After discharge from the Neonatal Unit

Taking your precious baby home is a time for celebration, but it can also be a time for uncertainty as you finally accept full responsibility for your baby.  It is perfectly normal for parents to express a mixture of emotions including relief, fear, happiness and apprehension.

In the first few weeks you may find your baby's feeding pattern is irregular. Some babies may demand more frequent feeds than they had while in the hospital. This is normal as each baby is an individual and can be fed according to his/her own needs.

If you offer feeds frequently and ensure your baby takes as much as they need, your baby should stop feeding when they have had enough. If you think your baby is feeding too much or too little, discuss it with one of the community team.

You can be sure your baby is getting enough milk if he/she has plenty of wet nappies, is growing and is alert and awake for some of the time.

Remember to always wash your hands before feeding your baby and, if you are bottle feeding make sure the bottle and teats are properly sterilised. Always test the heat of drink or food before giving it to your baby. 

Safe sleeping position

The safest position is to place your baby on his/her back at the start of sleep time. It is not safe for babies to sleep on their fronts. Babies tend to settle more easily on their backs if they have been placed to sleep that way from the very first day. If your baby is less than six months old and you find he/she has rolled over onto their stomach then gently reposition your baby onto his/her back. However do not feel that you need to keep getting up in the night to check on your baby for this reason.  

At some stage your baby will learn to roll onto their front and back again and will find their own comfortable position. This is fine once they have reached 6 months. However always place your baby on their back to sleep regardless of their age.

You may have noticed your baby, especially if he/she was premature, being placed on their tummy while in the NICU or SCBU for medical reasons to help with his/her breathing. If this was the case you still need to position your baby on their back to sleep once you are at home unless your doctor advises a different sleep position.  

If your baby has been used to being positioned on their front while in the NICU or SCBU it may take some time for them to settle. However, you should still persist with positioning your baby on his/her back and they will eventually get used to sleeping in this position.

We also advise you to position your baby so his/her feet are at the foot of the cot, with the bed clothes firmly tucked in and pulled up no higher than your baby's shoulders. This reduces the risk of your baby moving down the cot under the covers.

The reason it is so important to position your baby on his/her back at the foot of the bed during sleep is to reduce the risk of Sudden Infant Death syndrome. Fortunately, cot death is relatively rare now and often preventable. 

Firm Mattress

The Foundation of Sudden Infant Death Syndrome also advice that it is best to use a mattress that is firm, in good condition, clean, dry and well aired. Your baby should not use a pillow or have cot bumpers until they are at least a year old, because they might increase the risk of overheating.

Bed sharing

The safest place for your baby to sleep is in a cot.

It is dangerous for your baby to sleep in bed with you or your partner, and it is especially dangerous for your baby to sleep in your bed if you are smokers, have been drinking alcohol, taking prescribed medication or using drugs that make you drowsy or if you have had little sleep and you are very tired.

Your baby is particularly vulnerable if he/she was born premature before 37 weeks, was low birth weight and is under 3 months old. If you do decide to have your baby in bed with you to comfort or feed them, please put your baby back in the cot before you fall to sleep.

The risks of sleeping with your baby in your bed include:

• Accidentally rolling over in your sleep and suffocating your baby
• Accidentally trapping your baby between the wall and the bed
• Your baby could accidentally roll out of bed and be injured.

It is also very dangerous to fall asleep with your baby on a sofa or armchair or to let your baby sleep alone in an adult bed. 

The nursing staff will go through safe sleep positioning with you as your baby moves closer to being discharged. All parents are offered training on resuscitation skills prior to being discharged home. This is done by the nurses on the unit.

As parents taking your baby home for the first time you may worry about their temperature control.  Babies are unable to regulate their body temperature in the way adults do. However, by the time your baby comes home, he/she will be reasonably good at controlling their own body temperature.

It is still important to keep your baby neither too hot nor too cold; the following suggestions are given to help you keep your baby's temperature within the normal range:

Too hot?

To check if your baby is too hot, look for sweating or feel them. If you think your baby is too hot, remove one or more layers of blankets. Remember to take off your baby's outdoor clothes once you are inside.

Your baby does not need a hot room. Your house does not need to be as hot as the NICU or SCBU where babies are sick. Your baby is now well enough to be at home.

You should never lay your baby down to sleep next to a radiator or in direct sunlight. You should always put a hat on your baby in the summer to stop them becoming sunburnt.

In the summer make sure your baby stays well hydrated. If you are Breastfeeding make sure you drink plenty of liquids.

Too cold?

Do not worry if your baby's hands or feet are cold as this is normal, but if your baby's hands or feet look blue and blotchy, add mittens and socks. You may need to put on a hat and cardigan on your baby or a blanket.

Your baby will lose a lot of heat from his/her head, because babies' heads are large in proportion to their bodies. Your baby should wear a hat in the winter to stop him/her getting cold.

Make up your baby's bed with several layers of cotton blankets and sheets rather than a duvet. Before bathing your baby make sure the room is warm and the windows and doors are closed.  

To keep an eye on your baby's temperature buy a simple room thermometer. Generally, you should try to keep the room your baby is in between 16°C to 20°C, to maintain your baby's temperature within the normal range of 36.6°C to 37.2°C.

Premature babies

If your baby still weighs below 2.5kg, he/she may still need to be kept a bit warmer than bigger babies. Your home will probably be cooler than the SCBU and it may take some time for your baby to adjust to this new temperature. Avoid bathing your baby for the first 24hrs. Check the room temperature is within the recommended limits (16oC to 20°C) before undressing or bathing your baby. You may find it useful to purchase a thermometer to check your baby's temperature. If your baby's temperature is below 36.6°C do not bath your baby. 

Babies who are born too early or unwell often need extra time to start being able to feed by mouth. Pre-term and unwell babies are often initially fed by either Parenteral Nutrition (nutrition delivered via long line straight into the vein) and/or milk feeds through a nasogastric or orogastric tube (feeding tubes from nose or mouth to the stomach).

After all this early difficulty starting to take milk by mouth it can be hard to imagine your baby starting solids.  But it is important to get going at the right time so your baby will learn to accept and enjoy a full range of tastes and textures.

Research and experience tells us that babies who are born prematurely need to be introduced to solids by 5-7 months of age.  This is actual age not corrected for prematurity so if a baby is born at 32 weeks they would need to be starting having solids between 3 and 5 months from their due date.

1. Transition from smooth puree to lumpy solids (after 1-2 months on smoother consistencies or by 9 months of actual age) – this can be a bit tricky for babies to get used to and it is not uncommon for them to gag and spit out lumps when they are first offered.  They need practice to get used to managing the lumps to help try the following:

• Move from smooth to thicker and lumpier consistencies gradually – this is much easier with home cooking rather than jar foods which change consistency in big jumps. For example you can gradually mash a banana less and less over time. If you are using jars and your baby is struggling, try mashing the lumps a little bit to make the lumps smaller and more manageable.
• If your baby does gag or spit out the lumps don’t worry just offer a few more spoonful’s with an encouraging smile and see how they manage.  If they seem upset or to be really struggling make the food a bit less lumpy next time and gradually re-start to build up to a more lumpy texture. Avoid going back to completely smooth puree as children can get stuck on this stage if they are not helped to move on.
• Use an encouraging voice and facial expression when feeding your baby – if you sound or look anxious your baby will pick up on this

2. Babies like to be involved and if they want, let your baby hold a spoon and have a go at dipping the spoon or their fingers in the food at some time in the meal.
3. It is normal and important that meals times are a bit messy.  For normal feeding development babies need to get used to food on their faces and hands.  It is probably worth having big bibs and a wipable mat or old sheet on the floor underneath the high chair to contain the mess. By 12 months of age babies should be having chopped or mashed family foods 
4. Introduce a free flowing beaker to your baby from 6 months onwards; this will help them to develop a more mature drinking pattern which is very different to sucking from a bottle.  Avoid 'no spill’ beakers when babies are learning to drink free flowing liquids as 'no spill’ beakers work in the same way as bottles, with babies needing to suck to get the drink out
5. Your baby may have been discharged on a post discharge formula called Nutriprem 2 which is prescribed by your GP, they can remain on this until 6 -12 months or until adequate catch up growth has been achieved.  Your Health Visitor, GP or Dietician will be able to advise you further on this
6. It is important not to fill your baby up on milk so as to encourage solid foods. During weaning most babies will naturally decrease the amount of milk they drink. Once your baby is having three solid meals a day an appropriate amount is around 600mls or 18oz a day 
7. If you are concerned regarding your baby’s growth or their safety when eating and drinking please discuss with your GP who can refer you to a dietician or speech and language therapist as needed

It is likely that your baby may be discharged home on numerous medicines. These may include routine vitamins and supplements along with other medication that your baby may have been on prior to discharge, for example medication to help prevent reflux.

During your stay on SCBU you will gradually learn what medicines your baby is receiving, and as you move towards the transition to home, you will become familiar with adding your baby’s medicines to milk and correct timings for medication. Staff are here to help you learn and to teach you so that when the time comes to take your baby home you will not be daunted at all by any medicines that your baby is on. If you have any questions regarding additives or medication, then ask.

The routine supplements your baby is likely to go home on are:

• Abidec (vitamin supplement) - 0.3 – 0.6 mls once a day to continue as per medical instructions
• Sytron (iron supplement) - 1 ml daily from 4 weeks through to 12 months of age

What are the common symptoms of illness in a newborn baby?

Most babies have a smooth transition from life on the neonatal unit to that at home. However, you will need to be aware of common symptoms of illness –

• feverish, fretful
• irregular breathing or more rapid or noisy breathing
• change in colour – unusually pale or yellow
• uncharacteristically sleepy or non-responsive
• changes in feeding pattern  - becoming disinterested or reluctant to feed
• recurrent vomiting
• changes in stools
• floppy
• blotchy skin, or a rash

If you feel that your baby is unwell, or is showing some or most of the above symptoms then it is recommended that you seek medical help from your GP or call 999, rather than trying to contact the NICU, SCBU or community support team.

The long term effects of early birth can be difficult to predict in premature babies. Some very premature babies are slow to reach early milestones, such as rolling, sitting and crawling although this does not necessarily indicate a long term problem.  You will have been used to hearing the term ‘corrected age’, this is the age your baby would be if they had been born on their due date. When assessing development we will always expect progress for your baby’s corrected age and not their actual age.

Your baby’s Consultant will follow up your baby to monitor their growth and development.  Some babies will be referred to other health professionals, such as physiotherapists and speech therapists. It is likely your premature baby will have many appointments with paediatric specialists in the first few years.

Few very premature infants have major difficulties.  Those who do can have several problems, such as difficulty with feeding, walking, hearing, language development and vision.  Overall the majority of babies do well.

In the health board, we have a dedicated team of multidisciplinary professionals that offers a neurodevelopment follow up programme for all babies if they were born before 30 weeks or weighed less than 1500gms at birth.  The Neurodevelopment Clinic is an opportunity to be fully informed about your baby’s progress.

What is the neurodevelopmental follow-up programme?

This programme is a systematic way of assessing different aspects of your child’s development. When babies are born very prematurely or develop complications around the time of birth, it is important to closely monitor their developmental progress. As part of this follow-up programme, we will invite you to bring your child to the Children’s Outpatient Clinic to be seen by one of the team of developmental specialists who will assess your child’s development. The assessments may involve video recordings of your child's movements and play activities, which will be fun for your child and interesting for you as parents/carers. You will be able to see how your child is progressing and have an opportunity to discuss your child’s development with the Doctor or Therapist. We may recommend some activities for you to do at home. A written report will be provided for you after the appointment.

Who is the follow-up programme for?

The follow-up programme is for all babies who were born earlier than 30 weeks gestation or weighed less than 1500 grams (3.3 lbs) at birth. Babies who may have had injury to the brain or underwent cooling treatment soon after birth are also followed up.

Where will the developmental clinic be?

Developmental assessments for your baby will be in the Children’s Outpatient area in West Ward Block on level 2 of Singleton Hospital.

How often will my baby be seen?

In addition to follow-up in the baby clinic with your named paediatrician, your baby will be seen in this special clinic at 3 months, 1 year and 2 years of age (corrected for prematurity).

An appointment inviting you to attend the clinic will be sent out shortly before the assessment is due.

What if my child is already under the care of a paediatrician and having developmental tests anyway?

This is an additional clinic offering more detailed testing for your baby and will not interfere with or undermine what your own paediatrician has already arranged or planned.

What happens if a problem is detected?

If you are informed at the clinic that a problem has been detected then one of two things will happen:

1. The problem may be very mild, in which case we will give you appropriate advice and offer a further appointment for a re-evaluation.
2. If a more serious problem is identified (such as increase or decrease in your baby's muscle tone or a marked delay in reaching developmental milestones) then your baby is going to need more intense and prolonged follow-up and support. In this case we would refer your baby to the appropriate Child Development Team.

Crying

Coping with crying

Crying is the most effective way your baby has of communicating their needs. All babies cry, and some cry a lot. Crying is your baby’s way of telling you they need comfort and care. 

Often you will know exactly why your baby is crying. But sometimes it can seem as if nothing will stop your baby crying. This can be an anxious time. However, you will gradually begin to recognise your baby's different crying patterns and, as you get to know your baby better, you will be able to anticipate his/her needs.

Sometimes it’s easy to work out what they want, and sometimes it isn’t. The most common reasons are:

• Hunger
• a dirty or wet nappy
• tiredness
• wanting a cuddle
• wind
• being too hot or too cold
• boredom
• overstimulation

There may be times of the day when your baby tends to cry a lot and can’t be comforted. Early evening is the most common time for this to happen. This can be hard for you as it’s often the time when you’re most tired and least able to cope.

Comforting your baby

There are things you can try to comfort your crying baby. If your baby cries inconsolably, you might like to try some of these suggestions, not all of them will work for your baby but eventually you will get to know your baby's personality and find out what works best for them and for you.

• If you’re breastfeeding, let your baby suckle at your breast.
• If you’re bottle feeding, give your baby a dummy. Sterilise dummies as you would bottles. To avoid tooth decay don’t dip them in anything sweet. Some babies find their thumb instead.
• Later, some will use a bit of cloth as a comforter.
• Hold your baby or put them in a sling so that they’re close to you. Move about gently, sway and dance, talk to them and sing.
• Rock your baby backwards and forwards in the pram, or go out for a walk or a drive. Lots of babies like to sleep in cars. Even if they wake up again when you stop, at least you’ll have had a break.
• Find something for them to listen to or look at. This could be music on the radio, a CD, a rattle or a mobile above the cot.
• Try stroking your baby’s back firmly and rhythmically, holding them against you or lying face downwards on your lap. You could also undress your baby and massage them with baby oil, gently and firmly. Talk soothingly as you do it and keep the room warm enough. Some clinics run baby massage courses. For information, ask your midwife or health visitor.
• Try a warm bath. This calms some babies instantly, but makes others cry even more.
• Sometimes, rocking and singing can keep your baby awake. You might find that lying them down after a feed will help.
• Most parents have favourite ways to help their baby settle and if you have other children you may have already successfully used some of the above techniques.

Crying during feeds

Some babies cry and seem unsettled around the time of a feed. If you’re breastfeeding, you may find that improving your baby’s attachment helps them to settle. You can go to a breastfeeding or drop-in centre and ask for help, or talk to your peer supporter or health visitor.

It may be that something you’re eating or drinking is affecting your baby. Some things will reach your milk within a few hours, while others may take 24 hours. All babies are different, and what affects one won’t necessarily affect yours. You might want to consider avoiding dairy products, chocolate, fruit squashes, diet drinks and drinks containing caffeine.

If this doesn’t work, try keeping a note of when the crying happens to see if there’s a pattern. Sometimes, crying during feeds can be a symptom of reflux (acid indigestion), which is relatively common in babies. Speak to your community nurse, GP or health visitor for more information and advice.

Excessive crying

If your baby always cries at a particular time, and is difficult to comfort, this could be caused by colic or trapped wind after feeding. Talk to your visiting neonatal outreach nurse or Health Visitor, who will be happy to help you.

Crying and illness

Although all babies cry sometimes, there are times when crying may be a sign of illness.

Listen for sudden changes in the pattern or sound of your baby’s crying. Often, there’ll be a simple explanation. For example, if you’ve been going out more than usual your baby might be overtired.

If they seem to have other symptoms, such as a high temperature, they may have an illness. Your baby may have something minor, such as a cold, or something treatable, such as reflux. If this is the case, contact your GP or health visitor.

Get medical attention as soon as you can if your baby:

• has a weak, high-pitched continuous cry
• seems floppy when you pick them up
• takes less than a third of their usual amount of fluids
• passes much less urine than usual
• vomits green fluid
• passes blood in their stools
• has a fever of 38°C or above (if they're less than three months old) or 39°C or above (if they're between three and six months)  
• has a high temperature, but their hands and feet feel cold
• has a bulging fontanelle
• has had a fit
• turns blue, mottled or very pale
• has a stiff neck
• has difficulty breathing, breathes fast or grunts while breathing, or seems to be working hard to breathe (for example, sucking in under the ribcage)
• has a spotty purple-red rash anywhere on the body (this could be sign of meningitis)

If you think there’s something wrong, always follow your instincts and contact your GP, community nurse or health visitor, or phone NHS Direct on 0845 4647.

Getting help

If you’ve decided to talk to your community nurse, health visitor or GP it can help if you keep a record of how often and when your baby cries. For example, this might be after every feed or during the evening. This can help to work out whether there is a particular cause for the crying.

Keeping a record can also help you identify the times when you need extra support. You could also think about possible changes to your routine. There may be times when you’re so tired and angry you feel like you can’t take any more. This happens to a lot of parents, so don’t be ashamed to ask for help.

If you don't have anyone who can take care of your baby for a short time and the crying is making you stressed, put your baby in their cot or pram, make sure they’re safe, close the door, go into another room and try to calm yourself down. Set a time limit (for example, 10 minutes) then go back.

Never shake your baby

No matter how frustrated you feel, you must never shake your baby. Shaking moves their head violently, and can cause bleeding and brain damage.

Talk to a friend, your community nurse, health visitor or GP, or contact Cry-sis on 08451 228 669. They can put you in touch with other parents who’ve been in the same situation. 

Constipation

What causes constipation?

Constipation may be caused by a number of things including a change of diet (sometimes switching from breast milk to formula or from formula to solid food can jolt your baby’s digestive system, causing constipation) dehydration or a minor illness like a cold. It is rarely seen in breastfed babies because breast milk is more easily digested.

What can I do about it?

There are several things you can do for your constipated baby:

• Give your baby extra drinks of cooled, boiled water.
• Babies over 6 months who have started on solids can have fruit juice as well as fibre: pureed or chopped apples, apricots, blueberries, grapes, pears, plums, prunes, raspberries and strawberries are all high in fibre. You could also add a small amount of high-fibre cereal to your baby’s usual breakfast cereal.
• Check her/his bottles are being made correctly - too much baby milk powder will make the feed too concentrated.
• Gently massage your baby's tummy in a clockwise direction. Some baby oil on your hands may help. But if your baby seems tense or doesn’t like the sensation stop immediately.
• Gently move your baby’s legs in a cycling motion. Sometimes this gentle “exercise” can help move the poo through her/his system.
• Give your baby a warm bath and apply some cream or petroleum jelly around her/his bottom to soothe and prevent soreness.

Ask the experts

If you have any worries about your baby's health, it's always best to talk to your doctor or health visitor. If your baby’s constipation is severe, your doctor may suggest a laxative, probably via a suppository. Try not to worry too much if your baby becomes constipated. It's likely to happen now and then, especially if he/she is on formula feeds or eating solids.

Just pay attention, help with these natural home remedies and, in time, he’ll/she'll be regular as clockwork again! 

Gastro-oesophageal reflux (GOR)

GOR in babies is similar to heartburn in adults. Symptoms can include vomiting, gagging, and choking and tummy pain. Reflux is common in premature babies – the more premature your baby is, the more likely it is they will have GOR for a while.

GOR can be miserably uncomfortable for your baby, making it difficult for your baby to feed happily or to keep milk in his/her stomach afterwards. Thankfully, babies usually grow out of reflux during their first year and the reflux tends to disappear as your baby spends more time upright – first sitting up alone, then toddling and walking. Your community nurse and health visitor will be able to give you individual advice about the way your baby is feeding.

In general, if your baby has GOR, it may help to keep him/her as upright as possible most of the time. Try and position your baby so that their head is gently raised during the day, particularly during and after feeds. Kangaroo care or holding your baby upright after feeding may also help. At night, you could try semi-reclining your baby's mattress by standing it on something stable such as a couple of books.

Colic and wind

Excessive crying could be a sign that your baby has colic. Everyone agrees that colic exists but no one knows what causes it. Some doctors think it’s a kind of stomach cramp. The crying sounds miserable and distressed, and stops for a moment or two, then starts up again, which suggests it could be caused by waves of stomach pain. Colic is when a baby cries for longer than three hours every day for more than three days a week.

It is the extreme end of normal crying behaviour. The condition is harmless, though it can be very distressing for parents or carers.

Hopefully these tips will help you get through this difficult time. 

REMEMBER: Babies cry for many reasons – never assume that your baby's crying is always colic, check for other reasons too.

The symptoms of colic:

Looking after yourself

This can be a very stressful time for you - remember to look after yourself:

If breastfeeding, change anything which you believe might be affecting your baby:

Some mothers find that chamomile, dill or fennel teas help them. Colicky symptoms occur to babies throughout the world and in all cultures, it is not your fault. Your baby may have an immature digestive system. We all have our specific areas in our bodies where we suffer vulnerability.

If you feel you are losing control give your baby to someone who is calmer for a while. You must remember that everyone has a breaking point, (and by reaching that point) this does not mean that you are a bad parent. Recognise your own point of vulnerability and act on it.

What you can do to help:

Listen

Sometimes babies (all of us) need to cry to release built up tensions. Support him/her in times of need. You cannot spoil your child by holding or soothing.

Seek help

Seek advice from a member of the community team, your Health Visitors or a doctor if you think that your baby is unwell.

Correct Positioning

Use of the correct positioning of your baby during and after feeding may help prevent excessive wind and provide relief. If your baby is slouched or horizontal during feeds, it may cause wind build-up in the digestive system.

Movement

Try walking about with your baby's head cradled and facing out from the crook in your left arm; your right arm supporting his/her tummy from beneath the legs. With gentle squeezes of the tummy every now and then, you may feel the abdomen soften and relax.

 Warm towel

• Put a warm towel over your lap and place your baby, tummy down, on the towel and gently rock or jog on your knees
• Laying your baby on his/her tummy (when awake) will help stretch out and relax this area

A warm bath

A warm bath may help relax and warm tense muscles. Use the bath for pleasure and not for busy washing procedures.

Peace

Some babies are very sensitive and seem to be upset with the big, bright busy world. Try reducing too much environmental stimulation for a week or so:

• Reduce noise or light
• Reduce the number of visitors you have
• Reduce the number of outings you and your baby have
• Try taking away stimulating mobiles from the cot

Crying

• Try to understand the different types of crying and discuss it with somebody whose opinion you trust
• Sharing a problem can trigger a new perspective.
• When you feel more confident about reading your baby's cries, you will be better able to cope with them appropriately
• You will also find that you are less intimidated by all of the (often-well meaning) conflicting advice given at a time when you feel most vulnerable and can cause friction amongst family and friends

Touch and relaxation techniques

• Check your own breathing. Take some deep, slow, full breaths
• Think of a pleasant colour you would want to transfer to your baby to help him/her
• Take the baby's legs gently in your hands. Feel a heavy relaxation in your touch. Gently and slowly jiggle the legs, repeating in a soft voice “relax" -use the same tone each time you say it.
• As you feel the baby relax in any way give him/her some positive feedback saying “wonderful you relaxed your legs"
• Smile. Show your baby you are pleased that he/she is relaxing
• Some babies will relax better if you start on their back first

Oral Thrush

If your baby is not feeding as usual and you notice white spots or coating to your baby’s mouth he/she may have oral thrush.

Oral thrush is a common and usually harmless fungal infection in the mouth. It mostly affects children under two years of age.

Why does my baby have oral thrush?

Oral thrush is caused by a strain of yeast fungus called candida albicans, which lives on the skin and inside the mouth of most people.

It doesn't cause symptoms usually, but it can cause an infection in people with a weakened immune system. As the immune systems of newborn babies are still developing, they are more vulnerable to infection.

Who is affected?

Oral thrush is a common condition, affecting around 1 in 20 babies.

It is most common in babies around four weeks old, although older babies can get it too. Your premature baby (babies born before 37 weeks) will have an increased risk of developing oral thrush.

Symptoms of oral thrush in babies 

Symptoms of oral thrush can include one or more white spots or patches in and around the baby's mouth.

These may look yellow or cream-coloured, like curd or cottage cheese. They can also join together to make larger plaques.

You may see patches:

• on your baby's gums
• on the roof of their mouth (palate)
• inside their cheeks

You can easily rub the patches off. The tissue underneath will be red and raw. It may also bleed a little. The patches may not seem to bother your baby. But if they are sore, your baby may be reluctant to feed.

Other symptoms

 Other signs and symptoms of oral thrush in babies are:

• a whitish sheen to their saliva
• fussiness at the breast (keeps detaching from the breast) or with bottle
• refusing the breast
• clicking sounds during feeding
• poor weight gain
• nappy rash

Some babies may dribble more saliva than normal if they have an oral thrush infection. Many cases of thrush clear up without needing treatment. However, if these symptoms are particularly troublesome or persistent, ask your community neonatal nurse or health visitor for advice or speak to your GP. 

If there is any doubt about the diagnosis your GP can take a swab from your baby's mouth and send it to a lab to be tested.

Can thrush be prevented?

Nobody really knows if thrush can be prevented. The following advice may help prevent oral thrush in some cases:

• sterilise dummies regularly, as well as any toys designed to be put in their mouth
• sterilise bottles and other feeding equipment regularly, especially the teats

Mild oral thrush infections in babies often clear up after a few days without treatment. 

However, if you are concerned, visit your GP. You can also ask your community neonatal nurse or health visitor for advice, or call NHS Direct on 0845 4647.

Antifungal medicine

If your GP decides your baby needs treatment, they will probably prescribe an antifungal medicine.

If your baby is less than four months old, a medication called nystatin may be recommended.

In babies older than four months, a medication called miconazole is likely to be recommended. This is because there is a small risk of miconazole causing choking if it's not applied properly.

Nystatin

Nystatin comes as a liquid medicine (suspension). You put the liquid directly on the affected area using a dropper (oral dispenser) supplied with the medicine.

Nystatin does not usually cause any side effects and most babies will have no trouble taking the medication.

Miconazole

Miconazole is available as a gel. You apply the gel to the affected areas using a clean finger. It's important only to apply a little at a time and to try to avoid the back of your baby’s mouth to reduce the risk of choking.

A small number of babies are sick after being treated with miconazole. This side effect usually passes and is not cause for concern.

General advice on treatment

Medication is most effective if you use it after your baby has had a feed or drink.

Continue to use the medicine for two days after the infection has cleared up as this will help prevent the infection from coming back.

If treatment hasn't cleared the thrush after seven days, contact your GP for advice. 

Advice for breastfeeding mothers

If your baby has oral thrush and you're breastfeeding, it's possible for your baby to pass a thrush infection to you. This can affect your nipples or breasts and is known as nipple thrush.

Symptoms of nipple thrush include:

• pain while you're feeding your baby, which may continue after the feed is finished
• cracked, flaky or sensitive nipples and areolas (the darker area around your nipple)

You may be prescribed an antifungal cream, such as miconazole. You should apply the cream to your nipples after every feed, and remove any that's left before the next feed. Antifungal tablets may be recommended for severe nipple thrush.

Read more about how your baby’s oral thrush can affect breastfeeding. 

Plagiocephaly

What is plagiocephaly?

Positional plagiocephaly (sometimes known as “Flat head syndrome”) is a cosmetic condition where the rounded shape of a baby’s head becomes flattened at the back or side. It is quite common, and in most cases corrects itself as a child gets older and is able to change position more easily.

What are the symptoms?

There are no symptoms with plagiocephaly, other than a flattened appearance to the back or side of the head. It does not affect a baby’s brain, and it does not affect their health.

Checking with a doctor is always advisable if:

• You feel that the problem is significant and you continue to be worried
• You are worried that there is an additional problem, such as a health or development concern
• Your baby has difficulty turning their head from side to side, or has tightening of the neck muscles, as referral to a physiotherapist may be necessary before the head shape can improve

What causes it?

The skull is made up of several ‘plates’ of bone which, when we are born, are not tightly joined together. As we grow older, they gradually fuse, but when we are young, they are soft enough to be moulded, and this means the shape of the head can be altered by pressure on it to give a flattened look. Plagiocephaly can be caused by a baby’s position in the womb, but more commonly it is caused by the position a baby lies in after birth.

The Back to Sleep campaign advises parents that babies should always sleep on their backs to reduce the risk of Sudden Infant Death Syndrome (“Cot death”). As a result babies now spend much of their early lives lying on their backs e.g. when sleeping, and when sitting in car seats and bouncy chairs.

Lying in the same position for a long time can cause a baby’s head shape to become flattened because of the pressure from the surface it is resting on.

It is important that babies always sleep on their back but there are things you can do to help prevent plagiocephaly, or stop it getting worse.

What can you do?

Tummy to play. Back to sleep.

Babies should always sleep on their back; but placing them on their tummies when they are awake and supervised will help to prevent flattening of the head (positional plagiocephaly)

When awake your baby should spend time in different positions. This will avoid constant pressure on one part of the head. It will also strengthen the neck and back muscles, and improve movement skills (rolling, crawling, sitting and standing).

• Make Tummy Time part of your baby’s daily routine from birth. Start with just a minute or two, and gradually increase the time as your baby learns to like it. It is normal for babies to cry at first. You could try placing your baby on his/her front, putting a rolled up towel under the chest and arms for support or lay your baby on their tummy over your knees. Make it fun (play peek-a-boo, use toys).

            Always supervise your baby when they are playing on their tummy

            Never allow your baby to fall asleep when lying on their tummy

• Allow your baby plenty of time sitting on your knee. Play or read together to keep it interesting.
• Try holding your baby in different positions, or carry your baby in a sling or front carrier
• If your baby always faces one side when lying in the cot place a mobile or picture on the other side to encourage him/her to turn and face the other way 
• Change the position of the light or toys/mobiles in the room to the side your baby favours less
• Gently turn his/her head so that he/she is not always lying on the same part of the skull
• Alternate the side your baby is facing (Breast-fed babies are less likely to develop plagiocephaly because their position is changed more often during feeding. Bottle-fed babies tend to be fed from the same side)
• Only sit your baby in a car seat when travelling
• Limit time in bouncy chairs

Further information can be obtained from:

• Your Health Visitor, GP, Midwife or NHS Direct website.
• NHS Direct

Giving milk via a Nasogastric Tube to your baby at home

Your baby may be gaining weight, maintaining his/her temperature and have no other significant problems but still requires using a feeding tube for some of his/her feeds. It is possible for your baby to be discharged home whilst he/she still needs some tube feeds. Whilst your baby is on the NICU or, SCBU, the nurses will show you how to feed via the tube. The community team will make sure that you are confident with doing this and discuss his/her feeding plan, before your baby is discharged.

We provide you with all the necessary equipment for tube feeding and will visit you at home at least twice a week initially and help you with the gradual weaning from the tube. 

Feeding Guidance

It is important to be sure of the position of the tube prior to feeding as it might have become dislodged or moved slightly. Your baby will let you know if the tube is misplaced by coughing and gagging. If your baby has pulled the tube out a little way do not put it back take it out.

Checking the position of the tube

• Make a note of the level at which the tube is placed before you go home. This way you can always check the level of the tube before starting each feed and be fairly certain that it has not moved.
• Wash your hands and dry thoroughly
• Collect and place the PH indicator strip within reach  
• Inspect the length of the tube.  If the tube has changed position the length of the tube from the nostril may be an indicator of a position change 
• Connect a purple enteral syringe to the feeding port of the NG tube
• Slowly and gently withdraw the plunger from the syringe until at least 1ml of aspirate is obtained (to coat the coloured squares on the indicator strip)
• Disconnect the syringe from the NG tube ensuring the cap is closed
• Push down the plunger to coat the coloured squares on the indicator strip 
• Observe for any colour changes
• Colour changes should happen in 10 seconds
• Compare the indicator strips to the colour chart on the box  
• If the strip indicates a PH of 5.5 or below you may begin feeding. It is now safe to proceed with the feed. If you get a pH reading of 6 or above you should not feed your baby via the tube and contact the community team. The nurses will go through this with you while you are still in the hospital and will make sure you are confident before discharging your baby 

Trouble Shooting

If you cannot withdraw any milk/fluid there are a few things you can do:

- Wait a few minutes and try again
- Turn your baby onto his/her side and try again
- Offer your baby the breast or bottle for a few minutes and then try again

What to do if the tube has come out or you cannot test it?

If your baby is already taking a reasonable amount by breast/bottle then don't panic. As long as he/she is able to keep the nutrition going by taking 20-30mls per feed there is no immediate cause for concern. If however you know that you have a very sleepy baby that is not taking either breast or bottle then the tube will need to be replaced fairly quickly.

• If you know the community nurse is due to visit within a few hours, wait for her/him to arrive
• If the community team are not due to visit you should call the community office during working hours
• If your baby should pull out his/her tube at a weekend or evening you should contact your local PAU at Morriston for advice and if necessary tube replacement.

Morriston PAU Tel:  01792 285504

Your baby should never be left alone with the tube feed in progress. If the phone rings or another emergency happens then pour the milk back into the bottle and detach the syringe before attending to the problem.

Changing your baby's tube

Your community nurse will give you a date for the tube change. It is a quick procedure during which your baby may experience some slight discomfort but once the tube is in place there is no distress.

Community Team visits

Babies who go home with a feeding tube usually have at least 1 visit a week from the community team. We continue with the advice that is given in hospital, advice on feeding issues and give other advice pertaining to your baby's growth and development and weigh your baby. The team meet regularly with your baby's paediatrician and other health professionals to discuss progress.