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Looking at Your Newborn: What's Normal
In delivery room scenes on TV and in the movies, the mother-to-be,
often a famous actress in full makeup and with every hair in place,
"delivers" a baby after a few token grunts and groans. Seconds
later, the doctor presents the glowing parents with a
picture-perfect, neatly combed and scrubbed, cooing
several-month-old infant.
Contrast that picture with how a baby really looks just after
emerging from the womb: bluish, covered with blood and cream-cheesy
glop, and looking as though the little one has just been in a
fist-fight.
The fact that your newborn doesn't resemble one of those Hollywood
"stand-ins" shouldn't come as a great surprise. Remember that the
fetus develops immersed in fluid, folded up in an increasingly
cramped space inside the uterus. The whole process usually
culminates with the baby being pushed forcibly through a narrow,
bone-walled birth canal, sometimes requiring the assistance of metal
forceps or suction devices.
Still, it helps to remember two things:
1.
Usually, the features that may make a normal newborn look strange
are temporary.
2.
In the eyes of the adoring parent, every infant looks like the
perfect baby anyway.
General Appearance of Newborns
When you first get to see, touch, and inspect your newborn may
depend on the type of delivery, your condition, and the condition of
your baby. Following an uncomplicated vaginal delivery, you should
have the opportunity to hold your baby within minutes after the
birth.
In most cases, infants seem to be in a state of quiet alertness
during the first hour or so after delivery. It's a great time for
you and your newborn to get acquainted and begin the bonding
process. But don't despair if circumstances prevent you from meeting
your infant right away. You'll have plenty of quality time together
soon, and there's no scientific evidence that the delay will affect
your infant's health, behavior, or relationship with you over the
long run.
During the first several weeks, you'll notice that much of the time
your baby will tend to keep his or her fists clenched, elbows bent,
hips and knees flexed, and arms and legs held close to the front of
his or her body. This position is similar to the fetal position
during the last months of pregnancy. Infants who are born
prematurely may display several differences in their posture,
appearance, activity, and behavior compared with full-term newborns.
Infants are born with a number of instinctual responses to stimuli,
such as light or touch, known as
primitive reflexes,
which gradually disappear as the baby matures. These reflexes
include the:
Also, due to the immaturity of their developing nervous systems,
young infants' arms, legs, and chins may tremble or shake,
particularly when they're crying or agitated.
In the first weeks, infants usually spend most of their time
sleeping. This may be even more exaggerated during the first day or
two of life in newborns whose mothers received certain types of pain
medications or anesthesia during the labor or delivery.
Frequently, new parents become concerned about their newborn's
breathing pattern,
particularly with the increased attention that sudden infant death
syndrome (SIDS) has received in recent years. But rest assured that
it's normal for young infants to breathe somewhat irregularly.
When an infant is awake, his or her breathing rate may vary widely,
sometimes exceeding 60 breaths per minute, particularly when the
little one is excited or following a bout of crying. Newborns will
also commonly have periods during which they stop breathing for
about 5 to 10 seconds and then start up again on their own. This is
known as
periodic breathing,
which is more likely to occur during sleep and is considered very
normal. However, if your infant turns blue or stops breathing for
longer stretches of time, it's considered an emergency and you
should contact your child's doctor immediately or go to the
emergency room.
Although talking won't come until much later, your newborn will
produce a symphony of noises — especially high-pitched squeaks — in
addition to the obligatory crying. Sneezing and hiccups also occur
very frequently and don't indicate infection, allergies, or
digestive problems in newborns.
Head
Because the infant's head is usually the first part through the
birth canal, it can be affected by the delivery process. The
newborn's skull is made up of several separate bones that will
eventually fuse together. This situation permits the large head of
the infant to be squeezed through the narrow birth canal without
injury to mother or baby.
The heads of infants born by vaginal delivery often show some degree
of
molding,
which is when the skull bones shift and overlap, making the top of
the infant's head look elongated, stretched out, or even pointed at
birth. This sometimes bizarre appearance will go away over the next
several days as the skull bones move into a more rounded
configuration. The heads of babies born by cesarean section or
breech (buttocks or feet first) delivery usually don't show molding.
Because of the separation of your newborn's skull bones, you'll be
able to feel (go ahead, you won't harm anything) two
fontanels,
or soft spots, on the top of the head. The larger one, located
toward the front of the head, is diamond-shaped and usually about 1
to 3 inches wide. A smaller, triangle-shaped fontanel is found
farther back on the head, where a beanie might be worn. Don't be
alarmed if you see the fontanels bulge out when the infant cries or
strains, or if they seem to move up and down in time with the baby's
heartbeat. This is perfectly normal. The fontanels will eventually
disappear as the skull bones close together — usually in about 12 to
18 months for the front fontanel and in about 6 months for the one
in back.
In addition to looking elongated, a newborn's head may have a lump
or two as a result of the trauma of delivery.
Caput succedaneum
is a circular swelling and bruising of the scalp usually seen on top
of the head toward the back, which is the part of the scalp most
often leading the way through the birth canal. This will fade over a
few days.
A
cephalohematoma
is a collection of blood that has seeped under the outer covering
membrane of one of the skull bones. This is usually caused during
birth by the pressure of the head against the mother's pelvic bones.
The lump is confined to one side of the top of the baby's head and,
in contrast to caput succedaneum, may take a week or two to
disappear. The breakdown of the blood collected in a cephalohematoma
may cause these infants to become somewhat more jaundiced than
others during the first week of life. It's important to remember
that both caput succedaneum and cephalohematoma occur due to trauma
outside of the skull — neither indicates that there has been any
injury to the infant's brain.
Face
A newborn's face may look quite puffy due to fluid accumulation and
the rough trip through the birth canal. The infant's facial
appearance often changes significantly during the first few days as
the baby gets rid of the extra fluid and the trauma of delivery
subsides. That's why the photos you take of your baby later on at
home usually look a lot different than those "new arrival" nursery
shots. In some cases, a newborn's facial features can be quite
distorted as a result of positioning in the uterus and the squeeze
through the birth canal. Not to worry — that folded ear, flattened
nose, or crooked jaw usually comes back into place over time.
Eyes
A few minutes after birth, most infants open their eyes and start to
look around at their environment. Newborns can see, but they
probably don't focus well at first, which is why their eyes may seem
out of line or crossed at times during the first 2 to 3 months.
Because of the puffiness of their eyelids, some infants may not be
able to open their eyes wide right away. When holding your newborn,
you can encourage eye opening by taking advantage of your baby's
"doll's eye" reflex, which is a tendency to open the eyes more when
held in an upright position.
Parents are sometimes startled to see that the white part of one or
both of their newborn's eyes appears blood-red. Called
subconjunctival hemorrhage,
this occurs when blood leaks under the covering of the eyeball due
to the trauma of delivery. It's a harmless condition similar to a
skin bruise that goes away after several days, and it generally
doesn't indicate that there has been any damage to the infant's
eyes.
Parents are often curious to know what color eyes their infant will
have. If a baby's eyes are brown at birth, they will remain so. This
is the case for most black and Asian infants. Most white infants are
born with bluish-gray eyes, but the pigmentation of the iris (the
colored part of the eye) may progressively darken, usually not
becoming their permanent color until about 3 to 6 months of age.
Ears
A newborn's ears, as well as other features, may be distorted by the
position they were in while inside the uterus. Because the baby
hasn't yet developed the thick cartilage that gives firm shape to an
older child's ears, it isn't unusual for newborns to come out with
temporarily folded or otherwise misshapen ears. Small tags of skin
or pits (shallow holes) in the skin on the side of the face just in
front of the ear are also common. Usually, these skin tags can be
easily removed (talk to your doctor).
Nose
Because newborns tend to breathe through their noses and their nasal
passages are narrow, small amounts of nasal fluid or mucus can cause
them to breathe noisily or sound congested even when they don't have
a cold or other problem. Talk with your doctor about the use of
salt-water nose drops and a bulb syringe to help clear the nasal
passages if necessary.
Sneezing
is also common in newborns. This is a normal reflex and isn't due to
an infection, allergies, or other problems.
Mouth
When your newborn opens his or her mouth to yawn or cry, you may
notice some small white spots on the roof of the mouth, usually near
the center. These small collections of cells are called
Epstein's pearls
and, along with fluid-filled
cysts
sometimes present on the gums, will disappear during the first few
weeks.
Neck
Yes ... it's there. Normally the neck looks short in newborns
because it tends to get lost in the chubby cheeks and folds of skin.
Chest
Because an infant's chest wall is thin, you may easily feel or
observe your baby's upper chest move with each heartbeat. This is
normal and isn't a cause for concern.
Also, both male and female newborns can have
breast enlargement.
This is due to the female hormone estrogen passed to the fetus from
the mother during pregnancy. You may feel firm, disc-shaped lumps of
tissue beneath the nipples and, occasionally, a small amount of
milky fluid (called "witch's milk" in folklore) may be released from
the nipples. The breast enlargement almost always disappears during
the first few weeks. Despite what some parents believe, you
shouldn't squeeze the breast tissue — it will not make the breasts
shrink any faster than they will on their own.
Arms and Legs
Following birth, full-term newborns tend to assume a posture similar
to what their position in the cramped uterus had been: arms and legs
flexed and held close to their bodies. The hands are usually tightly
closed, and it may be difficult for you to open them up because
touching or placing an object in the palms triggers a strong grasp
reflex.
Infants'
fingernails
can be long enough at birth to scratch their skin as they bring
their hands to their faces. If this is the case, you can carefully
trim your baby's nails with a pair of small scissors.
Sometimes parents are concerned about the curved appearance of their
newborn's feet and legs. But if you recall the usual position of the
fetus in the womb during the final months of pregnancy — hips flexed
and knees bent with the legs and feet crossed tightly up against the
abdomen — it's no surprise that a newborn's legs and feet tend to
curve inward. You can usually move your newborn's legs and feet into
a "walking" position; and this will happen naturally as the infant
begins to bear weight, walk, and grow through the first 2 to 3 years
of life.
Abdomen
It's normal for a baby's abdomen (belly) to appear somewhat full and
rounded. When your baby cries or strains, you may also note that the
skin over the central area of the abdomen may protrude between the
strips of muscle tissue making up the abdominal wall on either side.
This almost always disappears during the next several months as the
infant grows.
Many parents are concerned about the appearance and care of their
infant's
umbilical cord.
The cord contains three blood vessels (two arteries and a vein)
encased in a jelly-like substance. Following delivery, the cord is
clamped or tied off before it's cut to separate the infant from the
placenta. The umbilical stump is then simply allowed to wither and
drop off, which usually happens in about 10 days to 3 weeks. You may
be instructed to swab the area with alcohol periodically or wash the
area with soap and water if the stump becomes dirty or sticky to
help prevent infection until the cord falls off and the stump dries
up. The baby's navel area shouldn't be submerged in water during
bathing until this occurs. The withering cord will go through color
changes, from yellow to brown or black — this is normal. You should
consult your baby's doctor if the navel area becomes red or if a
foul odor or discharge develops.
Umbilical
(navel)
hernias
are common in newborns, particularly in black infants. A hole in the
wall of the abdomen at the site of the umbilical cord/future navel
allows the baby's intestine to protrude through when he or she cries
or strains, causing the overlying skin to bulge outward. These
hernias are generally harmless and aren't painful to the infant. The
majority of them close on their own during the first few years, but
a simple surgical procedure can fix the hernia if it doesn't close
by itself. Home remedies for umbilical hernias that have been tried
through the years, such as strapping and taping coins over the area,
should
not
be attempted. These techniques are ineffective and may result in
skin infections or other injuries.
Genitalia
The genitalia (sexual organs) of both male and female infants may
appear relatively large and swollen at birth. Why? It's due to
several factors, including the exposure to hormones produced by the
mother and fetus, bruising and swelling of the genital tissues
related to birth trauma, and the natural course of development of
the genitalia.
In girls, the outer lips of the vagina (labia
majora)
may appear puffy at birth. The skin of the labia may be either
smooth or somewhat wrinkled. Sometimes, a small piece of pink tissue
may protrude between the labia — this is a
hymenal tag
and it's of no significance; it will eventually recede into the
labia as the genitals grow.
Due to the effects of maternal hormones, most newborn girls will
have a vaginal discharge of mucus and perhaps some blood that lasts
for a few days. This "mini-period" is normal menstrual-type bleeding
from the infant's uterus that occurs as the estrogen passed to the
infant by the mother begins to disappear. Although it's much more
common in boys, swelling in the groin of an infant girl can indicate
the presence of an
inguinal
(groin)
hernia.
In boys, the scrotum (the sack containing the testicles) often looks
swollen. This is usually due to a
hydrocele,
a common collection of fluid in the scrotum of infant boys that
usually disappears during the first 3 to 6 months. You should
consult your doctor about swelling or bulging in your son's scrotum
or groin area that persists beyond 3 to 6 months or that seems to
come and go. That may indicate the presence of an inguinal hernia,
which usually requires surgical treatment. The testicles of newborn
boys may be difficult to feel in the swollen scrotum. Muscles
attached to the testicles pull them up into the groin briskly when
the genital area is touched or exposed to a cool environment. Infant
boys also normally experience frequent
penile erections,
often just before they urinate.
More than 95% of newborns urinate within the first 24 hours. If your
baby is delivered in a hospital, nursery personnel will want to know
if this happens while your infant is with you. If a newborn doesn't
urinate for what seems like a while at first, it may be that he or
she urinated immediately after birth while still in the delivery
room. With all the activity going on, that first urination may not
have been noticed.
If your infant son was circumcised, it usually takes between 7 to 10
days for the penis to heal. Until it does, the tip may seem raw or
yellowish in color. Although this is normal, certain other symptoms
are not. Call your child's doctor right away if you notice
persistent bleeding, redness around the tip of the penis that gets
worse after 3 days, fever, signs of infection (such as the presence
of pus-filled blisters), and not urinating normally within 6 to 8
hours after the circumcision.
With both circumcised and uncircumcised penises, no cotton swabs,
astringents, or any special bath products are needed — simple soap
and warm water every time you bathe your baby will do the trick.
There are also no special washing precautions with newly circumcised
babies, other than to be gentle, as your baby may have some mild
discomfort after the circumcision. If your son has a bandage on his
incision, you might need to apply a new one whenever you change his
diaper for a day or two after the procedure (put petroleum jelly on
the bandage so it won't stick to his skin). Doctors often also
recommend putting a dab of petroleum jelly on the baby's penis or on
the front of the diaper to alleviate any potential discomfort caused
by friction against the diaper. How you take care of your baby's
penis may also vary depending on the type of circumcision procedure
your child's doctor performs. Be sure to talk to him or her about
what after-care will be needed.
If your baby boy wasn't circumcised, be sure to never forcibly pull
back the foreskin to clean beneath it. Instead, gently tense it
against the tip of the penis and wash off any smegma (the whitish
"beads" of dead skin cells mixed with the body's natural oil). Over
time, the foreskin will retract on its own so that it can be pulled
away from the glans toward the abdomen. This happens at different
times for different children, but most boys can retract their
foreskins by the time they're 5 years old.
Skin
There's little doubt about the origin of the expression "still wet
behind the ears," used to describe someone new or inexperienced.
Newborns are covered with various fluids at delivery, including
amniotic fluid and often some blood (the mother's, not the baby's).
Nurses or other personnel attending the birth will promptly begin
drying the infant to avoid a drop in the baby's body temperature
that will occur if moisture on the skin evaporates rapidly. Newborns
are also coated with a thick, pasty, white material called
vernix caseosa
(made up of the fetus' shed skin cells and skin gland secretions),
most of which will be washed off during the baby's first bath.
The hue and color patterns of a young infant's skin may be startling
to some parents.
Mottling
of the skin, a lacy pattern of small reddish and pale areas, is
common because of the normal instability of the blood circulation at
the skin's surface. For similar reasons,
acrocyanosis,
or blueness of the skin of the hands and feet and the area
surrounding the lips, is often present, especially if the infant is
in a cool environment.
When bearing down to cry or having a bowel movement, a young
infant's skin temporarily may appear beet-red or bluish-purple. Red
marks, scratches, bruises, and
petechiae
(tiny specks of blood that have leaked from small blood vessels in
the skin) are all common on the face and other body parts. They're
caused by the trauma of squeezing through the birth canal or by the
pressure from obstetrical forceps used during the delivery. These
will heal and disappear during the first week or two of life.
Fine, soft hair, called
lanugo,
may be present on a newborn's face, shoulders, and back. Most of
this hair is usually shed in the uterus before the baby is
delivered; for this reason, lanugo is more frequently seen on babies
born prematurely. In any case, this hair will disappear in a few
weeks.
The top layer of a newborn's skin will flake off during the first
week or two. This is normal and expected and doesn't require any
special skin care. Peeling skin may be present at birth in some
infants, particularly those who are born past their due date.
Despite what the name says, not all babies come with a
birthmark.
However, pink or red areas, sometimes called
salmon patches,
are common and generally disappear within the first year. Most
frequently found on the back of the neck or on the bridge of the
nose, eyelids, or brow (hence the fanciful nicknames "stork bite"
and "angel kiss"), they can occur anywhere on the skin, especially
in light-skinned infants.
Mongolian spots,
flat patches of slate-blue or blue-green color that resemble ink
stains on the back, buttocks, or elsewhere on the skin, are found in
more than half of black, Native American, and Asian infants and less
often in white babies. These spots are of no significance and almost
always fade or disappear within a few years.
Strawberry
or
capillary hemangiomas
are raised red marks caused by collections of widened blood vessels
in the skin. These birthmarks may appear pale at birth and then
typically become red and enlarge during the first months of life.
Then, they usually shrink and disappear without treatment within the
first 6 years.
Port-wine stains,
which are large, flat, reddish-purple birthmarks, won't disappear on
their own. As the child gets older, concerns (your or the child's)
about cosmetic appearance may require the attention of a
dermatologist.
Cafe-au-lait spots,
so called because of their "coffee with milk" light-brown color, are
present on the skin of some infants. These may deepen in color (or
may first appear) as the child grows older. They're usually of no
concern unless, they're large or there are six or more spots on the
body, which may indicate the presence of certain medical conditions.
Common brown or black moles, known as
pigmented nevi,
may also be present at birth or appear or deepen in color as the
child gets older. Larger moles or those with an unusual appearance
should be brought to a doctor's attention because some may require
removal.
Several harmless skin
rashes
and conditions may be present at birth or appear during the first
few weeks. Tiny, flat, yellow or white spots on the nose and chin,
called
milia,
are caused by the collection of secretions in skin glands and will
disappear within the first few weeks.
Miliaria
— small, raised, red bumps that often have a white or yellow "head"
— is sometimes called infant acne because of its appearance.
Although miliaria often occurs on the face and may be present on
large areas of the body, it's a harmless condition that will go away
within the first several weeks with normal skin care.
Despite the frightening sound of its medical name,
erythema toxicum
is also a harmless newborn rash consisting of red blotches with pale
or yellowish bumps at the center, which give the rash a hive-like
appearance. This rash usually blossoms during the first day or two
after birth and disappears within a week.
Pustular melanosis,
a rash present at birth mainly in black infants, is characterized by
dark brown bumps or blisters scattered over the neck, back, arms,
legs, and palms, which disappear without treatment. Also, it isn't
unusual to see infants born with
sucking blisters
on the fingers, hands, or arms because the fetus can suck while
still in the uterus.
Newborn
jaundice,
a yellowish discoloration of the skin and white parts of the eyes,
is a common condition that normally doesn't appear until the second
or third day after birth and disappears within 1 to 2 weeks.
Jaundice is caused by the accumulation of bilirubin (a waste product
produced by the normal breakdown of red blood cells) in the blood,
skin, and other tissues due to the temporary inability of the
newborn's immature liver to clear this substance from the body
effectively. Although a certain degree of this is expected, if an
infant becomes jaundiced earlier than expected or their bilirubin
level is higher than is normal, then the doctor will follow the baby
very closely.
Getting to Know Your Little One
The first days and weeks of a newborn's life are a time of great
wonder and delight for most new parents. However, being responsible
for such a seemingly fragile creature can be intimidating,
particularly if you're unfamiliar with how a normal newborn looks
and behaves. If you feel anxious or uncertain about any aspect of
caring for your infant, don't hesitate to consult your doctor, other
health care professionals, or family or friends who have had
experience caring for a newborn, too.
Reviewed by: Steven Dowshen, MD
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