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Newborn exam

As all new parents know only too well, each new birth does brighten our world. The feeling new parents experience when their newborn cries for the first time in the delivery room is something almost indescribable. Your life and world have been changed forever. In those first minutes, the feelings of elation and joy are so overwhelming that even pain is unfelt.

After those first unforgettable moments have passed, your baby will be taken to a warming table to be dried off and examined by a delivery room nurse, or a pediatrician, and will be assigned an Apgar score. Most first-time parents have scores of questions regarding not only care of their newborn, but questions regarding the appearance of their newborn. Newborn babies look different, especially in the first hours and days after birth. Below, we have compiled an extensive list of the most commonly asked about topics.

The Apgar score is a combined assessment of a newborn’s heart rate, respiratory effort, muscle tone, reflex irritability, and color. This scoring system was originally described by Virginia Apgar, MD, in 1953. The “1 minute Apgar score” reflects the newborn’s condition shortly after birth, while the “5 minute Apgar score” reflects the newborn’s response to resuscitative efforts, if any were needed. The total score is 10 (2 points for each of the above categories). It is very rare for a newborn baby to be given a score of 10, because the hands and feet in the first hours of life are almost always bluish in color; therefore, 1 point is usually subtracted for this. This is called acrocyanosis and is the purplish-blue coloration of the hands or feet in the newborn, considered to be normal in the first hours of life. The Apgar scores are not used to predict long term outcome. They are basically used to determine how much resuscitation (oxygen, etc.) a newborn baby needs.

There are several normal newborn rashes and skin discolorations that are a common cause of concern to new parents. Milia is a rash consisting of tiny, whitish dots over the nose, chin, and forehead that will disappear within the first few weeks of life. Erythema toxicum is a very common rash that appears 24 to 48 hours after birth, is blotchy and red, and can occur anywhere on the body. Some of the blotches have a small pustule in the center. This rash resolves within the first week to 10 days of life.Transient neonatal pustular melanosis is a rash that can also occur all over the body. There are small pustules with surrounding increase in skin pigment. This resolves in the first weeks, as well. Acne neonatorum is acne in the newborn. It is most evident around 1 month of age, and the rash, resembling acne, is most prominent on the cheeks and forehead. No treatment is required for any of these rashes. They will all spontaneously resolve. Many babies will have peeling skin in the first days after birth. This is normal, and it is particularly true for babies born after their due date. No treatment is needed.

Skin discolorations of common concern are “stork bites” and Mongolian spots. The term “stork bites” is used synonymously with “angel kisses” and refers to what is medically know as a macular hemangioma. These small reddish discolorations are very common, being found in nearly 50% of all newborns. They are routinely located on the eyelids or midline between the eyebrows, and the back of the head and neck. They are of no medical importance and disappear spontaneously within the first year of life; however, occasionally, they will persist faintly for a few years longer. Mongolian spots are dark blue or purplish flat spots that are located over the sacrum (lower back just above the buttocks) and over the shoulders and ankles. They are seen most commonly in Asians and in babies with dark skin. They occur in < 5% of Caucasian children. They are not at all related to Mongolism and are named Mongolian spots because of their frequency in babies of this decent. These spots disappear by the age of 4 years.

The head of your newborn may appear “funny-looking” at first glance. A newborn’s head will appear large compared to their body. Your baby may have a “cone-head” if delivered vaginally. This is normal and is from the tight squeeze through the vaginal canal. It is called molding. Your newborn’s head will have a normal shape by 1 week of age. The bones in your baby’s skull are not yet fused together to allow for the rapid brain growth that occurs in the first 2 years of life. There are two soft areas on the head, called fontanels. There is one on the upper, middle of the head, towards the front, the anterior fontanel, that will close between 9 and18 months of age. There is a second soft spot in the back, middle of the head, the posterior fontanel, that will close between 2 and 4 months of age. These soft spots are covered by a very tough membrane and thus, with normal handling, will not be injured. It is normal to see a pulse beating under the soft spot.

A newborn’s hair is very variable. It may be thick or thin and may stand up straight in the air. Most of the original newborn hair will fall out within the first month or two. Some infants may appear bald for a while. Others will re-grow a thick head of hair rather quickly. You cannot predict later hair color or texture based on your newborn’s early hair.

Your newborn’s face may appear bruised after a difficult vaginal delivery, or it may appear squished–with a flattened nose and chin. These will all resolve in the first days after birth.

The eyes may appear puffy in the first 24 to 48 hours after birth. If the delivery was difficult, you may note one or two red spots in the white part of the eye, called subconjunctival hemorrhages, which are not harmful and will resolve on their own. Some babies have “wandering” eyes. While your baby focuses on an object, one eye will wander. This is fairly common and will resolve by 4-6 months of age. If one eye ever appears fixed in a position, you should see the pediatrician. In addition, if the “wandering” does not resolve by 6 months of age, you should see the pediatrician. Early treatment of this condition, called strabismus, is extremely important and highly successful. Parents often ask when their baby will begin to have tears–your newborn baby will cry without tears for the first 3 to 6 weeks of life.

Swelling of the breasts is very common. This is due to maternal hormones passed to the baby through the placenta. This occurs in both male and female babies. You may notice a drop or two of fluid coming from the nipple–but fluid should not be expressed from your baby’s breast. This is all normal and will resolve within a few weeks to months.

In baby girls, there may be milky white vaginal discharge and even a few drops of blood coming from the vagina in the first week of life. This is also due to maternal hormones and will resolve by the end of the first week.

Newborn babies have what are called primitive reflexes or “normal newborn reflexes”, representing immaturity of the nervous system. The two primitive reflexes parents should absolutely know about are the Moro reflex and the rooting reflex. The Moro reflex occurs with a sudden, loud noise or with the sensation of falling. Your newborn will extend his arms and legs outward, flare the fingers, extend the head, then bring the arms and hands to the center and cry. This reflex will disappear by 4 to 6 months. The rooting reflex is very important for feeding. If you stroke your baby’s cheek just next the mouth, he will open his mouth and turn his head toward the cheek stroked. This is helpful especially for breastfeeding mothers to get the baby latching on well in the first weeks of life. This reflex disappears around the age of 4 months.