examination.

• Behavioral assessment of newborns with the BNBAS examines responses to seven categories: habituation, orientation, motor performance, range of state, regulation of state, autonomic stability, and reflexes.

• An instrument for assessing the reciprocal interchange between parent and infant is the NCAST Feeding Scale.

• Physical care for the newborn includes maintaining a patent airway, maintaining a stable body temperature, protecting from infection and injury, and providing optimum nutrition.

• Although the attachment, or bonding, process primarily affects infants and parents, siblings and other family members also play an important role.

• With short postpartum stays, teaching should begin before birth and continue after discharge with telephone or home visit follow-up.

• An essential aspect of discharge teaching is ensuring the newborn’s safe transportation home in a federally approved, backward-facing car safety seat restraint.

Abubakar, I, Iliyasu, Z, Kabir, M, et al. Knowledge, attitude and practice of female genital cutting among antenatal patients in Aminu Kano Teaching Hospital. Nigerian J Med. 2004;13(3):254–258.

Akers, SM, Groh-Wargo, SL. Normal nutrition during infancy. In Samour PQ, Helm KK, Lang CE, eds.: Handbook of pediatric nutrition, ed 3, Sudbury, Mass: Jones & Bartlett, 2005.

Alexander, GR, Himes, JH, Kaufman, RB, et al. A United States national reference for fetal growth. Obstet Gynecol. 1996;87(2):163–168.

American Academy of Pediatrics, Committee on Nutrition. Pediatric nutrition handbook, ed 6. Elk Grove Village, Ill: The Academy; 2009.

American Academy of Pediatrics, Committee on Infectious Diseases. Red book: 2009 report of the Committee on Infectious Diseases, ed 28. Elk Grove Village, IL: The Academy; 2009.

American Academy of Pediatrics. Clinical report—hearing assessment in infants and children: recommendations beyond neonatal screening. Pediatrics. 2009;124(4):1252–1263.

American Academy of Pediatrics, Committee on Pediatric AIDS. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics. 2008;122(5):1127–1134.

American Academy of Pediatrics, Newborn Screening Authoring Committee. Newborn screening expands: recommendations for pediatricians and medical homes—implications for the system. Pediatrics. 2008;121(1):192–217.

American Academy of Pediatrics, Committee on Nutrition. Use of soy protein-based formulas in infant feeding. Pediatrics. 2008;121(5):1062–1068.

American Academy of Pediatrics, Section on Ophthalmology. Red reflex examination in neonates, infants, and children. Pediatrics. 2008;122(6):1401–1404.

American Academy of Pediatrics. Committee on Fetus and Newborn: Cobedding twins and higher-order multiples in a hospital setting. Pediatrics. 2007;120(6):1359–1366.

American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120:898–921.

American Academy of Pediatrics. Neonatal resuscitation textbook, 5th edition. Dallas: American Heart Association; 2006.

American Academy of Pediatrics. Policy statement: the Apgar score. Pediatrics. 2006;117(4):1444–1447.

American Academy of Pediatrics. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116(5):1245–1255. [reaffirmed January 2009].

American Academy of Pediatrics. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496–506.

American Academy of Pediatrics. Policy statement: hospital stay for healthy terms newborns. Pediatrics. 2004;113(5):1434–1436.

American Academy of Pediatrics. Clinical report: prevention and management of positional skull deformities in infants. Pediatrics. 2003;112(1):199–202.

American Academy of Pediatrics. Facilities and equipment for the care of pediatric patients in a community hospital. Pediatrics. 2003;111(5):1120–1122. [reaffirmed September 1, 2007].

American Academy of Pediatrics. Policy statement: controversies concerning vitamin K and the newborn. Pediatrics. 2003;112(1):191–192.

American Academy of Pediatrics, Committee on Injury and Poison Prevention. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics. 2002;109(3):550–553.

American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. Pediatrics. 1999;103(3):686–693.

American Academy of Pediatrics, Committee on Bioethics. Female genital mutilation. Pediatrics. 1998;102(1):153–156.

American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care, ed 6. Elk Grove Village, Ill: The Academy; 2007.

Anand, KJS, International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2001;155(2):173–179.

Anderson, JW, Johnstone, BM, Remley, DT. Breastfeeding and cognitive development: a meta-analysis. Am J Clin Nutr. 1999;70(4):525–535.

Arbuckle, T, Wilkins, R, Sherman, G. Birth weight percentiles by gestational age in Canada. Obstet Gynecol. 1993;81(1):39–48.

Arora, S, McJunkin, C, Wehrer, J, et al. Major factors influencing breastfeeding rates: mother’s perception of father’s attitude and milk supply. Pediatrics. 2000;106(5):e67.

Arslanoglu, S, Moro, GE, Boehm, G. Early supplementation of probiotic oligosaccharides protects formula-fed infants against infections during the first 6 months of life. J Nutr. 2007;137(11):2420–2424.

Association of Women’s Health, Obstetric and Neonatal Nurses. Evidence-based clinical practice guideline: neonatal skin care, 2nd edition. Washington, DC: The Association; 2007.

Axton, SE, Smith, LF, Bertrand, S, et al. Comparison of brachial and calf blood pressures in infants. Pediatr Nurs. 1995;21(4):323–326.

Bachrach, VR, Schwarz, E, Bachrach, LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy. Arch Pediatr Adolesc Med. 2003;157(3):237–243.

Bailey, J, Rose, P. Axillary and tympanic temperature recording in the preterm neonate: a comparative study. J Adv Nurs. 2001;34(4):465–474.

Bailey, RC, Moses, S, Parker, CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet. 2007;369(9562):643–656.

Ball, TM, Wright, AL. Health care costs of formula-feeding in the first year of life. Pediatrics. 1999;103(Suppl 4):S870–S876.

Ballard, JL, Auer, CE, Khoury, JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63. [1001].

Ballard, JL, Khoury, JC, Wedig, K, et al. New Ballard score expanded to include extremely premature infants. J Pediatr. 1991;119:417–423.

Ballard, JL, Novak, KK, Driver, M. A simplified score for assessment of fetal maturation of newly born infants. J Pediatr. 1979;95(5):769–774.

Barnard, K. NCAST feeding manual. Seattle: University of Washington; 1994.

Bartman, T. Newborn circumcision and urinary tract infections (letter). Pediatrics. 2001;107(1):210–214.

Battaglia, FC, Lubchenco, LO. A practical classification of newborn infants by weight and gestational age. J Pediatr. 1967;71(2):159–161.

Beaudry, M, Dufour, R, Marcoux, S. Relation between infant feeding and infections during the first 6 months of life. J Pediatr. 1995;126(2):191–197.

Beck, CT. Mothering multiples. MCN. 2002;27(4):214–221.

Behring, A, Vezeau, TM, Fink, R. Timing of the newborn first bath: a replication. Neonat Netw. 2003;22(1):39–46.

Biancuzzo, M. Breastfeeding the newborn: clinical strategies for nurses, ed 2. St Louis: Mosby; 2003.

Blackburn, ST. Maternal, fetal, and neonatal physiology: a clinical perspective, ed 3. St Louis: Saunders; 2007.

Blain-Lewis, N. Comparative studies of bruising and healing after heelstick. Neonat Intensive Care. 1992;5(5):18–21.

Blass, EM, Watt, LB. Suckling- and sucrose-induced analgesia in human newborns. Pain. 1999;83(3):611–623.

Bliss-Holtz, J. Methods of newborn infant temperature monitoring: a research review. Issues Compr Pediatr Nurs. 1995;18(4):287–298.

Bliss-Holtz, J. Determination of thermoregulatory state in full-term infants. Nurs Res. 1993;42(4):204–207.

Brady-Fryer B, Wiebe N, Lander JA: Pain relief for neonatal circumcision. In Cochrane Database Syst Rev 18(4):CD004217, 2004.

Brazelton, TB. Mother-infant reciprocity. In: Klaus MH, Leger T, Trause MA, eds. Maternal attachment and mothering disorders: a round table. Sausalito, Calif: Johnson & Johnson Baby Products, 1974.

Brazelton, TB, Nugent, JK. Neonatal behavioral assessment scale. London: MacKeith Press; 1996.

Broussard, ER. The Pittsburgh firstborns at age 19 years. In: Call, J, Calerson, E, Tyson, R, eds. Frontiers of infant psychiatry, vol 2. New York: Basic Books; 1984.

Broussard, ER. Assessment of the adaptive potential of the mother-infant system: the Neonatal Perception Inventories. Semin Perinatol. 1979;3(1):91–100.

Broussard, ER. Neonatal prediction and outcome at 10/11 years. Child Psychiatr Hum Dev. 1976;7(2):85–93.

Bryant, KG, Horns, KM, Longo, N, et al. A primer on newborn screening. Adv Neonat Care. 2004;4(5):306–317.

Burgess, AW, Carr, KE, Nahirny, C, et al. Nonfamily infant abductions, 1983-2006. Am J Nurs. 2008;108(9):32–38.

Butt, ML, Kisilevsky, BS. Music modulates behavior of premature infants following heel lance. Can J Nurs Res. 2000;31(4):17–39.

Butte, NF, Wong, WW, Hopkinson, JM, et al. Infant feeding mode affects early growth and body composition. Pediatrics. 2000;106(6):1355–1366.

Canadian Paediatric Society, Community Paediatrics Committee. Temperature measurement in paediatrics. reaffirmed February 2009, available at www.cps.ca/english/statements. [accessed March 12, 2009].

Canadian Paediatric Society, First Nations, Inuit and Métis Health Committee. Vitamin D supplementation: recommendations for Canadian mothers and infants. Paediatr Child Health. 2007;12(7):583–589.

Carbajal, R, Veerapen, S, Couderc, S, et al. Analgesic effect of breast feeding in term neonates: randomized controlled trial. Br Med J. 2003;326(7379):13.

Cavaliere, T. Genitourinary assessment. In Tappero E, Honeyfield M, eds.: Physical assessment of the newborn: a comprehensive approach to the art of physical examination, ed 4, Petaluma, Calif: NICU Ink, 2009.

Centers for Disease Control and Prevention. Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United states. MMWR Weekly. 2010;59(rr09):1–15.

Centers for Disease Control and Prevention. Breastfeeding trends and updated national health objectives for exclusive breastfeeding—United States, birth years 2000-2004. MMWR. 2007;56(30):760–763.

Chen, A, Rogan, W. Isoflavones in soy infant formula: a review of evidence for endocrine and other activity in infants. Ann Rev Nutr. 2004;24:33–54.

Chertok, IR, Shoham-Vardi, I, Hallak, M. Four-month breastfeeding duration in postcesarean women of different cultures in the Israeli Negev. J Perinat Neonatal Nurs. 2004;18(2):145–160.

Choudhry, UK. Traditional practices of women from India: pregnancy, childbirth, and newborn care. J Obstet Gynecol Neonatal Nurs. 1997;26(5):533–539.

Codipietro, L, Ceccarelli, M, Ponzone, A. Breastfeeding or oral sucrose solution in term neonates receiving heel lance: a randomized, controlled trial. Pediatrics. 2008;122(3):e716–721.

Cohen, HA, Drucker, MM, Vainer, S, et al. Postcircumcision urinary tract infection. Clin Pediatr. 1992;31(6):322–324.

Connolly, JL, Carron, JD, Roark, SD. Universal newborn hearing screening: are we achieving the Joint Committee on Infant Hearing (JCIH) objectives? Laryngoscope. 2005;115(2):232–236.

Conover, E, Buehler, BA. Use of herbal agents by breastfeeding women may affect infants. Pediatr Ann. 2004;33(4):235–240.

Coryllos, A, Genna, C, Salloum, A. Congenital tongue-tie and its impact on breastfeeding. In American Academy of Pediatrics, Section on Breastfeeding: Breastfeeding: best for baby and mother. Elk Grove Village, Ill: The Academy; 2004.

Craig, JV, Lancaster, GA, Taylor, S, et al. Infrared ear thermometry compared with rectal thermometry in children: a systematic review. Lancet. 2002;360(9333):603–609.

, Williams obstetrics. Cunningham, FG, Gant, NF, Leveno, KJ, et al, eds. ed 21. New York: McGraw Hill; 2001.

Cyna AM, Middleton P: Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys, Cochrane Database Syst Rev 8(4):CD003005, 2008.

Damato, EG. Prenatal attachment and other correlates of postnatal attachment to twins. Adv Neonat Care. 2004;4(5):274–291.

de Onis, M, Onyango, AW. The Centers for Disease Control and Prevention 2000 growth charts and the growth of breastfed infants. Acta Paediatr. 2003;92:413–419.

Della Porta, K, Aforismo, D, Butler-O’Hara, M. Co-bedding of twins in the neonatal intensive care. Pediatr Nurs. 1998;24(6):529–531.

Dennison, BA, Edmunds, LS, Stratton, HH, et al. Rapid infant weight gain predicts childhood overweight. Obesity (Silver Spring). 2006;14(3):491–499.

Dewey, KG, Heinig, MJ, Nommsen, LA, et al. Breastfed infants are leaner than formula-fed infants at 1 year of age: the DARLING study. Am J Clin Nutr. 1993;57(2):140–145.

Dewey, K, Heinig, MJ, Nommsen, LA, et al. Adequacy of energy intake among breastfed infants in the DARLING study: relationships to growth velocity, morbidity, and activity levels. J Pediatr. 1991;119(4):538–547.

Dewey, KG, Heinig, MJ, Nommsen-Rivers, LA. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995;126(5 pt 1):696–702.

Dewey, KG, Peerson, JM, Brown, KH, et al. Growth of breast-fed infants deviates from current reference data: a pooled analysis of US, Canadian and European data sets. Pediatrics. 1995;96(3 Pt 1):495–503.

Dollberg, S, Botzer, E, Grunis, E, et al. Immediate nipple pain relief after frenotomy in breastfed infants with ankyloglossia: a randomized, prospective study. J Pediatr Surg. 2006;41(9):1598–1600.

Donovan, EF, Tyson, JE, Ehrenkranz, RA, et al. Inaccuracy of Ballard scores before 28 weeks’ gestation. J Pediatr. 1999;135(2 Pt 1):147–152.

Dore, S, Buchan, D, Coulas, S, et al. Alcohol versus natural drying for newborn cord care. J Obstet Gynecol Neonatal Nurs. 1998;27(6):621–627.

Douglas, LC, Sanders, ME. Probiotics and prebiotics in dietetics practice. J Am Diet Assoc. 2008;108(3):510–521.

Dubowitz, LMS, Dubowitz, V. Gestational age of the newborn. Menlo Park, Calif: Addison-Wesley; 1977.

Eriksson, M, Finnstrom, O. Can daily repeated doses of orally administered glucose induce tolerance when given for neonatal pain relief? Acta Paediatr. 2004;93(2):246–249.

Evans, CA, Porter, CL. The emergence of mother-infant co-regulation during the first year: links to infants’ developmental status and attachment. Infant Behav Devel. 2009;32(2):147–158.

Falkner, B. Hypertension in children and adolescents. In: Black HR, Elliott WJ, eds. Hypertension. Philadelphia: Saunders, 2007.

Ferketich, SL, Mercer, RT. Paternal-infant attachment of experienced and inexperienced fathers during infancy. Nur Res. 1995;44(1):31–37.

Foca, M, Jacob, K, Whittier, S, et al. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med. 2000;343(10):695–700.

France, CR, Taddio, A, Shah, VS, et al. Maternal family history of hypertension attenuates neonatal pain response. Pain. 2009;142(3):189–193.

Fuloria, M, Kreiter, S. The newborn examination, part 1, Emergencies and common abnormalities involving the skin, head, neck, chest, and respiratory and cardiovascular systems. Am Fam Physician. 2002;65(1):61–68.

Geller, M. Infant abduction in the hospital setting. QRC Advisor. 2000;16(5):1–4.

Georgieff, MK. Taking a rational approach to the choice of formula. Contemp Pediatr. 2001;18(8):112–130.

Geyer, J, Ellsbury, D, Kleiber, C, et al. An evidence-based multidisciplinary protocol for neonatal circumcision pain management. J Obstet Gynecol Neonatal Nurs. 2002;31(4):403–410.

Giampietro, PG, Bruno, G, Furcolo, G, et al. Soy protein formulas in children: no hormonal effects in long-term feeding. J Pediatr Endocrinol Metab. 2004;17(2):191–196.

Gibbins, S, Stevens, B, Hodnett, E, et al. Efficacy and safety of sucrose for procedural pain relief in preterm and term neonates. Nurs Res. 2002;51(6):375–382.

Gil, A, Ramirez, M, Gil, M. Role of long-chain polyunsaturated fatty acids in infant nutrition. Eur J Clin Nutr. 2003;57(Suppl 1):S31–S34.

Golombek, SG, Brill, PE, Salice, AL. Randomized trial of alcohol versus triple dye for umbilical cord care. Clin Pediatr. 2002;41(6):419–423.

Goodell, LS, Wakefield, DB, Ferris, AM. Rapid weight gain during the first year of life predicts obesity in 2-3 year olds from a low-income, minority population. J Community Health. 2009;34(5):370–375.

Goulet, C, Bell, L, St, Cyr, D, et al. A concept analysis of parent-infant attachment. J Adv Nurs. 1998;28(5):1071–1081.

Gradin, M, Eriksson, M, Holmqvist, G, et al. Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream. Pediatrics. 2002;110(6):1053–1057.

Gray, L, Miller, LW, Phillip, BL, et al. Breastfeeding is analgesic in healthy newborns. Pediatrics. 2002;109(4):590–593.

Gray, L, Watt, L, Blass, EM, Skin-to-skin contact is analgesic in healthy newborns. Pediatrics 2000;105(1):110–111. available at www.pediatrics.org/cgi/content/full/105/1/e14 [accessed November 25, 2009].

Gray, RH, Kigozi, G, Serwadda, D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet. 2007;369(9562):657–666.

Greenes, DS, Fleisher, GR. Accuracy of a noninvasive temporal artery thermometer for use in infants. Arch Pediatr Adolesc Med. 2001;155(3):376–381.

Greim, HA. The endocrine and reproductive system: adverse effects of hormonally active substances? Pediatrics. 2004;113(4):1070–1075.

Griffiths, DM. Do tongue-ties affect breastfeeding? J Hum Lact. 2004;20(4):409–414.

Grummer-Strawn, LM, Mei, Z, Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics. 2004;113(2):e81–e86.

Hale, T. Medications and mothers’ milk. Amarillo, Tex: Pharmasoft; 2008.

Hanson, LA, Korotkova, M. The role of breastfeeding in prevention of neonatal infection. Semin Neonatol. 2002;7(4):275–281.

Harrison, D, Johnston, L, Loughnan, P. Oral sucrose for procedural pain in sick hospitalized infants: a randomized-controlled trial. J Paediatr Child Health. 2003;39(8):591–597.

Havens, PL, Mofenson, LM, Committee on Pediatric AIDS. Evaluation and management of the infant exposed to HIV-1 in the United States. Pediatrics. 2009;123(1):175–187.

Hendriksz, CJ, Walter, JH. Feeding infants with undiluted goat’s milk can mimic tryosinaemia type 1. Acta Paediatr. 2004;93(4):552–553.

Hernandez, IF. Promoting exclusive breastfeeding for Hispanic women. MCN. 2006;31(5):318–324.

Herschel, M, Khoshnood, B, Ellman, C, et al. Neonatal circumcision: randomized trial of a sucrose pacifier for pain control. Arch Pediatr Adolesc Med. 1998;152(3):279–284.

Hicks, MA. A comparison of the tympanic and axillary temperatures of the preterm and term infant. J Perinatol. 1996;16(4):261–267.

Holzhauer, JK, Reith, V, Sawin, KJ, et al. Evaluation of temporal artery thermometry in children 3-36 months old. J Soc Pediatr Nurs. 2009;14(4):239–244.

Huang, CM, Tung, WS, Kuo, LL, et al. Comparison of pain responses of premature infants to the heelstick between containment and swaddling. J Nurs Res. 2004;12(1):31–40.

Hussink Muller, PC, van Berkel, LH, de Beaufort, AJ. Axillary and rectal temperature measurements poorly agree in newborn infants. Neonatology. 2008;94(1):31–34.

Janssen, PA, Selwood, BL, Dobson, SR, et al. To dye or not to dye: a randomized, clinical trial of a triple dye/alcohol regime versus dry cord care. Pediatrics. 2003;111(1):15–20.

Johnston, CC, Filion, F, Campbell-Yeo, M, et al. Enhanced kangaroo mother care for heel lance in preterm infants: a crossover trial. J Perinatol. 2009;29(1):51–56.

Johnston, CC, Stevens, B, Pinelli, J, et al. Kangaroo care is effective in diminishing pain response in preterm neonates. Arch Pediatr Adolesc Med. 2003;157(11):1084–1088.

Jones, HL, Kleber, CB, Eckert, GJ, et al. Comparison of rectal temperature measured by digital vs. mercury glass thermometer in infants under 2 months old. Clin Pediatr. 2003;42(4):357–359.

Juretschke, LJ. Unilateral neonatal testicular torsion. J Obstet Gynecol Neonatal Nurs. 2000;29(5):451–456.

Kapellen, TM, Gebauer, CM, Brosteanu, O, et al. Higher rate of cord-related adverse events in neonates with dry umbilical cord care compared to chlorhexidine powder: results of a randomized controlled study to compare efficacy and safety of chlorhexidine powder versus dry care in umbilical cord care of the newborn. Neonatology. 2009;96(1):13–18.

Kaye, CI, American Academy of Pediatrics, Committee on Genetics. Newborn Screening Fact Sheets. Pediatrics. 2006;118(3):e934–e963.

Kent, AL, Kecskes, Z, Shadbolt, B, et al. Blood pressure in the first year of life in healthy infants born at term. Pediatr Nephrol. 2007;22(10):1743–1749.

Kinkade, S, Meadows, S, Gracia-Trujillo, J. Does neonatal circumcision decrease morbidity? J Fam Pract. 2005;54(1):81–82.

Klaus, MH, Kennell, JH, Klaus, PH. Bonding: building the foundations of secure attachment and independence. Menlo Park, Calif: Addison-Wesley; 1995.

Kraft, NL. A pictorial and video guide to circumcision without pain. Adv Neonat Care. 2003;3(2):50–64.

Kramer, MS, Guo, T, Platt, RW, et al. Feeding effects on growth during infancy. J Pediatr. 2004;145(5):600–605.

Kramer, MS, Platt, RW, Wen, SW, et al. A new and improved population-based Canadian reference for birth weight for gestational age. Pediatrics. 2001;108(2):e35. [462].

Kyenkya-Isabirye, M. UNICEF launches the Baby-Friendly Hospital Initiative. MCN. 1992;17(4):177–179.

Lanham, DM, Walker, B, Klocke, E, et al. Accuracy of tympanic temperature readings in children under 6 years of age. Pediatr Nurs. 1999;25(1):39–42.

Lanting, CI, Fidler, V, Huisman, M, et al. Neurological differences between 9-year-old children fed breast-milk or formula-milk as babies. Lancet. 1994;344(8933):1319–1322.

Lawrence, RA, Lawrence, RM. Breastfeeding: a guide for the medical profession, ed 6. St Louis: Mosby; 2005.

Leick-Rude, MK, Bloom, LF. A comparison of temperature-taking methods in neonates. Neonat Netw. 1998;17(5):21–37.

Leung, AKC, Robson, WLM. Natal teeth: a review. J Natl Med Assoc. 2006;98(2):226–228.

Lu, B, Wu, Y, Nielson, CM, et al. Factors associated with acquisition and clearance of human papillomavirus infection in a cohort of US men: a prospective study. J Infect Dis. 2009;199(3):363–371.

Malloy, MH. Trends in postneonatal aspiration deaths and reclassification of sudden infant death syndrome: impact of the “Back to Sleep” program. Pediatrics. 2002;109(4):661–665.

Masaitis, NS, Kaempf, JW. Developing a frenotomy policy at one medical center: a case study approach. J Hum Lact. 1996;12(3):229–232.

McCleary, PH. Female genital mutilation and childbirth: a case report. Birth. 1994;21(4):221–223.

McDonald, RE, Avery, DR, Dean, JA. Dentistry for the child and adolescent, ed 8. St Louis: Mosby; 2004.

Medves, M, O’Brien, B. The effect of bather and location of first bath on maintaining thermal stability in newborns. J Obstet Gynecol Neonatal Nurs. 2004;33(2):175–182.

Merritt, RJ, Jenks, BH. Safety of soy-based formulas containing isoflavones: the clinical evidence. J Nutr. 2004;134(5):1220S–1224S.

Messner, AH, Lalakea, M, Aby, J, et al. Ankyloglossia: incidence and affected feeding difficulties. Arch Otolaryngol Head Neck Surg. 2000;126(1):36–39.

Metaj, M, Laroia, N, Lawrence, RA, et al. Comparison of breast-and formula-fed normal newborns in time to first stool and urine. J Perinatol. 2003;23:624–628.

Monk, C, Leight, KL, Fang, Y. The relationship between women’s attachment style and perinatal mood disturbance: implications for screening and treatment. Arch Women’s Mental Health. 2008;11(2):117–129.

Montgomery, DL, Splett, PL. Economic benefit of breast-feeding infants enrolled in WIC. J Am Diet Assoc. 1997;97(4):379–385.

Moolenaar, RL, Crutcher, JM, San Joaquin, VH, et al. A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol. 2000;21(2):80–85.

Mullany, LC, Darmstadt, GL, Katz, J, et al. Risk of mortality subsequent to umbilical cord infection among newborns of southern Nepal: cord infection and mortality. Pediatr Infect Dis J. 2009;28(1):17–20.

Murray, L, Fiori-Cowley, A, Hopper, R, et al. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcomes. Child Dev. 1996;67(5):2512–2526.

Nelson, CP, Dunn, R, Wan, J, et al. The increased incidence of newborn circumcision: data from the nationwide inpatient sample. J Urology. 2005;173(3):978–981.

Newman, J, Pitman, T. The ultimate breastfeeding book of answers. Roseville, Calif: Prima; 2000.

Nielson, CM, Schiaffino, MK, Dunne, EF, et al. Associations between male anogenital human papillomavirus infection and circumcision by anatomic site sampled and lifetime number of female sex partners. J Infect Dis. 2009;199(1):7–13.

Nuntnarumit, P, Yang, W, Bada-Ellzey, HS. Blood pressure measurements in the newborn. Clin Perinatol. 1999;26(4):981–996.

Paes, B, Janes, M, Vegh, P, et al. A comparative study of heel-stick devices for infant blood collection. Am J Dis Child. 1993;147(3):346–348.

Penny-MacGillivray, T. A newborn’s first bath: when? J Obstet Gynecol Neonatal Nurs. 1996;25(6):481–487.

Pessler, F, Nejat, M. Anaphylactic reactions to goat’s milk in a cow’s milk allergic infant. Pediatric Allergy Immunol. 2004;15(2):183–185.

Quan, R, Yang, C, Rubinstein, S, et al. Effects of microwave radiation on anti-infective factors in human milk. Pediatrics. 1992;89(4 Pt 1):667–669.

Rabier, V, Bataillon, S, Jolivet-Gougeon, A, et al. Hand washing soap as a source of neonatal Serratia marcescens outbreak. Acta Paediatrica. 2008;97(10):1381–1385.

Radmacher, P, Massey, C, Adamkin, D. Hidden morbidity with “successful” early discharge. J Perinatol. 2002;22:15–20.

Rautava, S, Salminen, S, Isolauri, E. Specific probiotics in reducing the risk of acute infections in infancy: a randomized, double-blind, placebo-controlled study. Br J Nutr. 2009;101(11):1722–1726.

Razmus, I, Dalton, M, Wilson, D. Pain management for newborn circumcision. Pediatr Nurs. 2004;20(5):414–417. [427].

Ricke, LA, Baker, NJ, Madlon-Kay, DJ, et al. Newborn tongue-tie: prevalence and effect on breastfeeding. J Am Board Fam Pract. 2005;18(1):1–7.

Riordan, J, Gill-Hopple, K. Breastfeeding care in multicultural populations. J Obstet Gynecol Neonatal Nurs. 2001;30(2):216–223.

Ross Mothers Survey, Breastfeeding trends—2003. Columbus, OH: Ross Products Division, Abbott Laboratories; 2003. Available at http://abbottnutrition.com/resources/en_US/home/breastfeeding/BF_Trends_2003.pdf [accessed June 16, 2008].

Sasidharan, K, Dutta, S, Narang, A. Validity of New Ballard score until 7th day of postnatal life in moderately preterm neonates. Arch Dis Childhood Fetal Neonat. 2009;94:F39–F44.

Scariati, PD, Grummer-Strawn, LM, Fein, SB. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics. 1997;99(6):e5.

Schoen, EJ, Colby, CJ, Ray, GT. Newborn circumcision decreases incidence and costs of urinary tract infections during first year of life. Pediatrics. 2000;105(4):789–793.

Schuh, S, Komar, L, Stephens, D, et al. Comparison of the temporal artery and rectal thermometry in children in the emergency department. Pediatr Emerg Care. 2004;20(11):736–741.

Seguin, J, Terry, K. Neonatal infrared axillary thermometry. Clin Pediatr. 1999;38(1):35–40.

Serour, F, Mandelberg, A, Mori, J. Slow injection of local anesthetic will decrease pain during dorsal penile nerve block. Acta Anaesthesiol Scand. 1998;42(8):926–928.

Severn, CB. Head circumference–crown rump length: practical measurements for neonatal screening. Neonat Intensive Care. 1994;7(4):52–57.

Sganga, A, Wallace, R, Kiehl, E, et al. A comparison of four methods of normal newborn temperature measurement. MCN. 2000;25(2):76–79.

Shah V, Ohlsson A: Venepuncture versus heel lance for blood sampling in term neonates. In Cochrane Database Syst Rev (2):CD001452, 2001.

Shogan, MG. Emergency management plan for newborn abduction. J Obstet Gynecol Neonatal Nurs. 2002;31(3):340–346.

Siberry, GK, Diener-West, M, Schappell, E, et al. Comparison of temple temperatures with rectal temperatures in children under 2 years of age. Clin Pediatr. 2002;41(6):405–414.

Siegfried N, Muller M, Volmink J, et al: Male circumcision for prevention of heterosexual acquisition of HIV in men, Cochrane Database Syst Rev (3):CD003362, 2003.

Singh, GK, Kogan, MD, Dee, DL. Nativity/immigrant status, race/ethnicity, and socioeconomic determinants of breastfeeding initiation and duration in the United States, 2003. Pediatrics. 2007;119(Suppl 1):S38–S46.

Smith, DP, Gjellum, M. The efficacy of LMX versus EMLA for pain relief in boys undergoing office meatotomy. J Urol. 2004;172(4 Pt 2):1760–1761.

Stang, HJ, Snellman, LW, Condon, LM, et al, Beyond dorsal penile nerve block: a more humane circumcision. Pediatrics 1997;100(2):e3. available at www.pediatrics.org/cgi/content/full/100/2/e3 [accessed November 25, 2009].

Stevens, B, Johnston, C, Franck, L, et al. The efficacy of developmentally sensitive interventions and sucrose for relieving procedural pain in very low birth weight infants. Nurs Res. 1999;48(1):35–43.

Stevens, B, Taddio, A, Ohlsson, A, et al. The efficacy of sucrose for relieving procedural pain in neonates: a systematic review and meta-analysis. Acta Paediatr. 1997;86(8):837–842.

Stevens B, Yamada J, Ohlsson A: Sucrose for analgesia in newborn infants undergoing painful procedures, Cochrane Database Syst Rev (3):CD001069, 2004.

Stoll, B. Routine delivery room care. In Behrman RE, Kliegman RM, Jenson HB, et al, eds.: Nelson textbook of pediatrics, ed 18, Philadelphia: Saunders, 2007.

Sullivan, JR. Development of father-infant attachment in fathers of preterm infants. Neonat Netw. 1999;18(7):33–39.

Taddio A, Ohlsson K, Ohlsson A: Lidocaine-prilocaine cream for analgesia during circumcision in newborn boys, Cochrane Database Syst Rev (2):CD000494, 2000.

Taddio, A, Pollock, N, Gilbert-MacLeod, C, et al. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med. 2000;154(5):620–623.

Taddio, A, Shah, V, Gilbert-MacLeod, C, et al. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002;288(7):857–861.

Taddio, A, Shah, V, Katz, J. Reduced infant response to a routine care procedure after sucrose analgesia. Pediatrics. 2009;123(3):e425–e429.

Taveras, EM, Rifas-Shiman, MB, Belfort, MB, et al. Weight status in the first 6 months of life and obesity at 3 years of age. Pediatrics. 2009;123(4):1177–1183.

Thomas, P, Peabody, J, Turnier, V, et al. A new look at intrauterine growth and the impact of race, altitude, and gender. Pediatrics. 2000;106(2):e21.

Tomlinson, PS, Bryan, AA, Esau, AL. Family centered intrapartum care: revisiting an old concept. J Obstet Gynecol Neonatal Nurs. 1996;25(4):331–337.

Trochtenberg, DS. Neonatal circumcision (letter to the editor). N Engl J Med. 1990;323(17):1206.

Trotter, CW. Gestational age assessment. In Tappero EP, Honeyfield ME, eds.: Physical assessment of the newborn: a comprehensive approach to the art of physical examination, ed 4, Santa Rosa, Calif: NICU Ink, 2009.

Tulassy, T, Ramanathan, R, Evans, JR, et al. Renal vascular disease in the newborn. In Taeusch HW, Ballard RA, Gleason CA, eds.: Avery’s diseases of the newborn,, ed 8, Philadelphia: Saunders, 2005.

US Department of Health and Human Services. Healthy people 2020 public meetings. Washington, DC, 2009, The Department, available at www.healthypeople.gov/hp2020/Objectives/ViewObjective.aspx?Id=177&TopicArea=Maternal%2c+Infant+and+Child+Health&Objective=MICH+HP2020%e2%80%9312&TopicAreaId=32. [accessed November 25, 2009].

Vandenplas, Y. Oligosaccharides in infant formula. Br J Nutr. 2002;87(Suppl 2):S293–S296.

Varda, KE, Behnke, RS. The effect of timing the initial bath on newborn’s temperature. J Obstet Gynecol Neonatal Nurs. 2000;29(1):27–32.

Wagner, CL, Greer, FR, American Academy of Pediatrics Section on Breastfeeding. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142–1150.

Walker, VP, Akinbi, HT, Meinzen-Derr, J, et al. Host defense proteins on the surface of neonatal skin: implications for innate immunity. J Pediatrics. 2008;152(6):777–781.

Warner, L, Ghanem, KG, Newman, DR, et al. Male circumcision and risk of HIV infection among heterosexual African American men attending Baltimore sexually transmitted disease clinics. J Infect Dis. 2009;199(1):59–65.

Weise, KL, Nahata, MC. EMLA for painful procedures in infants. J Pediatr Health Care. 2005;19(1):42–47.

Weiss, ME, Poeltler, D, Gocka, I. Infrared tympanic thermometry for neonatal temperature assessment. J Obstet Gynecol Neonatal Nurs. 1993;23(9):798–803.

Wiessinger, D, Miller, M. Breastfeeding difficulties as a result of tight lingual and labial frena: a case report. J Hum Lact. 1995;11(4):313–316.

Williamson, ML. Circumcision anesthesia: a study of nursing implications for dorsal penile nerve block. Pediatr Nurs. 1997;23(10):59–63.

Wilshaw, R, Beckstrand, R, Waid, D, et al. A comparison of the use tympanic, axillary, and rectal thermometers in infants. J Pediatr Nurs. 1999;14(2):88–93.

Wong, D. Topical local anesthetics: two products for pain relief during minor procedures. AJN. 2003;103(6):42–45.

World Health Organization. WHO child growth standards, World Health Organization. Geneva, Switzerland, 2006, available at www.who.int/childgrowth/en. [accessed July 2, 2009].

World Health Organization. Eliminating female genital mutilation: an interagency statement UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCHR, UNHCR, UNICEF, UNIFEM, WHO. Geneva: The Organization; 2008.

Wright, A, Rice, S, Wells, S. Changing hospital practices to increase the duration of breastfeeding. Pediatrics. 1996;97(5):669–676.

Wright, JT. Normal formation and development defects of human dentition. Pediatr Clin North Am. 2000;47(5):975–1000.

Yamada, J, Stinson, J, Lamda, J, et al. A review of systematic reviews on pain interventions in hospitalized infants. Pain Res Manage. 2008;13(5):413–420.

Yetman, RJ, Coody, DK, West, MS, et al. Comparison of temperature measurements by an aural infrared thermometer with measurements by traditional rectal and axillary techniques. J Pediatr. 1993;122(5):769–773.

Yoshinaga-Itano, C, Sedey, SL, Coulter, DK, et al. Language of early- and late-identified children with hearing loss. Pediatrics. 1998;102(5):1161–1171.

Young, TK, Martens, PJ, Taback, SP, et al. Type 2 diabetes mellitus in children: prenatal and early infancy risk factors among native Canadians. Arch Pediatr Adolesc Med. 2002;156(7):651–655.

Zupan J, Garner P, Omari AA: Topical umbilical cord care at birth, Cochrane Database Syst Rev (3):CD001057, 2004.