10 common neonatal concerns that have non-threatening explanations
One steady source of business in the emergency department comes from a group described as the “worried well.” Anxious new parents are frequent members of this tribe and come into the ED at all hours to point out perceived abnormalities or areas of concern in their little ones. To be fair, neonates can be more than a little mysterious, and even emergency physicians can pick up on odd physicial findings and begin to worry unnecessarily. To assist in your care of the “worried well,” here is a list of ten findings that can be normal in infants:
Cutis marmorata – this is the elegant Latin term for that lattice-like mottling that infants can get due to vasomotor instability. While mottling can be pathologic, it is seen in normal infants with cooling, starting in the newborn period and persisting for several months. If the baby looks well otherwise, warm them up and then come back and re-examine them. It should resolve.
Acrocyanosis – blue hands and feet, also due to vasomotor instability and also generally benign. It is usually seen when the baby gets cold and can be dramatic after they are pulled out of the bathtub. It may be seen in the first few months of life. If the baby has pink lips and tongue, it is not concerning and should disappear with warming.
Peri-oral cyanosis – the parent will come in and report that the baby turned blue around the mouth. You may even witness this yourself in the exam room. If the lips and tongue remain pink while the area around the mouth turns blue, this is fine. It is due to engorgement of a venous plexus around the mouth and is normal.
Harlequin color change – this one is dramatic. It is uncommon and is not due to disease in the heart or the vessels. The neonate appears to be divided down the middle into a pale half and a red half starting at the forehead and going to the pubis. It is due to vasomotor instability and is normal in the newborn period. Sometimes, if you lay them on the pale side, the color change will shift and the dependent side will get red and the other side will get pale.
Breast enlargement – this can occur on both male and female infants. It is due to stimulation from maternal estrogen in utero. It can persist for several months after birth. Sometimes, the breasts become engorged and drain a white liquid known as “witches milk”. This is not pathologic and will go away after 1-2 weeks.
Vaginal discharge – female infants can have a milky vaginal discharge in the first few weeks of life that can even be blood-tinged. This is from exposure to high levels of maternal estrogen prior to birth and is normal.
Hyperpigmented genitalia – this can occur in both male and female infants. It is also due to maternal estrogen effect and will fade during the first year of life.
Myoclonus – course trembling of the jaw, arms, and ankles can occur in the neonatal period, usually during a period when the infant is active. It does not persist. Twitching due to a convulsion is more likely to happen when the infant is in a resting state and may last longer.
Palpable liver – the liver edge is frequently felt in normal newborns. It can be normal up to 2 cm below the costal margin.
Palpable spleen – a spleen tip can also be felt occasionally in normal newborns.
Amy Levine, MD, is an associate professor of pediatric emergency medicine at UNC Chapel Hill.