The First 3 months

My Version of “The Truth”

Michael Dick MD, FAAP

 Much that happens during the first 3 months of life has to do with the liver.   Inside mom, blood flows through the liver on the way to the baby’s heart.  The liver’s blood supply changes drastically during the first few hours after birth.   This matters to new parents because the hormones that normally peak @ the end of pregnancy can not be “chewed up” by the liver.  This normal accumulation of hormones can cause:

a) a gradual increase in irritability that peaks around 6 weeks and gradually resolves by 3 months
b) temporary breast development
c) vaginal drainage
d) loose joints, especially the hips
e) many rashes: including but not limited to: neonatal acne, erythema toxicum (looks like a herpes vesicle on a red streak) etc.
These symptoms tend to peak @ 6 weeks and gradually subside by 3 months.

Your baby’s head may be asymmetrical and this tends to resolve by 3 – 4 days.  There are two soft spots (or fontanels) on the top of the head that requires no particular care or concern.  A flakey rash that can be yellow and looks dry may be present around 3 weeks.  This is commonly called “cradle cap” and the natural inclination is to treat this with baby oil.  Actually oil can make this condition worse.  Debridement with a soft brush and baby shampoo is preferable.  Rarely more aggressive treatment is required and it is usually advisable to contact your physician for guidance.

Vision is poorly developed in the neonate.  Color vision is basically absent.  When buying toys keep in mind red and yellow vision develops first and sharp contrasts are necessary.  Tear ducts are easily blocked and cause unsightly dried secretions.  Massage with a warm washcloth of the midline portion of the eye is usually all that is necessary.

Hearing is very well developed in the newborn.  It is an important source of comfort.  Your baby will appreciate and recognize voices and noises that were around her/his pregnant mother and home. Be persistent with a soft voice and you will be impressed with the results.

Breathing is anxiety provoking in the newborn and his/her parents.  One of the few guarantees in pediatrics is that your baby will scare you with his/her breathing.  Choking, sneezing, gagging and breath holding as long as 15-20 seconds are all normal activities.
The nose is very easily obstructed and it is difficult to provide medication that will clear it until late in the first year.

Putting your infant “back to sleep” is very important.  Your child should be laid on his back or side until 4-6 months when he/she can turn over on his/her own. There is undeniable statistical evidence that this reduces “crib death”.  This is an extremely rare and poorly understood cause of death in the newborn period.

Saline nasal irrigation is an important way to keep the airway open: The child is placed face up in the parent’s lap and the head is positioned below the level of the rest of the body.  A commercial (or homemade - 3tsp / cup water) salt water preparation is instilled drop by drop into one side of the nose and then the nares is “pumped”.  A bulb aspirator is used to removed the saline and mucous. The process is the repeated on the other side.  (Your baby will not appreciate this.)
 

The oral cavity can have small white spot on the top called Epstein’s Pearles, of no consequence whatsoever.  Newborns are susceptible yeast infections.  Lacey white plaques on the sides of the mouth can be a yeast infection called thrush.  This is painful and easily treated. The tongue can be normally coated.  Teeth usually erupt around 5 months but this is highly variable.
 

Emesis (spitting, throwing up etc.) is a normal part of newborn life. The tube that connects the oral cavity to the stomach is called the esophagus. (Gastro- is latin for stomach.)  The inlet to the stomach (on the left side) is called the lower esophageal sphincter. The outlet is called the pylorus (on the right side). A lower esophageal sphincter that is tool loose or a pylorus that is too tight can cause GERD (gastroesopgageal reflux disease). Most children have some degree of reflux (backward flow) from the stomach into the esophagus.  Some children can have occult reflux – it can cause symptoms without actually becoming evident externally. Reflux can be a serious “laundry problem” or GERD.
 Reflux becomes GERD if there is problem with growing, breathing, sleeping or pain (ie colic?).

Breast-feeding is the best form of nutrition for several reasons:
a) this is an important way immunity is passed from mother to child (peaks about 4 months)
b) hormones are present that help with growth and gut motility (important for reasons that will be evident below)
c) bonding that may have some important effect on intellectual and emotional development
There is no reason almost all infants should not be given a trial of breast-feeding!  Lactation consultants are available to help with this adaptation and encouraged.

Recommended Formulas:
 

 
Nutrition during the first 4-6 months drives an important stage of brain growth.  There is no reason to use “discount formulas” during this time.  Gerber, Carnation, Generic or Store-brand formula does NOT save money in the long run. A large percentage of lactose intolerant babies will not tolerate soy formulas either.  Formula intolerance usually rears it’s head as presents as diarrhea and gas – spitting is rare.

Constipation will almost certainly happen to any baby, usually around 3-6 weeks.  At that time you may need to start fruit juice (white grape and apple are preferred since they don’t stain clothes when spitting occurs) – usually ½ ounce of dilute juice twice / day.  Glycerin suppositories (1/4 or a “chip”) are safe to use frequently during the first few months (despite the dire warnings on the packaging!) Honey and Kayro (corn) syrup work well - but in rare cases cause botulism.

Umbilical drainage can be bloody, clear and the stump itself can produce a putrid smell.  Concern is raised if the abdominal wall itself become red and swollen.  The stump “falls off” between 3 days to a month.

Blood in the diaper can come from several sources:
a) most commonly hard stools can rip the rectal mucosa causing fissures and linear red streaks
b) baby kidneys can excrete urate crystals which are pink
c) normal vaginal secretions can be blood tinged
d) bloody drainage from the umbilical stump
e) bleeding from the circumcsion

Circumcision is the surgical removal of the sleeve of skin and mucosal tissue that normally covers the glans (head) of the penis. This double layer, sometimes called the prepuce, is more commonly known as the foreskin.

a) can be done 3 ways: I use the gomco apparatus which covers the head of the penis while clamping the foreskin so it can be cut off
b) "The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns."  "When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors." Canadian Medical Association Journal, March 15, 1996; 154 (6)
c) local anesthesia is used by myself on all circs

Several anatomical conditions exist that are worth mentioning
a) all babies are born bowlegged from intrauterine positioning – this is corrected by gravity remodeling the bones between 9 – 15 months
b) the feet may be slightly deformed for similar reasons, clubfoot is uncommon
c) umbilical hernias usually resolve spontaneously, if surgically repaired it is after the child is several years old
d) a bulge in the midline above the umbilicus may be present (ventral diastasis rectii)
 

Skin conditions of no concern:
a) Nevus flammus – a nonraised red birthmark between the eyes
b) Stork Bite – a similar lesion of the nape of the neck
c) Mongolian spots – bruise colored spots, usually on the buttocks of Blacks, Oriental and Mediterranean extraction
d) Strawberry hemangiomas – red raised birthmarks that look worse than they are

Fever
One adds approximately a degree to any axillary (armpit) temperature and subtracts approximately a degree to any rectal temperature.  Ear thermometers are not reliable until the 2nd half of the 1st year.
Any temperature greater than 100⁵ should prompt one to contact a physician until your baby is 6 – 8 weeks old.

Saftey
Infants tend to aquire motor skills abruptly.  They are literally "moving targets" in their motor development.  It is easy to get complacent about their abilities and end up with a fall.  Additionally a safe maximum temperature for the water heater to be set is 120⁰. Most homes and apartment are warmer than this and should be turned down until the infant is at least 9 months.

Sleep
Initially infants do not have regular sleeping patterns or are reversed (party all night, sleep all day).  They can sleep 22 hours / day.  “Sleeping through the night” formerly was defined as sleeping 6 continuous hours @ 6 weeks.  This is rarely achieved, especially in breast feeding moms whose infants tend to feed more often.
Sleep is influenced by light, feeding and social interaction.  Nighttime feedings should be business like and daytime feedings more stimulating.

Postpartum Depression
This is an extremely common condition and is not to be taken lightly. You can not take care of the baby if you can not take care of yourself. There is a limit to what any human can do.  Reasonable expectations, respite care and early referral to a mental health professional are always encouraged.
If you are not having fun, something is wrong……………….