In this age of ever-expanding information and technology it seems new parents are confronted with more do's and don'ts of baby care than ever! More often than not, tired and quizzical looking parents obediently nod as the newborn nursery pediatrician lists the host of things they must remember before hospital discharge. And there's more. As United States healthcare costs soar and hospital lengths of stay decline, harried clinicians caring for newborns have less time than ever to help parents prepare for parenthood. So, how do medical providers in the newborn nursery assist parents for the big job ahead without losing the opportunity to form a relationship and to acknowledge the wonder that accompanies the birth of every baby? The answer: Keep it simple. At Boston Medical Center we decided to begin by watching the baby.

Begin with the baby!
A picture is worth a thousand words. It means more to parents to "see" our advice than to hear a long drawn out explanation by the "experts." For example, most parents will not remember the statistics about Sudden Infant Death Syndrome (SIDS) nearly as well as they will remember how their pediatrician showed them the baby should be placed when being put to sleep. Exhausted mothers are in the post-delivery phase of "taking in." They need to assimilate the experience of childbirth and attend to themselves before directing their attention to their newborn. In this sensitive period we have found the Neonatal Behavioral Assessment Scale, modified for clinical use, to be helpful.

The Clinical Neonatal Behavioral Assessment Scale (CLNBAS) allows clinicians to systematically evaluate important aspects of newborn behavior during a routine physical examination. Clinicians can provide anticipatory guidance in a meaningful and memorable way for parents and every brief encounter becomes a teaching opportunity. Together, the clinician and parents notice the infant's strengths, reflexes, behaviors and potential vulnerabilities. The clinician weaves a newborn behavioral assessment into the traditional physical examination and discussion of anticipatory guidance. Watching the infant's behavior, the clinician mentions subtle feeding cues, sleep position, calming strategies and the infant's preferences. Parents will remember more of the clinician's advice when their own child becomes the center of the interaction. Anticipatory guidance takes on special significance because it is about this baby.

Identify strengths!
Like the NBAS, the CLNBAS focuses on infant states, transitions, orientation, habituation and reflexes. Because it is modified for clinical use, it offers critical flexibility for the clinician. The pediatrician lets the baby decide where to begin the interaction. If the infant is sleeping, the physician may begin by briefly mentioning habituation to light and sound. The important thing is to notice with the parents rather than to teach. In fact, it is preferable to give parents the opportunity to show the pediatrician what their child can do. Using phrases like "infant strengths" and the "talents" help parents see their infant in a positive, normal and healthy way. This holistic approach is a good reminder for clinicians who accustomed to a traditional medical model, which focuses on identification of pathology. Parents who recognize their infant's strengths and their own competencies will be more able to provide a healthy, nurturing environment for their infant than parents for whom these strengths are not recognized.

Baby Steps to Better Care.
The language of newborn development is for everyone who works with infants! Nurses are often the first group within the nursery staff to talk with mothers, fathers and grandparents about newborn behavior. The newborn bath is a perfect opportunity to identify the abilities and preferences of the baby. The nurse can identify newborn behavioral cues during the bath, creating a teachable moment where parents can discover their baby. Nurses make every interaction with parents a teachable moment and thereby reinforce guidance already provided by the physician or nurse practitioner. As the entire perinatal staff becomes familiar with infant development, the language of newborn behavior permeates the nursery environment. By the day of discharge, parents will have a better understanding their infant's cues and preferences. Most importantly, having been shown practical strategies for calming their infant, parents will feel more confident to face the job ahead.

Mother-baby couplet care
Ideally, the perinatal unit should provide a continuum of care for mothers and babies. As staff from the labor and delivery suite, the nursery and the postpartum units work collaboratively, parents will experience a seamless transition moving through the birth process. Providing all staff with the knowledge and skills of newborn behavior will help create a team which works synergistically and facilitates the bonding experience for parents and babies. Mothers and babies should be allowed to remain together throughout their hospital stay. This helps ensure breastfeeding success, facilitates bonding, and an overall positive birth experience for mothers, fathers and babies.

Breastfeeding and The Baby Friendly Hospital Initiative
The benefits of breastfeeding are numerous and well documented in the literature. Breast-fed babies have fewer ear infections, respiratory illnesses, and diarrhea. Breastfeeding is also protective against Sudden Infant Death Syndrome, necrotising enterocolitis, childhood-onset diabetes, obesity, Crohn's disease, ulcerative colitis and childhood lymphoma. For the mother, breastfeeding reduces the risk of breast, ovarian and endometrial cancer. It provides protection against hip fracture later in life and prolongs postpartum infertility.

The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) created the Baby-Friendly Hospital Initiative in 1991 in response to alarming rates of infant mortality worldwide from malnutrition. The "Baby-Friendly" status is an award received by hospitals and birthing centers which meet the Ten Steps to Successful Breastfeeding, articulated by WHO/UNICEF (Table). Currently, there are over 16,000 Baby-Friendly hospitals worldwide and only 26 in the United States. Boston Medical Center was awarded Baby-Friendly status in December of 1999, becoming the first hospital in Massachusetts to receive this designation. More information on Baby-Friendly may be obtained by contacting Baby-Friendly USA in Sandwich, Massachusetts at (508)-888-8044. International hospitals and birthing centers may contact their country's UNICEF office for more information.

Breastfeeding presents a perfect opportunity to talk about baby behavior! Babies often become fussy during or just around the time of a physical examination. The clinician can use this as an opportunity to encourage breastfeeding and to observe the infant's behavior with parent's during a feeding. The baby quiets during the feeding, allowing the parents to be focused on what the clinician is saying. The clinician can continue in many aspects of discharge preparation and many additional features can be brought out (e.g., rooting, sucking, hand-to-mouth movements, eye contact during feeding) as the baby feeds.

At Boston Medical Center we have noticed fewer cases of hyperbilirubinemia requiring phototherapy as more mothers have initiated breastfeeding. Medical interventions like phototherapy, blood draws and intravenous line placements have become less frequent, allowing staff opportunity to spend valuable time teaching parents behavioral cues, helping mothers breastfeed, and encouraging the father's involvement in the newborn's care.

Infant Touch
Touching a newborn can sometimes be intimidating, especially for first-time parents. Yet, many parents can become acquainted with their infant while learning infant massage. Infant massage classes in the nursery give parents an opportunity to explore touch and discover their touch preferences in a safe environment. For many cultures, infant massage is an old practice and some parents will even remember their own experiences of being massaged as infants and children. Other family members can join and fathers will be pleased to find that unlike some things that they cannot do, they have a special role in massaging their infants. Parents learn simple strokes to soothe their infant. They see the claming effect that their touch, face and voice provides for their infant and the concepts of infant behavior, cues and preferences are reinforced in yet another way. Information to become certified in infant massage can be obtained through the International Association of Infant Massage at 505-341-9381 and at www.infantmassageinstitute.com.

What about Dads?
At Boston Medical Center has a program called "Parents as Partners" where parents of newborns receive peer support from parents who serve on our staff. Fathers in our Parents as Partners Program greet new fathers and encourage them to attend breastfeeding and infant massage classes. Special attention given to new Dads helps them feel recognized as a key part of he birth experience.

Fathers who are included in their newborn's care are more likely to remain actively involved in their child's life. Fathers are affectionate, have positive attitudes, and spend more time with their infants are more likely to have securely attached infants at one year of age. Clinicians talk so much about mothers and babies that we need to be especially cognizant of fathers and make sure not to leave them out of the picture. This is especially critical at a time when more pressure is placed on families and it is all too easy to the family unit to be disrupted. Medical providers should be careful to recognize fathers and draw them into the conversation when talking with mothers. Staff physicians should include discussions about fathers when training residents and should set expectations for residents and medical students to recognize fathers through eye contact and involve them in discussions about their babies.

Often, fathers are required to return to work and miss some of the wonderful things that happen in the baby's first weeks of life. Physicians, nurses and nurse practitioners can help be being especially mindful of the father's role and by focusing on him when talking about his infant's development. Clinicians can help by talking with the father about upcoming steps in development and by asking him what he has noticed in his infant. Finally, all child care professionals can advocate for families by recognizing the need for fathers to have appropriate paid work leave in order to be with their families during the first critical weeks of life.

Opportunity knocks!
Newborns do amazing things, even in the first few hours of life. Clinicians have an opportunity to capture the complex abilities of newborn if they routinely incorporate newborn behavior into their physical examinations and discussions with parents. Even the brief nursery encounter can be an important teachable moment clinician if the clinicians and nurses take the time to "discover" the newborn with parents. As parents see a medical staff that invests time in the whole baby and family, a trust will be established that will continue well beyond the day of discharge.

(References are available from the author)