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Newborns: What's Typical, What's NotThere is so much love and care when a baby comes into this world it can be daunting to know what's normal and what's not. Here's a simple rundown.
Photo courtesy of Whitney Casares
Caring for a newborn can be a rewarding, but also scary and daunting task. Here's the blueprint.
“ At first, everything they notice on their newborns seems potentially serious.”
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The following is an excerpt from chapter 7 of "The New Baby Blueprint: Caring for you and your little one."
When I was in medical school, we had a lengthy class on abnormal dermatologic findings, spread out over the course of months and integrated across various body system courses. When we learned about cancerous diseases, we also learned about the ways those problems manifest themselves in the skin.
In the beginning, someone in the class would inevitably start to panic that he had some horrible illness whenever we learned about a new condition, convinced he should call his family and arrange for a memorial service on the spot.
Over time, though, we became more accustomed to recognizing normal and abnormal findings in our patients and in ourselves (that is the point of medical training, it turns out). We transformed into confident, knowledgeable experts who used our rational observation and decision-making skills to come to diagnostic conclusions.
The same transformation happens for most new parents over time. At first, everything they notice on their newborns seems potentially serious. Each rash drives them to do a daylong Google search. Slowly, over time, they learn what they should worry about and what is to be expected.
A parent’s education starts early in pregnancy with doctor visits and prenatal classes. The nursing staff at the hospital continues to inform and help new moms and dads and other parents, but things are so chaotic and new that it’s really at the first doctor visit that what’s typical and what’s not tends to become more apparent.
Doctor Visits
Your newborn will have an appointment with your pediatrician a few days after leaving the hospital (give or take, depending on your situation) and again at 2 weeks of age. Between those 2 appointments, visits in the first 2 weeks are determined by need. Here are the issues that tend to bring babies back in sooner (your baby’s doctor will let you know if your baby will need to be seen before then).
Newborn Weight Loss
Before a mom’s milk supply increases, sometimes described as the milk "coming in," about 2 to 3 days after giving birth, a baby naturally loses a bit of weight. If your milk doesn’t seem to be increasing, if your milk is ample but your baby is still not gaining weight, or if your baby continues losing weight beyond what is considered typical, we want to help your baby get on the right track.
This is super important in the first week: if a new baby doesn’t get enough calories, her "blood sugar" (blood glucose) level can drop, which can make her sleepier and not want to eat as much. Sometimes she gets dehydrated, which makes everything worse. She doesn’t have a lot of reserves, so she can start to spiral downward quickly. On the other hand, if we can get her moving in the right direction, she can bounce back with the energy she needs to thrive.
Jaundice
That first week is prime time for a baby to get jaundice. While almost every baby has a tiny bit of jaundice, which we call physiological jaundice, some babies reach a more dangerous jaundice zone and need additional help (or at least monitoring). Very rarely, this means going back to the hospital, but often it means working on becoming more hydrated and sometimes it means doing a home jaundice treatment called a bilirubin blanket.
Feeding Issues
I’ve brought families back into my office for issues with latching, for excessive spit-up, or just because a parent is concerned. It’s worth it to express your needs to me, because I want you to get super comfy in your own skin as you start to parent.
Signs of Illness
When you and your newborn go to the doctor for the first time, we’ll look closely for signs of infection and educate you about what to look for so that you can spot illness right away. You should call your newborn’s doctor about these concerns as soon as possible. (Remember, you are not a nuisance to your pediatrician. You should feel comfortable calling and asking your newborn’s doctor questions. That is what doctors are there for.) If you are worried, call anyway. Figuring out what you need to be worried about and what you don’t need to be worried about is part of the learning process as you become parent. Better to be safe than sorry.
Persistent Fast Breathing
It’s not typical for a baby to breathe fast consistently (>1 breath per second) or to have what is commonly called labored breathing for a sustained amount of time. I often describe labored breathing to parents as sucking in at the ribs or the belly, flaring at the nose, or breathing hard as if the baby just ran a marathon. If your baby has persistent fast breathing, call your pediatrician’s office right away. If she has sustained fast and labored breathing, call 911.
Fever 100.4°F (or 38°C) or Higher
You do not need to check your baby for a fever all day, every day. But if your baby seems fussy and is warm, check his temperature. When a newborn has a fever in the first month, it can signal a very serious infection in the blood, in the urine, or in the fluid surrounding the brain and spinal cord. Call your newborn’s doctor’s office for help with this, day or night.
Lethargy
Lethargy is a tough word because it means different things to different people. It doesn’t just mean sleepy to medical professionals. To me, it means a baby is acting out of it enough that you could poke him with a stick and he wouldn’t care. If a newborn misses more than one feeding, that could be a sign of lethargy. Lethargy is dangerous for babies. If you think your baby is lethargic, call your pediatrician’s office immediately. If your baby is not responsive at all, call 911.
Projectile Vomiting
As indicated in the name, this is when vomit projects itself across the room. Spit-up that dribbles down the chin is not projectile vomiting. Projectile vomiting can be a sign of something called pyloric stenosis, when the connection between the stomach and the duodenum (the upper part of the small intestine) becomes too tight. Your pediatrician will want you to call immediately if your child has more than one episode of this.
Blood in Stool or Vomit
It’s not typical to see blood in a newborn’s vomit or stool (or persistent bleeding from anywhere, for that matter); this can signal a major issue in the digestive tract. Occasionally, if a mom’s nipple cracks from breastfeeding trauma, a baby can swallow a little bit of blood and make us think it’s the mom’s blood, but don’t take any chances. If you see blood, call your pediatrician.
Cyanosis
Cyanosis is a gray or blue color of the lips, of the inside the mouth, or on the chest. In a newborn, it can be very dangerous, signaling infection or heart disease, especially if it comes on with feeding. Your pediatrician will want to know about this right away. If your baby has cyanosis and is not breathing, call 911. On the other hand, acrocyanosis, a purple, gray, or blue discoloration of the hands and feet, can be a typical newborn finding we attribute to an immature circulatory system.
Sweating or Panting During Feedings
If a baby pants or sweats while feeding, we worry that his body is stressed and that eating pushes it over the edge, taxing its basic metabolic functions. This can also be a sign of a dangerous infection or of heart disease. Call your baby’s doctor right away if you notice this.
Severe Fussiness
Most babies are fussy, with a peak around 6 to 8 weeks after birth, but we worry when babies are completely inconsolable for hours on end. If your baby is fussy, first try changing her diaper, feeding her, burping her, and soothing her by swaddling, swaying, or shushing her. If she’s still crying after you’ve attended to all the baby care basics and exhausted all your soothing tricks, that warrants a call or a trip to the doctor.
Typical "Freak Out" Findings
On the other hand, these are a bunch of common findings that tend to really freak parents out, even though they are typical.
Erythema Toxicum
This is a completely benign rash with a scary name and a worrisome appearance: scattered red dots or splotches with white to yellowish centers. It tends to resolve on its own by 1 week after birth. You don’t need to make a doctor visit for this rash, but it’s reasonable to have it double-checked if you’re worried or unsure, given new parents can occasionally confuse it with more troublesome viral or bacterial rashes.
Cross-eyed Appearance
A baby’s eye muscles are often not strong enough to keep her eyes aligned until a few months of age. It can be typical for a baby’s eyes to cross until about 3 to 4 months of age. If it lasts longer than expected, definitely let your pediatrician know.
No Poop for Days
When a baby is just out of the womb brand-new, pooping a lot means he is getting plenty of food. But after a few weeks, breastfed newborns can go up to 7 days without passing a stool (as long as it’s mushy when it eventually comes out). As long as you’re feeding your baby consistently, don’t feel pressured to intervene to speed up the process. If your baby is gassy in the meantime, you can bicycle his legs and gently massage his belly. Once you get past the 7-day mark, let your pediatrician know. Also, let your pediatrician know if your baby has hard stools at any time. Your pediatrician will want to make sure feeding is going well and that your baby is growing as expected.
Hiccups
Just like the rest of a baby’s nervous system is extremely immature, so is the diaphragm. Some babies hiccup a ton in the first few weeks. Don’t sweat it. This is something that takes time to resolve on its own.
Congestion and Sneezing
Babies have been living in a water-filled environment for months when they’re born—it’s typical that they would need to clear out some of that fluid from the nasal passages. Babies have small nasal passages, so sneezing helps keep them open. If babies have even more fluid after several weeks, though, that’s something to check with a doctor about. If they are coughing or sputtering during feedings, it may mean you need help with positioning or with overactive letdown.
Periodic Breathing
It’s OK if a newborn’s breathing is not completely uniform. Babies will often have episodes when they breathe fast for a few seconds and then go back to their usual rhythm. This should be brief, as opposed to the continuous fast breathing that makes pediatricians worry. If a baby has continuous fast or labored breathing, remember to seek immediate medical care.
The "Mini Period"
Baby girls may have a small amount of blood, or blood- tinged mucus, in the diaper at day 4 to 5 as their mothers’ hormone (estrogen) levels begin to drop. This is like a "mini period," which can scare even the most confident parent. It may last for a few diapers before resolving. Large amounts of blood, however, are not typical, so consult a doctor if you notice this occurring.
A Stinky Umbilical Cord
When the umbilical cord falls off a baby, it can be kind of stinky. That’s because the skin is dead. It’s OK if there is a slight odor, but if there is extreme redness, swelling, or pus around the navel, parents should call their pediatrician right away—those are signs of potential infection.
Primitive Reflexes
Until babies are about 3 months old, they have what we call primitive reflexes (also known as startle movements). The most commonly recognized is the Moro reflex, when a baby puts her arms out to the side and jerkily flutters them forward when she has the sensation of falling (eg, when being set onto her back).
Slate Gray Patches
These are small areas of pigmented skin that can show up on the back or the buttocks. Occasionally, they are mistaken for bruises or can concern parents that they are dangerous, but they are harmless. They are especially common on the skin of black babies and babies of Asian ancestry.
Dry Skin
When babies are first born, their skin can look dry and flaky a few days after birth. They have been in water for a long time—it takes a while for the skin to adjust. This is not dangerous. Just let it be, and it will resolve on its own. You can use gentle products such as Aquaphor Healing Ointment or CeraVe Healing Ointment if the skin gets super dry and cracked in the creases of the ankles or wrists.
Babies don’t need baths in the first few weeks after birth. They don’t get that dirty. Obviously, clean their bottoms when they poop and spot clean if they spit up onto themselves, but otherwise, letting a baby’s skin acclimate in the first few weeks without a bath is better, especially for umbilical cord healing.
Once you start giving baths, my favorite products are gentle cleansers. I love fancy, great-smelling, natural products just like the next mom, but they can often cause irritation. More basic options can help reduce the chance of rashes and other problems down the road.
The above is an excerpt from chapter 7 of "The New Baby Blueprint: Caring for you and your little one."
Whitney Casares, MD, MPH, FAAP is a pediatrician and mom to two young girls in Portland, Oregon. She completed her medical school training at The University of Vermont and her pediatrics residency training at Stanford University. She also holds a Masters of Public Health in Maternal and Child Health from The University of California, Berkeley. Dr. Casares is the creator of the popular website, ModernMommyDoc.com, where she helps parents win at parenting without losing themselves, especially in the baby and toddler years.
When I was in medical school, we had a lengthy class on abnormal dermatologic findings, spread out over the course of months and integrated across various body system courses. When we learned about cancerous diseases, we also learned about the ways those problems manifest themselves in the skin.
In the beginning, someone in the class would inevitably start to panic that he had some horrible illness whenever we learned about a new condition, convinced he should call his family and arrange for a memorial service on the spot.
Over time, though, we became more accustomed to recognizing normal and abnormal findings in our patients and in ourselves (that is the point of medical training, it turns out). We transformed into confident, knowledgeable experts who used our rational observation and decision-making skills to come to diagnostic conclusions.
The same transformation happens for most new parents over time. At first, everything they notice on their newborns seems potentially serious. Each rash drives them to do a daylong Google search. Slowly, over time, they learn what they should worry about and what is to be expected.
A parent’s education starts early in pregnancy with doctor visits and prenatal classes. The nursing staff at the hospital continues to inform and help new moms and dads and other parents, but things are so chaotic and new that it’s really at the first doctor visit that what’s typical and what’s not tends to become more apparent.
Doctor Visits
Your newborn will have an appointment with your pediatrician a few days after leaving the hospital (give or take, depending on your situation) and again at 2 weeks of age. Between those 2 appointments, visits in the first 2 weeks are determined by need. Here are the issues that tend to bring babies back in sooner (your baby’s doctor will let you know if your baby will need to be seen before then).
Newborn Weight Loss
Before a mom’s milk supply increases, sometimes described as the milk "coming in," about 2 to 3 days after giving birth, a baby naturally loses a bit of weight. If your milk doesn’t seem to be increasing, if your milk is ample but your baby is still not gaining weight, or if your baby continues losing weight beyond what is considered typical, we want to help your baby get on the right track.
This is super important in the first week: if a new baby doesn’t get enough calories, her "blood sugar" (blood glucose) level can drop, which can make her sleepier and not want to eat as much. Sometimes she gets dehydrated, which makes everything worse. She doesn’t have a lot of reserves, so she can start to spiral downward quickly. On the other hand, if we can get her moving in the right direction, she can bounce back with the energy she needs to thrive.
Jaundice
That first week is prime time for a baby to get jaundice. While almost every baby has a tiny bit of jaundice, which we call physiological jaundice, some babies reach a more dangerous jaundice zone and need additional help (or at least monitoring). Very rarely, this means going back to the hospital, but often it means working on becoming more hydrated and sometimes it means doing a home jaundice treatment called a bilirubin blanket.
Feeding Issues
I’ve brought families back into my office for issues with latching, for excessive spit-up, or just because a parent is concerned. It’s worth it to express your needs to me, because I want you to get super comfy in your own skin as you start to parent.
Signs of Illness
When you and your newborn go to the doctor for the first time, we’ll look closely for signs of infection and educate you about what to look for so that you can spot illness right away. You should call your newborn’s doctor about these concerns as soon as possible. (Remember, you are not a nuisance to your pediatrician. You should feel comfortable calling and asking your newborn’s doctor questions. That is what doctors are there for.) If you are worried, call anyway. Figuring out what you need to be worried about and what you don’t need to be worried about is part of the learning process as you become parent. Better to be safe than sorry.
Persistent Fast Breathing
It’s not typical for a baby to breathe fast consistently (>1 breath per second) or to have what is commonly called labored breathing for a sustained amount of time. I often describe labored breathing to parents as sucking in at the ribs or the belly, flaring at the nose, or breathing hard as if the baby just ran a marathon. If your baby has persistent fast breathing, call your pediatrician’s office right away. If she has sustained fast and labored breathing, call 911.
Fever 100.4°F (or 38°C) or Higher
You do not need to check your baby for a fever all day, every day. But if your baby seems fussy and is warm, check his temperature. When a newborn has a fever in the first month, it can signal a very serious infection in the blood, in the urine, or in the fluid surrounding the brain and spinal cord. Call your newborn’s doctor’s office for help with this, day or night.
Lethargy
Lethargy is a tough word because it means different things to different people. It doesn’t just mean sleepy to medical professionals. To me, it means a baby is acting out of it enough that you could poke him with a stick and he wouldn’t care. If a newborn misses more than one feeding, that could be a sign of lethargy. Lethargy is dangerous for babies. If you think your baby is lethargic, call your pediatrician’s office immediately. If your baby is not responsive at all, call 911.
Projectile Vomiting
As indicated in the name, this is when vomit projects itself across the room. Spit-up that dribbles down the chin is not projectile vomiting. Projectile vomiting can be a sign of something called pyloric stenosis, when the connection between the stomach and the duodenum (the upper part of the small intestine) becomes too tight. Your pediatrician will want you to call immediately if your child has more than one episode of this.
Blood in Stool or Vomit
It’s not typical to see blood in a newborn’s vomit or stool (or persistent bleeding from anywhere, for that matter); this can signal a major issue in the digestive tract. Occasionally, if a mom’s nipple cracks from breastfeeding trauma, a baby can swallow a little bit of blood and make us think it’s the mom’s blood, but don’t take any chances. If you see blood, call your pediatrician.
“Remember, you are not a nuisance to your pediatrician. You should feel comfortable calling and asking your newborn’s doctor questions.”
Cyanosis
Cyanosis is a gray or blue color of the lips, of the inside the mouth, or on the chest. In a newborn, it can be very dangerous, signaling infection or heart disease, especially if it comes on with feeding. Your pediatrician will want to know about this right away. If your baby has cyanosis and is not breathing, call 911. On the other hand, acrocyanosis, a purple, gray, or blue discoloration of the hands and feet, can be a typical newborn finding we attribute to an immature circulatory system.
Sweating or Panting During Feedings
If a baby pants or sweats while feeding, we worry that his body is stressed and that eating pushes it over the edge, taxing its basic metabolic functions. This can also be a sign of a dangerous infection or of heart disease. Call your baby’s doctor right away if you notice this.
Severe Fussiness
Most babies are fussy, with a peak around 6 to 8 weeks after birth, but we worry when babies are completely inconsolable for hours on end. If your baby is fussy, first try changing her diaper, feeding her, burping her, and soothing her by swaddling, swaying, or shushing her. If she’s still crying after you’ve attended to all the baby care basics and exhausted all your soothing tricks, that warrants a call or a trip to the doctor.
Typical "Freak Out" Findings
On the other hand, these are a bunch of common findings that tend to really freak parents out, even though they are typical.
Erythema Toxicum
This is a completely benign rash with a scary name and a worrisome appearance: scattered red dots or splotches with white to yellowish centers. It tends to resolve on its own by 1 week after birth. You don’t need to make a doctor visit for this rash, but it’s reasonable to have it double-checked if you’re worried or unsure, given new parents can occasionally confuse it with more troublesome viral or bacterial rashes.
Cross-eyed Appearance
A baby’s eye muscles are often not strong enough to keep her eyes aligned until a few months of age. It can be typical for a baby’s eyes to cross until about 3 to 4 months of age. If it lasts longer than expected, definitely let your pediatrician know.
No Poop for Days
When a baby is just out of the womb brand-new, pooping a lot means he is getting plenty of food. But after a few weeks, breastfed newborns can go up to 7 days without passing a stool (as long as it’s mushy when it eventually comes out). As long as you’re feeding your baby consistently, don’t feel pressured to intervene to speed up the process. If your baby is gassy in the meantime, you can bicycle his legs and gently massage his belly. Once you get past the 7-day mark, let your pediatrician know. Also, let your pediatrician know if your baby has hard stools at any time. Your pediatrician will want to make sure feeding is going well and that your baby is growing as expected.
Hiccups
Just like the rest of a baby’s nervous system is extremely immature, so is the diaphragm. Some babies hiccup a ton in the first few weeks. Don’t sweat it. This is something that takes time to resolve on its own.
Congestion and Sneezing
Babies have been living in a water-filled environment for months when they’re born—it’s typical that they would need to clear out some of that fluid from the nasal passages. Babies have small nasal passages, so sneezing helps keep them open. If babies have even more fluid after several weeks, though, that’s something to check with a doctor about. If they are coughing or sputtering during feedings, it may mean you need help with positioning or with overactive letdown.
Periodic Breathing
It’s OK if a newborn’s breathing is not completely uniform. Babies will often have episodes when they breathe fast for a few seconds and then go back to their usual rhythm. This should be brief, as opposed to the continuous fast breathing that makes pediatricians worry. If a baby has continuous fast or labored breathing, remember to seek immediate medical care.
The "Mini Period"
Baby girls may have a small amount of blood, or blood- tinged mucus, in the diaper at day 4 to 5 as their mothers’ hormone (estrogen) levels begin to drop. This is like a "mini period," which can scare even the most confident parent. It may last for a few diapers before resolving. Large amounts of blood, however, are not typical, so consult a doctor if you notice this occurring.
A Stinky Umbilical Cord
When the umbilical cord falls off a baby, it can be kind of stinky. That’s because the skin is dead. It’s OK if there is a slight odor, but if there is extreme redness, swelling, or pus around the navel, parents should call their pediatrician right away—those are signs of potential infection.
Primitive Reflexes
Until babies are about 3 months old, they have what we call primitive reflexes (also known as startle movements). The most commonly recognized is the Moro reflex, when a baby puts her arms out to the side and jerkily flutters them forward when she has the sensation of falling (eg, when being set onto her back).
Slate Gray Patches
These are small areas of pigmented skin that can show up on the back or the buttocks. Occasionally, they are mistaken for bruises or can concern parents that they are dangerous, but they are harmless. They are especially common on the skin of black babies and babies of Asian ancestry.
Dry Skin
When babies are first born, their skin can look dry and flaky a few days after birth. They have been in water for a long time—it takes a while for the skin to adjust. This is not dangerous. Just let it be, and it will resolve on its own. You can use gentle products such as Aquaphor Healing Ointment or CeraVe Healing Ointment if the skin gets super dry and cracked in the creases of the ankles or wrists.
Babies don’t need baths in the first few weeks after birth. They don’t get that dirty. Obviously, clean their bottoms when they poop and spot clean if they spit up onto themselves, but otherwise, letting a baby’s skin acclimate in the first few weeks without a bath is better, especially for umbilical cord healing.
Once you start giving baths, my favorite products are gentle cleansers. I love fancy, great-smelling, natural products just like the next mom, but they can often cause irritation. More basic options can help reduce the chance of rashes and other problems down the road.
The above is an excerpt from chapter 7 of "The New Baby Blueprint: Caring for you and your little one."
Whitney Casares, MD, MPH, FAAP is a pediatrician and mom to two young girls in Portland, Oregon. She completed her medical school training at The University of Vermont and her pediatrics residency training at Stanford University. She also holds a Masters of Public Health in Maternal and Child Health from The University of California, Berkeley. Dr. Casares is the creator of the popular website, ModernMommyDoc.com, where she helps parents win at parenting without losing themselves, especially in the baby and toddler years.
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