12.5 Infant Feeding Education, Circumcision Counseling & Care Through 28 Days

Educating Parents About Infant Feeding

The blueprint lists "educates about breastfeeding" and "educates about formula feeding" as separate tasks. Both are midwifery work, and formula education delivered grudgingly is a documented driver of parental shame and of unsafe preparation practices.

Formula Types

Safe Preparation — the Part Most Often Taught Poorly

1. Powdered formula is not sterile. It can carry Cronobacter sakazakii, which causes neonatal meningitis and sepsis. For infants under 3 months, preterm, or immunocompromised, use ready-to-feed liquid, or reconstitute with water that has been boiled and cooled to about 70 °C, then cooled again before feeding.
2. Never dilute or over-concentrate. Adding extra water to stretch formula causes hyponatremic seizures and water intoxication; adding extra powder causes hypernatremia and renal solute load.
3. Timing: use prepared formula within 2 hours at room temperature, or refrigerate for up to 24 hours. Once the infant has started a bottle, discard the remainder within 1 hour — saliva contaminates it.
4. Never microwave a bottle; uneven heating scalds. Warm in a container of warm water.
5. Volumes: roughly 5–10 mL per feed on day 1, rising to 60–90 mL every 3 to 4 hours by the end of the first week, approximately 150–200 mL/kg/day.
6. Paced, responsive bottle feeding: hold the infant semi-upright, keep the bottle near horizontal, follow hunger and satiety cues. Never prop a bottle and never put an infant to bed with one — the risks are aspiration, otitis media, and dental caries.
7. Nothing else before 12 months: no cow's milk as a drink, no honey (infant botulism), and no plain water as a beverage before about 6 months.

Reassure families using combination feeding that supplementing does not require abandoning breastfeeding, and protect supply with pumping if that is the parent's goal.

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Circumcision Counseling

The blueprint asks for patient-centered guidance and counseling regarding male circumcision — counseling, not advocacy in either direction.

The Policy Position

The American Academy of Pediatrics, endorsed by ACOG, concludes that the health benefits of newborn male circumcision outweigh the risks, but are not great enough to recommend routine universal circumcision. The decision belongs to the parents, weighing medical, religious, cultural, and ethical factors, and third-party payment should be available.

Serious complications occur in well under 1% of procedures.

Analgesia Is Not Optional

Newborns experience and remember pain. Adequate analgesia is required for every circumcision: a dorsal penile nerve block or, more effective still, a subcutaneous ring block using 1% lidocaine without epinephrine, supplemented by oral sucrose on a pacifier, swaddling, and post-procedure acetaminophen. Topical EMLA alone is less effective and carries a methemoglobinemia risk in neonates.

Contraindications

Hypospadias, epispadias, chordee, or ambiguous genitalia — the foreskin is needed for reconstruction — plus a known or suspected bleeding disorder or family history of one, an unstable or preterm infant, and an infant who has not received vitamin K.

Methods and Aftercare

Common techniques are the Gomco clamp, Mogen clamp, and Plastibell. Teach parents that a yellow granulation film over the glans during healing is normal and is not infection; apply petrolatum gauze with each diaper change for the Gomco and Mogen methods. Instruct them to call for bleeding larger than a quarter, no urination within 12 hours, fever, foul odor or spreading redness, or a Plastibell ring that has not fallen off by 10 to 14 days.

For uncircumcised infants: teach parents not to retract the foreskin. Separation from the glans occurs naturally over months to years; forced retraction causes scarring and true phimosis.

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Routine Newborn Care Teaching Before Discharge

• Safe sleep (AAP): supine for every sleep, on a firm, flat, non-inclined surface, in the parents' room but not in their bed for at least the first 6 months. No soft bedding, bumpers, positioners, or weighted products. Avoid overheating, offer a pacifier at sleep onset once feeding is established, and eliminate smoke exposure. Breastfeeding itself reduces SIDS risk.
• Cord care: dry cord care is standard in high-resource settings — keep it clean and dry and fold the diaper below it. The stump separates in 1 to 3 weeks. Call for periumbilical redness, purulent drainage, or foul odor (omphalitis).
• Bathing: two to three times a week is plenty; over-bathing dries the skin. Delay the first bath at least 24 hours.
• Car seat: rear-facing, in the back seat, harness at or below the shoulders, chest clip at armpit level, no bulky coats. Infants born before 37 weeks need a car seat tolerance screening before discharge.
• Temperature: take axillary temperatures. A temperature of 38.0 °C (100.4 °F) or higher in an infant under 28 days is a medical emergency, not something to observe at home.
• Elimination and jaundice: teach expected diaper counts and to call if jaundice spreads below the chest, or with any of the warning signs below.

Call immediately for: fever of 38.0 °C or higher, temperature instability, poor feeding or refusal to feed, lethargy or inconsolable irritability, fewer wet diapers than expected, green or bilious vomiting, abdominal distension, no stool in 48 hours, labored breathing, grunting or cyanosis, apnea, or a seizure.

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Primary Care From Birth Through 28 Days

Midwifery scope routinely includes the well newborn from birth through the first month.

Visit Schedule

• First outpatient visit at 3 to 5 days of life, which is 48 to 72 hours after discharge — the key checkpoints are weight, jaundice, feeding, and elimination.
• Two weeks: birth weight should be regained.
• One month: growth, development, feeding, and the second hepatitis B dose.

Follow-Up on Screening

Confirm that the dried blood spot screen was collected after 24 hours of feeding and repeat it if it was drawn earlier. Confirm the hearing screen result and the CCHD pulse oximetry result, and make sure any "refer" result has an actual appointment attached, not just a note.

Recognizing the Sick Newborn

Neonatal sepsis is subtle before it is catastrophic, and its early signs are non-specific: temperature instability in either direction, poor feeding, lethargy, irritability, hypotonia, tachypnea, grunting, apnea, jaundice appearing in the first 24 hours, hypoglycemia, and petechiae. Early-onset disease (under 7 days) reflects intrapartum transmission of group B streptococcus and E. coli; late-onset disease reflects postnatal acquisition.

[!CAUTION] A febrile infant under 28 days requires a full sepsis evaluation — blood, urine, and cerebrospinal fluid cultures with empiric antibiotics — not outpatient observation. Refer immediately. The same applies to hypothermia, which in a newborn is as ominous as fever.

Anything outside the normal newborn course — persistent jaundice, poor weight gain, abnormal tone, a murmur with abnormal pulses, an abnormal screening result, or a parent who reports that the baby "just isn't right" — is referred to pediatrics rather than managed within midwifery scope.