Cribsheet

by Emily Oster

  In the 1990s, there was a brief controversy about the possibility that this shot led to increased incidence of childhood cancer. The concern was based on very small studies, with suspect methods, and subsequent follow-up work rejected this link.27 There are, therefore, no known risks to a vitamin K shot, but clear benefits from it. (Adam, my wonderful medical editor, begs you to please get the shot.)

  Antibiotics in the Eye

  If a mother has an untreated sexually transmitted infection—gonorrhea, in particular—and her child is born vaginally, there is a substantial risk of blindness as a result of infection. As a result, there is a policy of treating babies with antibiotic eye ointment as prophylaxis. This can prevent 85 to 90 percent of infections and does not have any recognized downsides.

  The reasons for this treatment are increasingly less common, as all pregnant women are now tested and treated for STIs. And if you know you are not at risk, the antibiotics are unnecessary. You can opt out of this treatment in many states—easier in some than others—and this may be an option for you.

  The Bottom Line

  Newborn baths early on are unnecessary, but not damaging. Tub baths are better than sponge baths.

  Circumcision has some small benefits and also carries some small risks. The choice is likely to come down largely to preference.

  Rooming in doesn’t have any compelling effects on breastfeeding outcomes either way. It is worth being careful about falling asleep with your infant if you choose to keep them with you at all times.

  Infant weight loss should be monitored and compared with expectations; you can do this yourself at www.newbornweight.org.

  Jaundice is monitored with a blood test and should be treated if outside the normal range; you can monitor this yourself at www.bilitool.org.

  Delayed cord clamping is likely recommended, especially if your baby is premature. Vitamin K supplements are a good idea. Eye antibiotics are likely unnecessary for most babies but are mandated in some states and have no known downsides.

  2

  Wait, You Want Me to Take It Home?

  I have two incredibly vivid memories from Penelope’s first weeks at home. One is a moment around three weeks where I recall sitting on the couch in the basement, crying hysterically, after realizing I would never feel rested again. (This was only partially true.) But the first is of the moment we arrived. Penelope had fallen asleep on the way. We came through the back door. I was carrying the car seat. I put the seat down. And I remember thinking, It’s going to wake up. What do we do then?

  Perhaps because of this total uncertainty about what’s going on (which, luckily, mostly lessens with later children), small concerns can totally take over. You are very tired, and you are now facing a challenge unlike any you have ever known. So cut yourself some slack if things get a little absurd.

  For example, when we left the hospital, the doctors told us to keep mittens over Penelope’s hands so she wouldn’t scratch herself. But when my mother came to visit, she told us that if we did this, Penelope would never learn to use her hands.

  In reflecting on this now, I cannot imagine why I was especially animated about this either way. But when I look back to my notes from that time, I find a paper entitled “Injury by Mittens in Neonates: A Report of an Unusual Presentation of This Easily Overlooked Problem and Literature Review.”1 Apparently this is the only paper I could find about mitten injuries, and it suggests a child can be injured by mittens, rather than that mittens prevent injury. The paper reports twenty cases of mitten injury since the 1960s, which, I think it’s fair to say, makes this type of injury rare. I could not find anything that suggested mittens would prevent children from learning to use their hands.

  I recall that we did stick with the mittens, despite the developmental concerns and injury risk. My mother had already lost some credibility earlier in her visit by insisting (in contrast to my doctor’s advice) that I should limit how frequently I walked up and down the stairs.

  It is beyond the scope of this book (or probably any book) to address all the crazy concerns that will come up in each particular case. And there are some questions I cannot answer—for example, is there any way to get infant poop stains out of white onesies? It’s a question for the ages, and one we won’t answer here.

  In this chapter, I cover some concerns that come up right away: germ exposure, vitamin D drops, colic, and, finally, the value (or lack thereof) of data collection. These may seem mundane and minor. But they can loom very large for the brand-new parent.

  Take for instance, the prisoner’s dilemma, aka swaddling.

  SWADDLING

  When the nurses take your baby away at the hospital, it will invariably be returned tightly packed in a little blanket, swaddled up like a burrito. The hospital-grade swaddle is a baby straitjacket. No baby can escape it.

  They’ll probably send you home with a couple of the hospital blankets. Before you go, the nurse will show you how to use them to swaddle the baby. It looks easy! Fold, fold, tuck, fold, tuck, solve a differential equation, more tucking, and voilà!

  When you get home and try it, you’ll find it impossible to replicate. You can wrap up the baby, sure, but three minutes later, its arms are out and it’s flailing around. You’ll wonder, Is it fold fold tuck, or fold tuck fold, or tuck fold fold tuck? Wait, was there something about an equation in there? Did I imagine that?

  Let me suggest you learn from the mistakes of those of us who have come before. If you want to swaddle, you cannot use a regular blanket. The nurses in the hospital can, but not you. Luckily, the market has solved this problem. There are a variety of blankets that will allow you to successfully swaddle your baby so they can’t escape. The key is that these have some way of keeping your baby tucked in other than folding—for example, many yards of fabric or some Velcro. We used one called the Miracle Blanket.

  Of course, you might ask, Why swaddle? Is there any reason to do this, or is it just adorable?

  Swaddling is thought to improve sleep and decrease crying. If true, these are very good reasons to swaddle, since the main things babies seem to like to do are cry and not sleep. And fortunately, this turns out not to be very difficult to study, since sleep is a very short-term outcome. Researchers can look at the same baby swaddled and unswaddled. This avoids a lot of our concerns about different parents doing different things with their babies.

  To give an example: One study followed twenty-six infants under three months of age.2 The researchers brought the infants into a sleep lab, and observed them during both swaddled and unswaddled sleep. They used a special type of swaddle that could detect movement. It was basically a zippered bag, since even sleep researchers cannot fold successfully. In addition to the sensors, they also videotaped the babies to see what they were up to during sleep.

  The study strongly supported the value of swaddling for sleep. While swaddled, the babies slept longer overall, with more time spent in REM sleep. This paper also identified the mechanism: swaddling improves sleep because it limits arousals.3 Swaddled babies are equally likely to have the first stage in arousal—measured with baby “sighs”—but are less likely to move from this to the second stage (“startles”) or the third (“fully awake”). Something about the swaddle discourages these second and third stages. These effects are big. The study found that when babies were not swaddled, a sigh turned into a startle 50 percent of the time. When they were swaddled, this occurred only 20 percent of the time. This type of laboratory evidence is confirmed by observational data and descriptive studies.

  Swaddling may also limit crying, especially in newborns who are preterm or have neurological issues. There are several small studies focused on infants with brain injuries or neonatal abstinence syndrome that have shown reductions in crying as a result of consistent swaddling.4 Whether this translates to healthy infants who cry a lot is unclear, but certainly plausi
ble.

  There are some concerns about swaddling, and some cautions. First, in cultures where it is common to tightly swaddle infants all the time (for example, groups that tie babies to cradleboards), there is a risk of the infant developing hip dysplasia.5 This is a condition where the hip bone is loose in the socket and can cause long-term pain and mobility difficulties if untreated. Although hip dysplasia can be treated with a harness or a body cast, it is not a trivial complication. These risks arise if the baby’s legs are not able to flex at the hip, so it is crucial to swaddle the baby in a way that allows them to move their legs around. Most of the standard swaddle blankets are designed to allow this.

  You’ll also sometimes see swaddling discussed in connection with an increased risk of sudden infant death syndrome (SIDS). To the extent we have data, this concern does not seem valid, as long as you are putting the baby to sleep on its back (which you should do regardless).6 Infants who are put to sleep on their stomach and are swaddled are at an increased risk of SIDS relative to those put to sleep on their stomach alone. But the crucial thing to avoid is putting your baby to sleep on their stomach, not swaddling.

  Finally, some people worry that swaddling can lead to their infant overheating. This is possible in principle—if, say, you use a swaddle made from very heavy cloth and cover the baby’s head in a hot room, especially if the child is sick—but it is not a significant risk in typical circumstances.

  Obviously, you’ll eventually have to take the kid out of the swaddle. Once they can roll over, you definitely want to have them out, since you do not want them on their stomach while swaddled. Even if you do not have a rolling kid, as the baby gets larger and stronger, they’ll start fighting the swaddle, and you’ll come into their room in the morning to find they have escaped, despite the blanket maker’s assurance that this is impossible.

  At this point, you pretty much have to cut it out, and are likely in for a few days of crying as the baby gets used to it. But as you know, Finn only fussed a bit when he lost his swaddle due to power outage. So I, personally, come down on the side of the swaddle.

  COLIC AND CRYING

  Most parents, especially with their first child, think their baby cries a lot. I certainly did. In the early months, Penelope had an especially sensitive period between five and eight p.m., during which she was often inconsolable. I’d walk her up and down the halls, bouncing up and down, sometimes just crying (me crying, that is—obviously she was crying). I once did this in a hotel—up and down, up and down, Penelope screaming at the top of her lungs. I hope no one else was staying there.

  I remember this experience as exhausting—all those bouncing muscles—but also deeply frustrating. Why couldn’t I get this to work? People had all kinds of suggestions. “Just nurse her!” (Attempts to do this made her cry more.) “Bounce faster.” “Bounce slower.” “Bounce more deeply.” “No bouncing.” “Swing while you bounce.”

  Both my mother and mother-in-law told me Jesse and I had been just the same. My mother-in-law, Joyce, said when she left the hospital with Jesse, the nurses said, “Good luck.” So maybe it was genetic, or some kind of intergenerational payback.

  By the time I had Penelope, I was thirty-one. Up to that point in my life, there had been surprisingly few instances in which I could not defeat a problem with hard work. General equilibrium theory comes to mind, but I had rarely found something where trying harder didn’t make the problem at least somewhat better.

  But you basically cannot defeat a crying baby with hard work. There may be some things that improve this in the moment, but babies cry—some of them cry a lot—and there is often really nothing you can do. In a sense, the most important thing to understand is that you are not alone and that your baby is not broken. How do we know you are not alone? That’s what data is for.

  Babies who cry a lot are often described as “colicky.” Infantile colic isn’t a biological diagnosis like strep throat, but a label we give to babies who cry a lot for no identifiable reason. A common definition of colic (although not the only one) is the rule of three: unexplained crying for more than three hours a day for more than three days a week for more than three weeks.

  Based on this definition, colic is pretty rare. In one study of 3,300 babies, researchers found that at one month of age, 2.2 percent of babies fit the “rule of three” colic definition; this is similar at three months.7 As you relax the definition, the shares go up. For example, if you look for babies who cry more than three hours a day for more than three days a week for more than one week (this is like the rule of 3–3-1), this share is 9 percent at one month. If you rely on parental reports that the infant “cries a lot,” the share is close to 20 percent. This is probably not a good way to judge, but it gives a sense of how people experience infant crying.

  Colic-type crying, whether it fits the rule of three exactly or not, is exhausting and depressing for new parents. Part of this definition is crying inconsolably—this isn’t hungry crying or wet-diaper crying or tired crying. Infants will often arch their back, ball up their legs, and seem to be in distress or pain.

  If you have an infant who cries a lot, whether it is true colic by the formal definition or not, the most important thing is to try to take care of yourself. Infant crying links to postpartum depression and anxiety, and parents—both parents—will need a break. Try to find one, even if it means leaving the infant crying in their crib for a few minutes while you shower. They will be fine. No, really, they will be fine. Take a shower. If you really cannot bear to leave them, call your best friend and tell them to come over and hold the crying baby. Call any random mom of an older kid, for that matter. They will do it.

  It is also important to say that this is “self-limiting”: colic will go away, typically around three months. Not all at once, but things will start to improve.

  There are a few things that may improve colic, but since the cause of colic is poorly understood, solutions are hard to develop. Many of the theories involve digestion—poorly developed gut flora or an intolerance to milk protein. These are just theories, although, since they are the leading theories, most of the proposed solutions relate to them.

  One commonly suggested solution, at least according to the internet, is simethicone, a gas-relieving drug (Gerber sells a set of these drops). There is no evidence to suggest this works. Trials are limited, and the two small trials that compared this treatment with a placebo showed no impact on crying. The same can be said of various herbal treatments and things like gripe water.8

  Two treatments have some known success with colic. One is supplementation with a probiotic, which a number of studies have shown to reduce crying. These effects seem to show up only in breastfed infants.9 This treatment isn’t complicated—probiotics are delivered in drops, and Gerber and others make easily accessible over-the-counter versions. With no recognized downsides, probiotics are certainly worth a try.

  The other treatment that has shown some success is managing the baby’s diet, either by changing formula types or, if the baby is breastfed, changing the mother’s diet. Changing formula is relatively straightforward, although the formulas appropriate for colic tend to be a bit more expensive. One recommendation is to switch to a soy-based or hydrolyzed protein formula10 (most of the major formula makers—Similac, Enfamil—have versions of these). The evidence on formula switching is mostly financed by formula companies, so do with that what you will, but it may be worth a try.

  If you’re breastfeeding, changing the baby’s diet is complicated, since it means changing your own. There is some evidence supporting a “low-allergen” diet for Mom: randomized studies have shown reductions in crying and infant distress when mothers adopt this type of diet.11 The standard recommendation is the elimination of all dairy, wheat, eggs, and nuts, so this means a pretty dramatic dietary change. Unfortunately, we don’t know if just one of these foods, all, or a combination makes the difference, and the evidence is overall pretty
limited (this definitely does not work for everyone).

  The effects of this elimination diet seem to appear quickly if they appear at all—within the first few days of implementing the changes—so it is possible to try this and see if it works.12 The obvious downside is that this change in diet is no fun at all for Mom and can make it hard to get enough calories, so there is some appropriate caution around making this a blanket recommendation. This is also likely not a time in your life when you’re looking to experiment with new recipes. Still, without other options, there is reason to give it a try.

  Regardless of what you do, your baby will still cry, sometimes for what seems to be no reason at all. It may not feel like it at the time, but this will go away, and you’ll more or less forget about it as your child ages (this is presumably why people are willing to have a second child). Older babies do cry, but mostly for reasons you can understand or at least identify. Management of your own stress levels is at least as important as managing the baby’s crying.

  DATA COLLECTION

  When we left the hospital with Penelope, the doctors and nurses suggested we keep track of how much she pooped and peed, since if an infant stops peeing, it is a sign of dehydration and needs to be monitored. This is good advice, and not that difficult to do.

  What they did not suggest—but Jesse insisted we do anyway—was setting up a spreadsheet to enter this data. Jesse’s idea was to keep track of everything that happened with Penelope in terms of feeding and diapers.

  Here is day 4 of her life.

  Date