I completed my pediatric residency in July 2000 and found out I was pregnant with my first daughter shortly thereafter. One of the pediatricians I worked with at that time said, “You know the final step in becoming a good pediatrician is having a child”. Eighteen years later, I often think about what he said and how true a statement it is. The ability to identify with the parents of our patients, as well as our patients, and the ability to feel the emotional as well as intellectual component of what we do is a very essential part of the job.
My daughter was born premature at 34 weeks and 5 days. She weighed 5 pounds and spent 12 days in the NICU. Now I had training as a doctor and a mom in this arena. I dutifully played the mom role and even took the CPR course required before discharge! I had an eventful maternity leave filled with reflux, colic and lots of fussiness and eventually returned to work. Those first few weeks back, I had an intense connection with the newborns I saw and their families and realized things had changed. In an effort to convey this connection, I often started visits by asking new moms “How are you doing?” followed by “I found the first few weeks very emotionally and physically trying.” I indeed connected and most of the mothers winded up breaking down into tears when given this empathy and window of opportunity. I’m sure all parents can identify with the uncertainty and the lack of confidence felt when you bring your first newborn home which brings me to this ALL Pediatrics Blog topic. The following are my take on the top 10 concerns (in no specific order) raised by parents at the newborn visit. This visit usually takes place when the baby is about 3 days old and about 1-2 days after leaving the hospital.
1. Newborn rashes: A newborns skin is not smooth and silky. There is an extra layer of skin that protected the infant while bathing in the amniotic fluid that needs to shed in the first weeks of life. This is often mistaken for “dry skin”. The closer to term the infant is, the more “dry”and wrinkled the skin appears -almost like soaking in a bath too long. No lotion is needed and usually the extra layer is shed by 2-3 weeks of age. Two other skin issues are also frequently a cause of parental concern: Erythema toxicum: a completely benign bumpy rash that changes location over the body for the first 2-3 weeks and often looks like insect bites. Text books call it a “fried egg appearance” with the yolk of the egg being the center bump which often has a yellowish hue and the white of the egg being an irregularly shaped reddened area. It does not cause any discomfort or itch and there is no treatment needed. Infant acne: basically pimples where you would expect pimples to be – face, upper chest, upper back. Infant acne starts at about 2 weeks of age and is related to maternal hormones circulating in the infant. It usually resolves by 6-8 weeks of age but can worsen before it gets better. It can also appear to fluctuate in severity day to day and even hour to hour which is often a source of concern for new parents. No special treatment is needed. I recommend just regular bathing and washing with water or a mild infant soap.
2. Noisy breathing: Other than crying, newborns make many concerning noises the first few weeks of life. They seem congested (another result of bathing in the amniotic fluid for 9 months) and snort, squeak, snore and generally seem like they need to perpetually clear their throat. Much of this is due to benign issues such as reflux or immature, less strong airways and eventually goes away. When is a parent to worry? Any perceived difficulty feeding (sweating or unable to eat) or increased effort of breathing (pulling in chest or abdominal breathing) should prompt a call to the pediatrician. In addition, it is reassuring if the noises come and go and aren’t constantly present when the infant inhales and exhales. Lastly, assess the infants comfort level. If he is sleeping peacefully despite the cacophony of noises that are disrupting your rest more than his, this is a good sign.
3. Umbilical cord drainage: The umbilical cord drains mucus like material as well as old dark blood while it is separating and for several days after it falls off. The drainage can even be somewhat foul smelling. At the time of discharge, the hospital recommends that parents put nothing on the cord and I agree with this. However, it is OK to wipe away some of the foul drainage with a damp cloth trying your best not to get the cord wet. Once the cord falls off, it is also OK to wipe away the drainage. If there is copious drainage requiring you to clean more than 1-2 times per day, this is concerning. If there is redness and warmth to the skin (like a sunburn) surrounding the umbilical cord or umbilicus (belly button), this is concerning. If there is drainage that persists for more than 7 days after the umbilical cord has separated, this is concerning. The above three scenarios should prompt a call to your pediatrician.
4. Eye drainage: A blocked tear duct is the most common reason a newborn has eye drainage. In this case, the drainage comes and goes – somedays seem better and other days worse. The white part of the eye is clear (not red) and there is minimal swelling or redness to the eyelids and surrounding eye area. As with the umbilical cord, copious drainage requiring you to wipe the eyes every 1-2 hours or increased redness to the eye is worrisome and you should contact your pediatrician. With a blocked tear duct, the drainage is most often significant after a prolonged period of sleep (first thing in the morning) and the eye itself can appear to be stuck shut. However, once the drainage/crusting is gently wiped away with a warm cloth, the eye is not red or swollen. A homeopathic treatment commonly recommended for a blocked tear duct is to drop some breast milk in the eye. Breast milk is filled with lots of good antibodies that are made to fight any infection. Breast milk also contains digestive enzymes that help the infant digest it so easily and some researchers have hypothesized that these enzymes help open the duct and thus help resolve the blockage. Most of the time, the blocked tear duct will resolve on its own by 4-6 months of life and can be addressed at a routine well child check as long as there aren’t any signs of an eye infection as noted above.
5. Jaundice: Most newborns have jaundice – a yellow coloring to their skin due to a substance called bilirubin. Bilirubin is an antioxidant and experts believe it serves some protective critical function in the vulnerable newborn period. However, if the bilirubin level gets to high in the first 48-72 hours, there can be complications such as hearing loss and seizures. In 2018, most newborns will have a bilirubin level drawn prior to leaving the hospital. The doctors and nurses should explain the significance of the level and let families know if it is worrisome or not. They should also give clear follow up instructions if the level is borderline or high. The bilirubin level usually peaks at 3-4 days of age so it may get worse once you leave the hospital. Therefore, it is very important to follow the instructions of the hospital team at discharge regarding bilirubin levels. Once home, try to place your infant in a sunny window. Indirect sunlight can help lower the bilirubin level and your infant will not be negatively affected by sun received through a glass window or door. Infants also excrete the bilirubin through the urinary and GI tracts, so the more an infant eats, pees and poops, the better. However, elevated jaundice can cause a newborn to get sleepy which can negatively impact feeding. If your newborn seems excessively sleepy (not awakening to eat or feeding for less than 10 minutes at a time) and more yellow than when she left the hospital, I recommend calling your pediatrician. ‘
Please visit us next week for part two of this blog that will have concerns six through ten.
Written by Dr. Kathleen Parker-Lundgren