MINOR PROBLEMS IN NEWBORNS

Although essentially benign and frequently self-limiting, following problems are common cause of parental concern. No treatment is indicated in these cases, except assurance. However, some of them must be differentiated from more serious pathologies, discussed in later chapters.

a. Common skin problems include:

Milia, i.e. tiny, white dots over nose and face due to blocked and distended sebaceous gland, are common on 2-3rd days and disappear spontaneously (Fig. 12.6).

TABLE 12.13: Common rashes in newborn

Benign and transient

• Milia

• Erythema toxicum

• Pustular melanosis

Pathological

• Staphylococcal pustules,

• Intrauterine infections, e.g. HSV, syphilis

• Cutaneous thrush (candidiasis)

• Staphylococcal scalded skin syndrome

• Toxic epidermal necrolysis

Erythema toxicum, i.e. tiny, discrete, erythematous papules/vesicles over face, trunk and extremities, usually appear on 1-3rd day and persist for as long as one week, before spontaneous resolution (Fig. 12.6). On scrapping, these lesions are filled with eosinophils.

Pustular melanosis are benign Vesiculobullous eruptions over chin, neck, back and limbs, present at birth, lasting for 2-3 days (Fig. 12.6). On scrapping, these lesions are filled with neutrophils. (d/d Impetigo or Herpes simplex). Some common causes of neonatal rash are given in Table 12.13.

Mongolian spots, i.e. slate-blue, well-demarcated spots on trunk, back or buttocks, are present in gt;50% newborns and usually disappear by 6-24 months (Fig. 12.6). These spots have no relation with Down syndrome. (d/d Congenital melanocytic nevi, seen in lt;1% newborns).

Stork-bites (Salmon patch), i.e. small, diffuse, pinkish­grey macules (capillary hemangioma), are seen in ~40% newborns, specially over eyelids, forehead and nape of the neck (see Fig. 25.3). These lesions are usually bilateral, symmetrical and more prominent during cry.

Acrocyanosis over finger tips and perioral region is very common during first few days of life, which becomes more prominent during cry and improves rapidly after protective clothing. (d/d central or persistent cyanosis in cardiorespiratory disorders).

Harlequin color change, i.e. a transient vertical deli­neation of body into red and pale halves, is a striking but harmless sign of vasomotor instability in first few day of life. (d/d cutis marmorata-bilateral diffuse mottling with lacy appearance, suggestive of sepsis or hypothermia). Physiological jaundice appears in ~70-80% of normal newborns on 2-3rd day of life, and persists till 7-10th day in terms and 10-14th day preterms (d/d see Ch 12.14.1).

Edema: Transient pedal edema is common in preterms, while its persistence indicates possibility of Turner syndrome or lymphatic malformations, e.g. Milroy disease. (d/d generalised edema is seen in hydrops fetalis,

of immune (Rh-incompatibility) or non-immune (renal agenesis, severe anemia) origin.

Subcutaneous fat necrosis, i.e. patchy induration over buttocks, cheeks and limbs that resolves spontaneously. (d/d diffuse sclerema in sepsis, hypothermia).

b. Common problems of oral cavity include:

Epstein pearls are tiny, white masses over hard palate near midline, due to temporary accumulation of epithelial cells (retention cysts) that disappear spontaneously within a few weeks. Similar lesions may be present on gums (epithelial pearls) and prepuce (prepucial pearls). Sucking pads/sucking callus are temporary callosities over lips and cheeks respectively, due to accumulation of extra fat and stratified epithelium, which disappear after some time.

Natal tooth are not uncommon in normal newborns, usually seen at the site of lower incisors, representing a supernumerary or prematurely erupted deciduous tooth (Fig.

Tongue-tie due to short ventral frenulum is common, but rarely leads to feeding or speech problems (Fig. 12.6). A thick and tight frenulum with notches over the tongue, may be snipped at 3 months.

c. Common ocular problems include:

Physiological photophobia is common in normal newborns during first few weeks of life.

Subconjunctival hemorrhage, usually near the outer canthus is common in vertex delivered newborns, which resolve spontaneously in 1-2 weeks.

Unilateral mucoid eye discharge is seen in ~5% of newborns, due to incomplete canalization of naso­lacrimal duct. Frequent massage over nasal sides and cleaning of eyelids with lukewarm water is enough in most cases, before spontaneous resolution by 3-6 months. Topical antibiotics are indicated only if discharge is mucopurulent. Persistent cases (gt;6 months) may need punctal probing or dacryocystorhinostomy.

d. Common genital problems include:

Physiological phimosis is present in ~80% newborns, which rarely interfere with micturation and resolves spontaneously by 2-3 years. Prepuce should not be etracted forcibly.

Transitory hydrocele due to persistent processus vaginalis is common in male newborns, presenting as unilateral scrotal enlargement with small fluid-sac and usually resolves spontaneously by 3-4 months.

Vaginal discharge: A whitish, mucoid vaginal discharge is common in female babies during first few days of life, due to the transplacentally transferred maternal estrogen on vaginal mucosa. No treatment is required. (d/d purulent discharge in infections).

Vaginal bleeding: 20-25% female babies develop vaginal bleed on 3-7^th day due to withdrawal of maternal estrogens. It clears spontaneously in 2-3 days, with no specific treatment except local cleaning. (d/d hemorrhagic disease of newborn or other bleeding disorders).

e. Mastitis neonatorum is a misnomer, since it is not an infection but merely indicates breast hypertrophy on 3^rd-4^th day, due to effects of transplacental maternal hormones and disappears in a few days.

f. Common GIT problems include:

Vomiting: Transient vomiting soon after birth may be due to swallowed maternal blood/ amniotic fluid, which may be easily controlled by gastric lavage.

Possetting, i.e. effortless regurgitation of some curdy milk is common in newborns and indicates developmental immaturity of cardiac sphincter in early infancy. It is more common in vigorous babies, during rapid limb movements and soon after feeding.

Aerophagia, i.e. swallowing of air during feeding and overfeeding are two commonest causes of possetting, specially in bottle-fed babies. Adequate burping after each feed is all that is required in these cases. Vomiting associated with bile, blood, abdominal distension or poor weight gain in newborn is pathological and need detailed evaluation.

Diarrhea: Appearance and frequency of stools in normal newborns vary according to the postnatal age and type of feeding, apart from individual variations.

• Meconium, the Initial stools during first 48-72 hours are typically black, thick, viscid and odorless, passed 5-6 times a day. The color and consistency changes gradually to transitional stools.

• Transitional stools, from 3-7th day are relatively watery, greenish, explosive and contain mucus or solid soapy flakes. Stools may be passed ~8-10 times/day, gradually culminating into breast-milk or top-milk stools.

• Breast-milk stools: A breastfed baby passes dark yellow or greenish semi-watery stools, usually 5-6 times a day but frequency may vary from once a week to 10-15 times a day. Although worrisome for parents, this pattern is physiological and must not be construed as diarrhea.

• Top-fed babies tend to be relatively constipated and pass thicker and lighter stools.

• Hyperactive gastro-colic reflex is a common cause of increased stool frequency in newborns and early infancy, characterized by passage of stools soon after feeding.

Pathological diarrhea is more common in top-fed or sick newborns, indicated by sudden increase in frequency and fluidity of stools and needs need careful evaluation. Constipation: Nearly 95% of newborns pass first stools within 24 hours of birth, and failure to do so by 48 hours indicates possibility of intestinal obstruction or ano-rectal malformations. Newborns with higher intestinal atresia,

e. g. duodenal atresia, may pass 1-2 stools initially, before developing absolute constipation and abdominal distension.

Constipation is a common cause of parental concern, though normal variations are common in stool frequency. Top-fed children tend to be more constipated due to high- solute load and relative dehydration. Mild constipation may be overlooked, though significant discomfort may be relieved by glycerine rectal suppository after excluding pathological causes.

Constipation from 2^nd week of life, with/without intermittent attacks of diarrhea suggests a possibility of Hirschsprung disease or hypothyroidism.

Hiccups: Most normal newborns develop hiccups, specially after feeds, due to distension of stomach with diaphragmatic irritation.

g. Dehydration fever: Some healthy newborns may develop transient fever on 2-3rd day of life, specially during summer season due to immature heat-loss mechanisms. Fever rarely exceeds 38.5°C and baby remains active and keen to feed. No treatment is required except adequate feeding and reducing the environmental temperature.

h. Sneezing or noisy breathing is common in newborns, frequently confused with common cold. As newborns are obligate nose-breathers, severe nose block may interfere with feeding, which can be managed with nasal instillation of 1-2 drops normal saline, 10-15 minutes before feeds. Nasal decongestants are contraindicated.

i. Excessive cry: During first 4-6 weeks, babies usually sleep throughout the day and cry at night probably due to in utero pattern.

While duration, intensity and pattern of cry may vary in different newborns, common causes may be— (a) hunger, (b) discomfort, e.g. wet, soiled, too hot, too cold, (c) insect-bites, (d) aerophagia or abdominal colic (e) blocked nose, and even (g) loneliness.

Babies often cry before passing urine due to unpleasant sensation of full bladder. However, crying during (rather than before) micturation may indicate dysuria with possibility of urinary tract infection.

Some unusual neonatal cries include shrill high-pitched cry in kernicterus or cerebral hypoxia; weak, low-pitched cry in hypotonia disorders; intermittent cry in abdominal colic, sudden cry due to insect-bite, etc.

Evening colic is well-recognized entity of unknown etiology, characterized by unexplained sudden crying spells during evenings with flexion of thighs and flushing of face. Each spell lasts for a few minutes to a few hours and continues for many days with consistent regularity and timing before spontaneous disappearance by 2-3 months (Ch.4.1).

12.8