20 How to care for a newborn

Each year, about 3,500 infants in the U.S. lose their lives to sleep-related issues, including sudden infant death syndrome, deaths of unknown cause, and accidental suffocation in bedding. The American Academy of Pediatrics recommends a safe sleep environment consisting of: infants sleeping on their backs; using a firm, non-inclined sleeping surface; sharing a room without sharing a bed; and avoiding soft bedding and overheating. Additional protective measures include breastfeeding, keeping infants away from nicotine and alcohol, ensuring all vaccinations are up to date, and offering a pacifier.

The World Health Organization says: "All infants should receive the hepatitis B vaccine as soon as possible after birth (within 24 hours)." The reason is that "about 95% of infections in infancy and early childhood develop into chronic hepatitis." The great majority of people infected as adults clear it on their own (they get better without treatment). The WHO's own words are that "under 5%" of infections after adulthood become chronic. The National Health Commission (国家卫生健康委员会) protocol for interrupting mother-to-child transmission requires that a child born to a mother who is positive for hepatitis B surface antigen "receive the 1st dose of hepatitis B vaccine as early as possible within 12 hours after birth, and at the same time an injection of 100 international units of hepatitis B immune globulin."

When a child enters daycare or school, the daycare or the school checks the vaccination certificate. If the child was not vaccinated on the immunization schedule as required, they report it to the vaccination provider and help press the guardian to catch up. So a missed vaccine is generally found when the certificate is checked at daycare or school entry. The schedule now in force is the 2026 edition. Human papillomavirus (HPV) vaccine is already on the national immunization schedule. The starting age for the diphtheria-tetanus-pertussis vaccine (百白破) changed from 3 months to 2 months. There are 5 doses in all, 1 dose at each of 2 months, 4 months, 6 months, 18 months, and 6 years. From March 2026, children of the right age in Tibet, Qinghai, Xinjiang, and the Xinjiang Production and Construction Corps (新疆生产建设兵团) also receive Japanese encephalitis vaccine (乙脑) as a routine vaccination. Several vaccines can be given on the same day: at this stage, national immunization-schedule vaccines can be given at the same time, following the schedule or the catch-up rules. 2 or more injected vaccines must go into different sites. "It is strictly forbidden to draw 2 or more vaccines into the same syringe and inject them." If they are not given on the same day, 2 or more injected live attenuated vaccines need an interval of not less than 28 days. There is no interval limit between inactivated vaccines, oral live attenuated vaccines, and other vaccines. The catch-up rule for a child under 18 years of age is to catch up as soon as possible: "only the doses not yet finished need to be given; there is no need to start the whole series over." The same vaccine can be continued if the manufacturer changes (nationwide, 2026 edition of the schedule).

The World Health Organization recommends "starting breastfeeding within the 1st hour after birth." For the first 6 months, "exclusive breastfeeding, meaning no other food or liquid, including water." Then "from 6 months of age, start safe and adequate complementary foods, and continue breastfeeding to 2 years or beyond." The National Health Commission service guide also promotes exclusive breastfeeding from 0 to 6 months. The same guide requires that from a full 6 months "the day's complementary foods must include iron-rich animal foods."

Formula is not sterile. It can carry Cronobacter (阪崎克罗诺杆菌). The reported death rate after a newborn is infected is 40% to 80%. Experimental work shows: pour the hot water into the bottle first, wait until the water falls to about 73.8 °C, then add the powder, and in the great majority of cases the milk is still above 70 °C. That can cut this bacterium by 5 or more orders of magnitude, down to below 1/100000 of what it was. The price of hot water shows up in vitamin C. The World Health Organization and the UN Food and Agriculture Organization held an expert meeting in 2006. The figures seen at that meeting were: when formula is mixed with boiling water, only vitamin C falls clearly, by 5.6% to 65.6% across 4 formulas. Formula leaves the factory with extra vitamin C already added. The formula that lost the most still had 9.0 milligrams per 100 kilocalories after mixing, above the Codex Alimentarius floor of 8 milligrams. The meeting saw only this 1 study, so it drew no conclusion on it.

The US Centers for Disease Control and Prevention says "do not feed honey to children under 1 year of age," because "honey may contain the bacteria that cause botulism." An adult's gut bacteria can hold down these spores (the dormant form of this bacterium). An infant's cannot.

A newborn has very little vitamin K stored. Without a supplement, vitamin K deficiency bleeding can occur, and the kind that shows up late often presents as intracranial hemorrhage (bleeding in the brain). The Belgian consensus recommendation is "1 intramuscular injection of 1 or 2 milligrams of vitamin K at birth." Where prevention is not provided systematically, the rate of vitamin K deficiency bleeding is 478 cases per 100,000 people. That figure comes from 42000 newborns in Tashkent. The authors estimate that prevention can bring the rate down by "more than 78.5%."

The American Academy of Pediatrics wrote a specific guideline for full-term infants from 8 to 60 days of age who still look all right. That guideline defines fever as "a temperature of 38.0 °C or above." It splits them into 3 bands, 8 to 21 days, 22 to 28 days, and 29 to 60 days, and gives each band its own path. Infants under 8 days of age are outside that guideline. The UK NICE fever guideline covers children under 5 years of age. It states that a child under 3 months with a temperature of 38 °C or above is in the "high-risk group for serious illness."

Because a baby’s head is proportionally large and their neck muscles are underdeveloped, violent shaking can result in intracranial and retinal hemorrhage — bleeding in both the brain and eyes. This can be fatal or leave lifelong disability. Such harm is distinct from any gentle rocking used to calm them. Medically, injuries caused by shaking or impact are termed “abusive head trauma.” This condition is the leading cause of death from head injuries among children 2 years old or younger. In the United States between 1999 and 2014, it accounted for nearly 2,250 deaths of children under 5.

No official body has published a ranking of "which brand is best," so this book does not recommend a brand. Only 2 kinds of information can be checked. The 1st is product-quality sampling notices from the State Administration for Market Regulation. The 2nd is a regulator's investigation of a specific event. After the "infant diaper formamide problem" drew attention in June 2026, the State Administration for Market Regulation led a joint investigation team to look into it.

Strollers, cribs, swaddles, and toys are all used for a short time, and the used market has far more supply than demand. Used goods have 3 safety lines. The 1st is the car seat. The US National Highway Traffic Safety Administration says a seat that has been in a moderate or severe crash must be replaced and never used again. All 5 conditions must be met before a crash counts as minor and the seat can stay in use. The 5 are: the car could be driven away on its own, the door nearest the seat was not damaged, no one in the car was injured, the airbag did not deploy, and no damage can be seen on the seat. A used seat can be used only after you confirm 5 things. The 5 are: it has not been in a crash worse than minor, the label shows the date of manufacture and the model, it has not been recalled, the parts are complete, and the instructions are still there. The date of manufacture and the model are how you check recalls and whether the seat is too old. The 2nd is the mattress. A Scottish study compared infants who died suddenly with healthy infants of the same age, and looked back at which mattress each slept on. Usually sleeping on a mattress another child had used carried a higher risk of sudden infant death syndrome (OR 3.07, about 3 times, 95% CI 1.51–6.22). When the mattress came from another home the figure was 4.78. When it came from the same home it was 1.64, and the latter does not count as a difference. The authors say the evidence is not yet enough to judge whether the mattress itself caused it. The 3rd is the crib. From June 28, 2011, the United States has enforced a new mandatory crib standard, and a used crib has to meet it too. The old style, with 1 side rail that drops, was phased out. The US Consumer Product Safety Commission says an old crib has to be taken apart and broken in the test before anyone knows whether it complies, so it gives no way to check it yourself. From November 2007 to April 2010, the United States reported 147 deaths linked to standard-size cribs. Of those, 35 were a problem in the crib's structure, and 18 were a failure of a rail that could be dropped. Loose screws caused at least 10 deaths. US law lists inclined infant sleepers as banned goods, no matter which year they were made, and that was written into the regulations in 2023 (United States, United Kingdom).

The UK LEAP randomized trial. 640 infants were enrolled, on the condition of severe eczema, an egg allergy, or both. They were 4 to 11 months old at enrollment. They were randomly split into 2 groups. 1 group ate peanut products regularly, and 1 group avoided them completely, and peanut allergy was checked at 60 months of age. Among the 530 whose peanut skin test was negative at enrollment, 13.7% of the avoidance group were allergic, against 1.9% of the group that ate peanuts (P<0.001). Among the 98 whose skin test was already weakly positive at enrollment, 35.3% of the avoidance group were allergic, against 10.6% of the group that ate peanuts (P=0.004). Serious adverse events did not differ between the 2 groups.

The American Academy of Pediatrics 2022 guideline says "more than 80% of newborns will have some degree of jaundice." Bilirubin that is too high can cause acute bilirubin encephalopathy and kernicterus (核黄疸). The guideline calls kernicterus "a permanent disabling neurological disease." Its features include cerebral palsy with limbs that twist on their own, an inability to look upward, poor enamel on the baby teeth, and hearing damage. The guideline lists "jaundice within 24 hours after birth" as a risk factor for going on to severe jaundice. The UK National Health Service (NHS) splits what it tells parents into 2 tiers. Tier 1 is to call emergency services or go straight to emergency care. That tier is a child who has jaundice and, at the same time, is sleepier than usual or hard to wake, is not feeding, is floppy or stiff, or has jerking movements. A child who is jaundiced before 24 hours of age is also in this tier. Tier 2 is to see a doctor as soon as possible. That tier is age past 24 hours, jaundice that is not getting better or is getting worse, urine that is dark yellow or brown, or stool that is pale cream. A global estimate is that in 2010 about 480000 newborns had Rh hemolytic disease (caused by a blood-type mismatch between mother and child) or extreme hyperbilirubinemia. Of those children, 24% died, and 13% developed kernicterus. Of the children who survived kernicterus, more than 83% were left with 1 or more impairments. Pale stool can be biliary atresia. That disease needs a Kasai operation (葛西手术) within 60 days before the result is clearly better. From 2004, Taiwan printed a stool color card in every newborn's child-health handbook. The share who had the operation within 60 days rose from 60% in 2004 to 74.3% in 2005. In another Taiwan-wide study, after the color card was introduced, mortality among children with biliary atresia fell from 26.2% to 15.9%. That is a before-and-after comparison, not a trial that split children into groups.

In 2003 the US Centers for Disease Control and Prevention reported 2 children. Both were breastfed by mothers who ate vegetarian, both were short of vitamin B12, and both failed to grow and fell behind in development. The 1st child's mother had eaten fully vegan for 7 years. The child was admitted at 15 months of age, was found to have severe anemia, and a brain scan showed atrophy of the whole brain. After B12 was given the child improved, but at 32 months of age speech and language were still behind. The report says the most common reason an infant or young child is short of B12 is that the mother's diet is short of it. A breastfed child usually shows it at 4 to 8 months of age. If the shortage lasts long enough, some children are left with nerve damage that cannot be reversed. How bad it is depends on how severe the shortage was and how long it lasted. The only reliable sources that do not depend on fortification are animal foods: meat, dairy products, and eggs. Most of the B12 that occurs naturally in plants cannot be used by the body. Cereal, soy milk, and nutritional yeast with B12 added can be a steady source. The report asks people who eat vegetarian, especially women who are pregnant or breastfeeding, to find out how much B12 is in what they eat, or to ask a nutrition professional. The 2016 position paper of the Academy of Nutrition and Dietetics states: "People who eat fully vegan need a reliable source of vitamin B12, such as fortified foods or a supplement." The 2017 complementary-feeding position paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition states that all infants should eat iron-rich complementary foods, including meat or iron-fortified foods. A fully vegan diet should be followed only under proper supervision by a doctor or a dietitian, and parents have to understand the serious consequences of not supplementing as advised. The National Health Commission's 2020 core feeding messages require no fewer than 4 kinds of complementary food a day. That includes at least 1 animal food, 1 vegetable, and 1 cereal or tuber food.

From 1990 to 2014, children under 15 months who went to emergency care for a baby-walker injury made an estimated 230000 visits (exact value 230676). Of those, 90.6% were injured on the head or neck, and 74.1% fell down stairs while sitting in the walker. 4.5% were admitted after the injury, and 37.8% of the admitted children had a skull fracture. From 2010 the United States enforced a mandatory safety standard for baby walkers. Over the 4 years after that, the average number of injuries each year was 22.7% lower than over the 4 years before. The authors still say a baby walker remains an important source of injury to children, and it can be avoided. The American Academy of Pediatrics 2001 position statement says that from 1973 to 1998 the United States reported 34 deaths linked to baby walkers. Warning labels, publicity and education, an adult watching beside the child, and a stair gate have all been shown not to prevent this kind of injury. A baby walker also has no clear benefit, so the academy calls for a ban on making and selling wheeled baby walkers, and recommends a fixed activity center with no wheels instead. The note the academy gives parents says most baby-walker injuries happen while an adult is right there watching. A child sitting in a walker can shoot 3 feet (about 0.9 meters) or more in 1 second. On whether a walker helps a child learn to walk, the academy says it does not, and may delay it. The evidence that it delays walking is not strong. In 1 Irish survey of 190 infants, children who used a walker walked independently about 3 weeks later on average (61.12 weeks against 58.14 weeks). The more they used it, the later they walked. That was only a 1-time questionnaire, with no grouped comparison. 1 small review in 2002 found 2 trials that assigned children at random, and neither showed a clear effect on when walking started. Pooling 4 studies, the delay was 11 to 26 days, and the quality of the studies was low throughout.

A Cochrane review in 2020 says breast milk is low in vitamin D, and an infant who takes only breast milk is likely to fall short. The American Academy of Pediatrics says a child who stays outside for long needs sun protection, so every infant needs vitamin D. The National Health Commission's 2020 core feeding messages say: "From birth, an infant should receive 400-800 international units of vitamin D every day, under a doctor's guidance." The same passage also says: "A normal full-term infant generally does not need a calcium supplement in the 6 months after birth." The 2016 global consensus on rickets had 11 international academic bodies taking part. The consensus says 400 IU (10 micrograms) a day is enough to prevent rickets. Every infant should be supplemented from birth to 12 months, whether breastfed or formula-fed. That is a strong recommendation, and the evidence quality is moderate. In a study in rural northeastern Turkey, no child who received 400 IU a day got rickets. Among the children who were not supplemented, 3.8% newly developed rickets over 12 months. The consensus also says that, worldwide, there is no report of radiographically confirmed rickets in an infant who received 400 IU on time every day. In 1992 China ran a grouped study in 4 cities, north and south, supplementing 100, 200, or 400 IU a day. By 6 months, no child in any of the 3 groups had rickets. But vitamin D in the cord blood of northern newborns was only about 1/3 of the southern level (12.5 against 35.0 nmol/L). The more that was supplemented, the higher the level at 6 months, and the authors suggest 400 IU a day.

The US Consumer Product Safety Commission says most adults get a 3rd-degree burn from 2 seconds in water at 150 °F (about 65 °C). Water at 140 °F (60 °C) for 6 seconds, or water at 130 °F (about 54 °C) for 30 seconds, also scalds. Even at 120 °F (49 °C), a soak of 5 minutes can still cause a 3rd-degree burn. A World Health Organization report says the skin of infants and young children is thinner than an adult's, so a lower temperature can scald, and the scald goes deeper. The American Academy of Pediatrics teaches parents to test the water in the basin with the inside of the wrist or the elbow, and that it should be "warm, not hot." "Never bathe a baby under running water," because water moving through the pipes swings hot and cold, and a small change can scald. In 1983 the US state of Washington passed a law that new water heaters leave the factory preset at 49 °C. By 1988, the average home hot-water temperature had fallen from 61 °C in 1977 to 50 °C. Hospital admissions of children for tap-water burns fell from 5.5 a year in the 70s to 2.4 a year. Burned area, skin grafts, deaths, and days in hospital all fell too. That is a before-and-after comparison, not a trial that split people into groups. Australia sets a maximum of 50 °C for bathroom hot-water taps. In New South Wales from 1989 to 1996, the rate of hospital admission for burns among children aged 0 to 4 fell by 13%. Severe burns, those with a hospital stay of 10 days or more, fell by 30% in the last 2 years of the 2nd stage. In 3 Chinese hospital series of childhood burns, scalds from hot liquid accounted for 87.6% to 90.6%, and children 3 years or younger were the largest share.