Updated: 9/26/2022

Normal and Abnormal Findings of the Newborn

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  • 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

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