Snapshot A 2-month-old infant is brought to the pediatrician due to persistent crying. The parents report that the baby is adequately fed and diapers are frequently monitored; however, they cannot find an apparent reason for the infant's crying. The infant cries approximately 4 hours a day and 3 days per week. A thorough physical examination is unremarkable. Techniques in effective swaddling, gentle rocking, and decreased infant stimulation is advocated. (Colic) Crying Normal crying all infants cry the most during the first three months of life Colic broadly defined as an otherwise healthy infant < 3 months of age who is crying for no apparent reason that lasts ≥ 3 hours/day and ≥ 3 days/week management includes parental reassurance and behavioral interventions (first-line) e.g., effective swaddling and gentle rocking Feeding Frequent feeding prevents the newborn from developing hypoglycemia Breastfeeding high in whey protein improves gastric emptying compared to casein has less iron than formula; however, it has a higher bioavailability of it low in vitamin K and vitamin D higher bioavailability of calcium and phosphorus contains immunoglobulin A (passive immunity) and lysozymes to improve infant immunity contraindications to breastfeeding include human immunodeficiency virus (HIV) infants with galactosemia herpes simplex virus (HSV) infection if there is a present lesion mother with untreated active tuberculosis infection mother taking chemotherapeutic agents substance abuse Formula-feeding can be used to substitute or supplement breastfeeding cow's milk should not be given to infants < 1 year of age Introducing solid foods (> 6 months) pureed foods vomitting, poor feeding, and lethargy should prompt workup for hereditary fructose intolerance Weight Changes Weight changes a weight loss of 5-7% of birth normally occurs in the first few days of life weight loss usually stops at five days of life by 10-14 days gestation the weight is typically regained excessive weight loss (> 7%) should be managed by observation of a feed (e.g., how adequate the latch on is) determine adequacy of milk production and transfer physical examination of the infant and mother to determine if the infant is jaundice and has signs of hypovolemia if the mother has signs of engorgement Skin Select Dermatologic Findings of the Newborn Skin Finding Clinical Findings Management Neonatal acne (neonatal cephalic pustulosis) Mean age of onset is ~ 3 weeks Inflammatory papules and pustules in the face (especially the cheeks) without comedonal lesions Cleaning newborn with soap and water daily usually spontaneously resolves within 4-months without scarring Milia White papules typically found on the nose and cheeks secondary to keratin and sebaceous material retention in the pilaceous follicles Usually resolved by the first few weeks of life and thus no treatment Nevus simplex (salmon patch) Pink-red patches that are blanchable Usually disappears within 1-2 years Congenital dermal melanocytosis (mongolian spots) Most common in Asian neonates Blue-grey, evenly pigmented patch most commonly found in the sacral-gluteal region Usually disappears by 1-2 years of age Management is observation Differential diagnosis must include child abuse Cutis marmorata Reticular mottling of the skin that is symmetric and affecting the extremity trunk Secondary to a vascular response to cold and resolves with warming No treatment required Erythema toxicum neonatorum Erythematus macules and papules that rapidly progress to pustules and have an erythematous base These lesions can be found over the trunk and proximal extremities and spare the palms soles The cause is unknown but believed to be due to pilosebaceous follicle immaturity Usually appears 24-48 hours after birth and resolves in 5-7 days No treatment is required Superficial hemangioma ("Strawberry hemangioma") Papule, nodule, or plaque that is bright-red and above normal skin Spontaneously regress by 5-8 years of age Genitourinary and Stooling Stool first meconium typically passes before 24-48 hours of life no first meconium occuring > 48 hours is concerning for colonic obstruction secondary to imperforate anus meconium plug syndrome Hirschprung disease first meconium usually appears black, tarry, and sticky meconium transitions from green-brown to mustard yellow that is seedy and loose Urine first urine usually occurs in the first 24 hours of life precipitated uric acid crystals ("brick dust") in the diaper often be misidentified as blood but is completely benign Maternal estrogen effects breast hypertrophy, swollen labia, physiologic leukorrhea, uterine withdrawal bleeding resolves within first 2 months of life