For brand new parents, caring for a newborn infant can be terrifying. Babies do scary things all the time—things that will turn your hair gray and take years off your life. Sometimes it’s worth getting excited, but all that terror might be a waste of perfectly good hair follicles. Many of those frightening things are normal (–ish) and nothing to worry about. The section below attempts to clarify when panic is justified.
When to REMAIN CALM in the newborn period:
1. You notice your baby’s hands and feet are blue or purple. This is a normal condition called acrocyanosis of the newborn. The hands and feet of most infants are usually on the blue side—scary to observe, but not a problem. Anecdotally, this condition persisted with my own kids until about two years of age. It worsened in cold weather and was more obvious at the onset of fever.
2. Your baby has short periods of breath holding (less than 10 seconds), followed by a series of rapid breaths. He almost appears to be hyperventilating, which makes you start hyperventilating. No need to worry! This is called periodic breathing of the newborn. It occurs in most babies in the first two weeks of life. Fortunately, periodic breathing isn’t normally associated with respiratory distress or color changes.
3. When your baby is inhaling, she makes a high-pitched noise. It almost sounds as though she’s having trouble breathing, but she looks perfectly content. Many infants are born with a floppy upper airway that partially collapses when they inhale. This leads to a high-pitched, inspiratory noise called “stridor.” Though the noise is scary to hear, the condition, otherwise known as laryngomalacia, is completely benign, and babies will eventually outgrow it
4. Your baby’s face breaks out in a terrible rash, recalling some teenage memories you would rather forget. Okay, this is terrible to admit, but when my first daughter was six weeks old, I nicknamed her, “pizza face.” She had an awful case of infant acne. Luckily the rash resolved without any treatment within a month or two, as it usually does
5. Your baby hasn’t pooped in seven days. Alternatively, your baby is pooping seven times a day, or even more! In my practice, I often refer to the “rule of sevens” regarding newborn bowel movements. A baby might poop seven times a day, or once every seven days. These intervals and everything in between are NORMAL. If the stool is soft, and doesn’t contain any blood or mucous, all is well. Incidentally, stool can be almost any color—green and orange are just fine! In the beginning, a newborn’s stool usually looks dark green and sticky (this is called meconium), but it will soon become yellow and seedy. The only truly abnormal color is white, which can be a sign of liver disease.
6. Your look at a photograph of your baby and her eyes are misaligned. Though some babies have a true “lazy” eye that will require treatment by an ophthalmologist, a more common diagnosis is “pseudostrabismus.” In many infants, the inner folds of the eyelids partially cover the white portion of the eye. This creates an optical illusion in which the eyes look misaligned but really aren’t. If the corneal light reflex (a bright white spot of light on the pupil) is symmetric, then your baby probably has pseudostrabismus. Be sure to let your pediatrician know if you have any concerns about regarding your baby’s eye alignment.
7. Your baby’s eyes are always watery, and sometimes they have a goopy discharge. No worries. She probably has blocked tear ducts, which will resolve over time, usually by one to two years of age. In the meantime, you can treat blocked tear ducts with warm compresses two to three times daily. Massaging the inner corner of the affected eye(s) can help to open the ducts. If the discharge starts to look thick, or the eye becomes irritated, contact your pediatrician. In this case, your baby might benefit from antibiotic eyedrops or ointment. When nasolacrimal duct obstruction persists past one year of age, babies are sometimes referred to a pediatric ophthalmologist.
8. Your baby suddenly throws both arms over her head and begins wailing. This is a normal newborn startle response, called the moro reflex. It usually resolves by four to six months of age.
9. Sometimes your baby eats for 30 minutes, and at other times she’s finished in five. Just like adults, babies have some days (or meals) in which they’re feeling ravenous, and other days not so much. The volume of feedings can vary dramatically, so expect variation.
10. You’re nursing, and your baby starts spitting up blood. For better or worse, the blood is probably coming from your own traumatized nipples. Let your pediatrician or obstetrician know if you’re struggling to get a good latch.
11. Your new baby girl has vaginal bleeding. “Pseudomenses” is due to hormone withdrawal and requires no treatment. Be aware that the bleeding can last for a couple weeks.
12. Your little girl (or boy) has swollen (though not inflamed) breasts and is producing “witches milk,” which resembles breast milk. This is a benign condition caused by hormone withdrawal. No treatment is needed. Be sure to resist the impulse to squeeze out the milk, which can prolong the symptoms.
13. Your baby goes limp in your arms and briefly becomes unresponsive after an obvious episode of spitting up. Sometimes reflux can trigger what appears to be an “acute life-threatening event,” or ALTE. While most of these episodes quickly resolve with some stimulation and cause no lasting harm to the baby, parents may be permanently traumatized. Please contact your pediatrician for support when something like this occurs.
14. Your baby constantly hiccups. Don’t worry, this is completely normal and doesn’t require treatment. She’ll outgrow it eventually.
15. The umbilical stump bleeds a bit as it’s detaching—another normal phenomenon in newborns. The base of the belly button will also exhibit some yellow or green discharge as the cord is detaching. If the skin surrounding the belly button isn’t red or inflamed, then all is well. If the area develops a foul odor, you can cleanse it with a small amount of rubbing alcohol once or twice daily. In general, NOTHING needs to be done to manage a detaching umbilical cord. Once the umbilical stump has detached, your baby can get a full bath. If the stump falls off and your baby continues to have umbilical drainage a few days later, make an appointment with the pediatrician. Your baby could have an umbilical granuloma, a common condition which benefits from treatment with silver nitrate to cauterize the area. Call your pediatrician right away in the skin around the belly button becomes significantly red or inflamed.
16. You notice blood in your baby’s stool. Babies can have blood in the stool for a variety of reasons. Small rectal and anal fissures can bleed a little, but they will usually heal quickly if the stool is soft. A milk protein allergy (sensitivity to whey and/or casein) can also cause blood in the stool. For nursing mothers, most pediatricians and GI doctors recommend eliminating dairy from the diet if a milk protein allergy is suspected. Babies taking regular formula should be switched to a fully hydrolyzed formula, like alimentum or nutramigen. Though it can be frightening to see bloody stool (and it may take a week or two to resolve), this usually turns out to be a minor problem. Happily, most infants outgrow milk protein allergies by the time they reach their first birthday.
17. Your baby spits up, all the time. Spitting up in the newborn period (otherwise known as gastroesophageal reflux) is an extremely common problem because the muscles that keep milk in the stomach aren’t well developed at this age. Some babies spit up with every feeding, and sometimes the spit ups are so violent that milk shoots right out the nasal passages. Yuck! If your baby is a “happy spitter” (he regularly vomits and couldn’t care less), then the condition likely doesn’t require treatment or further evaluation. However, if you’re getting tired of doing laundry, you can try to minimize the reflux by keeping your baby elevated after feedings. Baby Bjorns work well for this purpose because they keep babies suspended in a vertical position. Remember, when it comes to dealing with reflux, gravity is your friend. Raising your bassinette or crib mattress with a pillow underneath similarly helps to minimize reflux symptoms. Due to their natural elevation, car seats are also useful for managing reflux. Be sure to securely buckle your child into the car seat after feedings to avoid shifts in position that can compromise the airway.
If your baby is bottle feeding, you can try thickening breast milk or formula with some infant cereal. The usual ratio is one to three teaspoons of infant cereal (like rice or oatmeal) per ounce of breast milk or formula. Be careful not to overthicken the milk to the point where it can’t traverse the nipple.
Speaking of nipples, if your baby is prone to reflux, a Nuk nipple might be very helpful. Unlike most regular nipples, the Nuk is designed to slow down the flow of milk, which helps to prevent babies from guzzling milk too quickly, overfilling their stomachs, and choking.
Babies suffering from significant reflux who appear to be in pain are frequently treated by pediatricians with antacids. Heartburn medications like Prevacid, Zantac, and Pepcid are some of the most commonly prescribed medications for babies in the first year of life. Yet many studies have shown that these medications don’t work much better than placebo or the modifications mentioned above. Furthermore, antacids can have unwanted side effects. Studies in young infants (especially preemies) and the elderly have demonstrated that antacids may increase the risk of upper respiratory infections, pneumonia, gastroenteritis, and infections with bad bacteria like clostridium difficile. In my opinion, unless a baby (and parents) are miserable with reflux symptoms, antacids should be avoided.
18. Your baby is super fussy and squirming from bad gas. In the beginning, ALL babies struggle with gas to some degree. If you remember nothing else about gas, remember this: the gas will pass. Gassiness is NOT a reason to switch formula, stop breastfeeding, or put your child on reflux medication. For the first month or two of life, newborns have a reflex in which they clench their butt cheeks together when they need to pass gas. Instead of just farting and feeling better, they squirm and cry, holding onto the gas. Luckily this is a short-lived problem. By four to six months of age, most babies are happily farting and not fighting their own gas.
On a related point, babies often grunt, squirm, and turn red when passing stool. This DOESN’T mean they’re constipated. If the stool is soft, then all that fussing is normal.
19. Your baby has clear mucous pouring out of his nose and has been coughing for two weeks. Is it time for antibiotics? The answer is likely not yet. When a cold or runny nose lasts more than a few days, it can feel like forever; but viral upper respiratory illnesses in babies usually take more than 10 days to resolve. Anecdotally, in my own practice, babies with significant respiratory viral illnesses will frequently cough for a month or more. Most of these children do not require treatment with antibiotics.
20. Your baby sweats like a professional basketball player. For reasons that I can’t explain, some babies are super sweaty. Following a nap, their clothing may be soaked with sweat. If a baby’s core temperature is normal, excessive sweating at rest is usually nothing to worry about.
21. Due to their immature neurologic systems, babies do some strange, scary things. Their chins frequently quiver, and they may display some clonus (rapid rhythmic movements) in their legs and ankles. They can also have fine tremors of their limbs. The good news is they aren’t shivering from cold, and they probably aren’t having seizures.
Clonus, tremors, and the classic newborn “chin quiver” are due to an immature neurologic system. They eventually go away without treatment. FYI, the chin quiver can take more than one year to resolve. If a baby is awake and alert, and tremors can be stopped by gently holding the limb, then the baby is NOT having seizures and doesn’t need to see a neurologist.
22. Pieces of hair can sometimes get wrapped around fingers, toes, or private parts, blocking circulation. If your baby develops sudden pain and swelling of one of these body parts, look for a hair tourniquet. The hair can usually be removed with fine scissors or Nair. If you’re unable to remove the tourniquet at home, head to your nearest pediatric emergency room (but don’t panic, as the condition will soon be remedied).
23. Your baby has white patches on the tongue, lips, gums, and/or cheeks. This is oral thrush, a common type of yeast infection that occurs in babies. Thrush is usually harmless and can be remedied with oral antifungal treatments.
24. Your baby sleeps most of the day. In the beginning, infants can sleep 18 hours per day, and sometimes longer. Spending most of the day sleeping for new babies is perfectly normal, especially if naps are punctuated by periods of alertness.