The Normal Newborn's
Appearance and Behavior

Even after we assure you that your baby is normal, your baby does not have the perfect body you have seen in baby books. Be patient. Most newborns have some unusual characteristics. Fortunately they are temporary. Your baby will begin to look "normal" by one to two weeks of age. A few minor congenital defects that are harmless but permanent are also included. Call our office if you have questions about your baby’s appearance that this list does not address.

Head

Molding: Molding refers to the long narrow head that results from passage through a tight birth canal. This compression of the head can temporarily hide the fontanel or soft spot. The head returns to a normal shape in a few days.

Caput: This refers to swelling on top of the head or throughout the scalp due to fluid squeezed into the scalp during the birth process. The caput is present at birth and clears in a few days.

Cephalohematoma: This is a collection of blood on the outer surface of the skull. It is due to friction between the infant’s skull and the mother’s pelvic bones during the birth process. The lump is usually on one side of the head. It appears on the second day of life and may grow larger for up to fie days. In some cases it doesn’t resolve until the baby is two or three months of age.

Anterior fontanel: The soft spot is found on the top front part of the skull. It is diamond-shaped and covered by a thick fibrous layer. The purpose of the soft spot is to allow rapid growth of the brain. The spot will normally pulsate with each beat of the heart. It normally closes with bone when the baby is between nine and 18 months of age. Occasionally, we see the soft spot remain open for longer periods. It is very tough and can stand the rigors of washing. Be sure to wash this part of the head the same as all other parts.

Swollen eyelids: The eyes may be puffy because of the increased pressure on the face during delivery. They may also be puffy and reddened because of medicaton used in the eyes after the birth. This irritation should clear in three days.

Subconjunctival hemorrhage: A flame-shaped hemorrhage on the white of the eye (sclera) is common. It’s harmless and is due to pressure during the delivery. The blood is reabsorbed in two to three weeks. It leaves no lasting problems.

Iris color: The iris is usually blue, green, gray, or brown, or a variation of these colors. The permanent color of the iris is often uncertain until your baby reaches six months of age. White babies are usually born with blue-gray eyes. Black babies are usually born with brown-gray eyes. Children who will have dark irises often change eye color by two months of age; children who will have light-colored irises usually change by five or six months of age.

Blocked Tear Duct: If your baby’s eye waters continuously, they may have a blocked tear duct. This means the channel that normally carries tears from the eye to the nose is blocked. It is a common condition, and more than 99% of blocked tear ducts opens up by nine to 15 months of age. This is a common condition, affecting 6% of newborns. If the obstruction persists beyond 15 months of age, an ophthalmologist probes it open.

The main treatment for blocked tear ducts is gentle massage. Always wash your hands carefully before doing this. A little sac where tears accumulate is located in the inner lower corner of the eye. Start at the inner corner of the eye and press upward, using a cotton swab. This sac should be massaged three times a day in an attempt to force out the fluid. We can show you how to do this during one of your routine visits. In most children a plug of cells and mucus blocks the tear duct, and the massaging process can release it. If the white part of the eye becomes red, call us when the office is open and we can perscribe antibiotic drops.

Folded Over Ears: The ears of newborns are commonly soft and floppy. Sometimes one of the edges is folded over. The outer ear will assume normal shape as the cartilage hardens over the first few weeks.

Ear Pits: About 1% of normal children have a small pit or dimple in front of the outer ear. This minor congenital defect is not important unless it becomes repeatedly infected.

Flattened Nose: The nose can become misshaped during the birth process. It may be flattened or pushed to one side. It will look normal by one week of age.

Sucking Callus on the Mouth (or blister): A sucking callus occurs in the center of the upper lip from constant friction at this point during bottle or breastfeeding. It will disappear when your baby begins cup feeding. A sucking callus on the thumb or wrist may also develop.

Tongue-tie: The normal tongue in newborns has a short tight band that connects it to the floor of the mouth. This band normally stretches with time, movement and growth. Therefore, you should leave it alone. Babies with symptoms from tongue-tie are rare.

Epithelial Pearls: Little cysts containing clear fluid or shallow white ulcers can occur along the gum line or on the hard palate. These are a result of blockage of normal mucous glands. They disappear between one to two months.

Teeth: The presence of a tooth at birth is rare. Approximately 10% of these are extra teeth without a root structure. The other 90% are prematurely erupted normal teeth. A dentist can remove the extra teeth. The normal teeth need to be removed only if they become loose (with a danger of choking) or if they cause sores on your baby’s tongue.

Body

Breast Engorgement: Swollen breasts are present during the first week of life in many babies. They are caused by the passage of female hormones across the mother’s placenta. Breasts are generally swollen for four to six months, but they may stay swollen longer in breastfed and female babies. One breast may lose its swelling before the other one by a month or more. Never squeeze the breast because this can cause infection. Be sure to call our office if a swollen breast develops any redness, streaking, or tenderness.

Swollen Labia on girls: The labia minora can be quite swollen in newborn girls because of the passage of female hormones across the placenta. The swelling resolves in two to four weeks.

Hymenal tags: The hymen can be swollen due to maternal estrogen and have smooth ½-inch projections of pink tissue. This normal tag occurs in 10% of newborn girls and slowly shrinks over two to four weeks.

Vaginal discharge: As the maternal hormones decline in the baby’s blood, a clear or white discharge can flow from the vagina during the latter part of the first week of life. Occasionally, the discharge will become pink or blood-tinged (false menstruation). This normal discharge should not recur once it stops.

Hydrocele in boys: The newborn scrotum fills with clear fluid. The fluid is squeezed into the scrotum during the birth process. This painless collection of clear fluid is called a hydrocele. It is common in newborn males. A hydrocele should clear by 12 months. It is harmless and is rechecked during regular visits. If the swelling frequently changes size, a hernia may also be present. Call during office hours to discuss it.

Undescended Testicle: The testicle is not in the scrotum in about 4% of full-term newborn boys. Many gradually descend into the normal position during the following months. In one yearold boys only 0.7% of all testicles are undescended and need to be brought down surgically.

Tight Foreskin: Most uncircumcised infant boys have a tight foreskin that doesn’t allow you to see the head of the penis. It is not necessary to retract the foreskin. During teenage years, the foreskin will normally retract.

Erections: Erections occur commonly in boys. A full bladder usually triggers them. Erections demonstrate that the nerves to the penis are normal.

Gas: All babies are gassy. The more they eat the more gas they have. One of the most common complaints is that of the baby who constantly passes gas. Usually the gas comes after a feeding. The baby will bend their knees and pull them up, move around a lot, push off of you and arch their back while trying to pass the gas. This gas is caused by the action of normal intestinal bacteria on the milk in the digestive system. Gas is a good sign in the newborn. It occurs when they are feeding well.

Umbilical Hernias: Commonly called an "Outie", the belly button occasionally sticks out in the newborn infant. This tends to run in families. Usually the umbilical hernia will go down during two to three years of age. Do nothing for them. Do not put "belly binders" on them and do not put tape on them to keep them from protruding.

Bones and Joints

Tight Hips: During your well visit exam we will test how far your child’s legs can be spread apart to be certain the hips are not too tight. As long as the upper legs can be bent outward, and are even on both sides, they are fine. The most common cause of a tight hip is a dislocation.

Tibial Torsion: The lower legs (tibia) normally curve inward because of the cross-legged posture your baby was confined to while in the womb. If you stand your baby up, you will also notice that the legs are bowed. Both of these curves are normal and will straighten out after your child has been walking for six to 12 months. Tibial torsion tends to straighten out even up until seven years of age.

Feet turned up, in, or out: Feet may be turned in any direction inside the cramped quarters of the womb. They are normal as long as your child’s feet are flexible and can be easily moved to a normal position. The direction of the feet will become more normal between six and 12 months of age. We will show you how to massage them during a routine office visits.

Long Second Toe: The second toe is longer than the great toe as a result of heredity in some ethnic groups that originated along the Mediterranean, especially Egyptians. However, it is occasionally seen in all ethnic groups.

“Ingrown” Toenails: Many newborns have soft nails that easily bend and curve. However, they are not truly ingrown because they don’t curve into the flesh. When you look at them they appear as if they were ingrown. Often one of the toes will have a red area around the side of the toe. You can gently lift the toenail out of this area and use warm compresses to decrease the redness. As your baby grows older, be sure to cut the toenails straight across.

Skin and Hair

Scalp Hair: The first hair you baby has may be temporary and begins to shed by one month of age. It is usually dark-colored. Some babies lose it gradually while the permanent hair is coming in; others lose it rapidly and temporarily become bald. The permanent hair will appear by six months. It may be an entirely different color from the newborn hair.

Body Hair (lanugo): Lanugo is fine downy hair that is sometimes present on the back and shoulders. It is more common in premature infants. It is rubbed off with normal friction by four weeks of age.

Acne of Newborn: Around two to four weeks of age, small red bumps appear on the cheeks and face, some may spread to the scalp, chest and back. This occurs due to the transference of maternal hormones. It usually resolves spontaneously and can last until four to six months of age. Areas may appear red with crying or after sleeping. They cause the baby no discomfort. You can use mild soap to wash the areas. This will not speed up the disappearance of the rash. No treatment is necessary.

Drooling rash: Most babies have a rash on the chin or cheeks. This is due to drooling or contact with food and acid that has been spit up from the stomach. Rinsing the face with water after feeding can help.

Erythema toxicum: More than 50% of babies get a rash called erythema toxicum on the second or third day of life. The rash is composed of 1/4– to 1/2–inch size red blotches with a small white lump in the center. They look like insect bites. They can be numerous and can occur anywhere on the body surface. Their cause is unknown, but they begin to resolve themselves by two weeks of age.

Vacuum Extraction: On occasion a vacuum extraction is used to deliver babies. This can leave a circular blue-reddish mark on the scalp. The vacuum extractor will leave a soft fluid filled purple area on the scalp. Leave it alone and it will disappear in about three days.

Milia: Milia are tiny white bumps that occur on the faces of 40% of newborn babies. The nose and cheeks are most often involved, but can also be seen on the forehead and chin. Although they look like pimples, they are not infected. They are blocked-off skin pores and will open up and disappear by one to two months of age. No ointments or creams should be applied to them. Washing them is the best way to make them disappear. Use mild baby soap and a washcloth. Gentle scrubbing will break them up.

Heat Rash (Miliaria): Fine, pinpoint, pink bumps may appear on the neck, chest and upper back if your baby is too warm or overdressed. This is also called prickly heat. Your baby is comfortable dressed in the same or just one more layer than you are. Let your baby’s face tell you what to do. If your baby’s cheeks are too red, remove a layer of clothing. Feel your baby’s chest or back. Since hands and feet are often naturally cool, they are not a good indicator of your baby’s comfort level.

Mongolian spots: Mongolian spots are bluish-green or bluish-gray flat birthmarks found in more than 90% of Native American, Asian, Hispanic, and black babies. They occur most commonly over the back and buttocks or can be present on any part of the body. They vary greatly in size and shape. Most fade away by two or three years of age, although a small amount may persist into adult life.

Stork bites (pink birthmarks): Flat pink birthmarks (also called capillary hemangiomas) occur over the bridge of the nose, the eyelids, or the back of the neck in more than 50% of newborns. The birthmarks on the bridge of the nose and eyelids clear completely by two years of age. Most birthmarks on the nape of the neck also clear, but 25% can persist into adult life.

Strawberry Hemangiomas: Bright red-raised birthmarks develop after the birth of the baby during the first two months of age. They are more frequent on fair skinned babies and may be located anywhere on the body. You see them on the head and in many cases on the face. They grow rapidly during the first year then slowly shrinks down. Most will resolve in early childhood. Leave them alone.

Behavior

Some findings in newborns that concern parents are not signs of illness. Most of these harmless reflexes are due to an immature nervous system and will disappear in two or three months:

Chin trembling
Lower lip quivering
Hiccups
Irregular breathing (normally, if your baby is content, the rate is less than 60 breaths per minute, a pause is less than six seconds, and your baby doesn’t turn blue)
Passing gas (not a temporary behavior)
Sleep noise from breathing and moving
Sneezing
Spitting up or belching
Startle reflex (also called the Moro or Embrace reflex) following noise or movement
Straining with bowel movements
Throat clearing (or gurgling sounds)
Trembling of arms and legs during crying. (Note: Jittery babies are common. Convulsions are rare. During convulsions babies jerk, blink their eyes, rhythmically suck with their mouths, and don’t cry.)
Yawning

Adapted from B.D. Schmitt, M.D., author of “Your Child’s Health,” Bantam Books.

Provided as a service to medicine by Wyeth Pediatrics,

Makers of SMA* and Nursoy* infant formulas

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