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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, who, if he were any older, probably could walk out of the delivery room on his own.

Contrast that picture with how a baby really looks just after emerging from the womb: bluish, waterlogged, covered with blood and cream-cheesy glop, and battered as though he has just been in a fistfight - and lost. Not a pretty sight.

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, and (2) in the eyes of the adoring parent, every infant looks like the "Gerber 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:

• sucking reflex, which triggers an infant to forcibly suck on any object put in the mouth
• grasp reflex, which causes an infant to tightly close the fingers when pressure is applied to the inside of the infant's hand by a finger or other object
• Moro reflex, or startle response, which causes an infant to suddenly throw the arms out to the sides and then quickly bring them back toward the middle of the body whenever the infant has been startled by a loud noise, bright light, strong smell, sudden movement, or other stimulus

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, it's considered an emergency and you should contact your child's doctor immediately or go to the emergency room, if your infant turns blue or stops breathing for longer stretches of time.

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 child's 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 baby's doctor or health care provider 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 are small collections of cells called Epstein's pearls. These spots, as well as 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 infant'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 an infant'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. An antibacterial dye is applied to the remaining stump in most nurseries, which accounts for the blue staining of the cord and surrounding skin. The umbilical stump is then simply allowed to wither and drop off, which usually happens in about 10 days to 3 weeks. You maybe instructed to swab the area with alcohol periodically to help prevent infection until the cord falls off and the stump dries up. The infant'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 baby's 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 2 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 baby's doctor, other health care professionals, or family or friends who have had experience caring for a newborn, too.