A Child Grows has started something new.…..a monthly column by a Brooklyn pediatrician. I asked Dr. Hugh Gilgoff at LICH if he would be interested in being the
columnist. He happily agreed and I am thrilled to have his
expertise on this blog.

This is his second post. His first one was on Fever.

Dr. Gilgoff is a pediatrician relatively new to the Brooklyn
community.  He has a balanced approach to medicine, combining a western
training at top institutions with an alternative outlook shaped by a
mom who is both a midwife and creator of Mother Nurture Inc. – a Doula
company since 1987.  Dr. Gilgoff worked in Manhattan for 11 years, and
now practices with the LICH group on 185 Montague Street. Dr. Gilgoff
is available for free prenatal consults, second opinions, and is
accepts new patients with all types of insurance plans. To see his
listing information, check the blog here under “Recommended Pediatricians”.

Here, Dr. Gilgoff gives us a detailed summary of what to look for in the first few days after the birth of your new baby. He’ll cover breathing, rashes, spit-up, jaundice and fevers in Part I.  Part 2 will be forthcoming.

Before Baby Comes!
You and your pediatrician will usually know a great deal of information about your newborn’s health even before they emerge from the womb.  As a result of some cool technology and a medical system fearing lawsuits, we often check (read over-check) your baby’s health via sonograms, blood tests and a number of health screens on mom.  We check mom for Rubella, HIV, Hepatitis B, and Group B strep to name just a few.  As pediatricians, we also examine the actual birth, counting the hours of ruptured membranes, and seeing whether mom had a fever.  All this will affect how we view your newborns risk of infection and guide our management. While these first few days are filled with endless joy and utter amazement at the miracle of life, it’s our job to keep a keen eye out for danger.  While most of the issues will resolve with minimal intervention (our goal – as well as yours and your babies as well!), these little guys can get sick quickly – so we must review what to look for.

Breathing.
Is she breathing too fast?
Your baby’s respiratory rate is much faster than yours or mine.  We breathe at 16 times a minute and we never show any effort unless we are sick or exercising.  A baby’s normal breathing rate is about 50 times a minute, and to really make our lives difficult, it is normal for it to be abnormal!  In other words, your baby will often breathe a bit faster, and deeper, only to relax and then even hold their breath for a few seconds on end.  You should worry when there is an increased effort or work of breathing.   You should not see the ribs pulling in or the nose flaring, and if you can check the respiratory rate, it shouldn’t stay above 60 times a minute.

But what about the noises?
Many babies are born with upper airway congestion.  It’s not a cold they caught inside you – but rather a shift in the hormones such as progesterone.  And those noses are just so tiny – so any congestion will seem to make your little one suffer and make noises.  Short of some saline drops and bulb suction, there is not much you can, nor need to do.  Just look for the signs of distress, as mentioned above – but don’t stress the snoring!
Some babies also squeak a lot.  This is usually normal, and relates to “floppy cartilage” in the breathing tubes – also called laryngomalacia.   This will resolve as your baby gets older.

Spit up
About 80% of babies have some spit up, and officially this is a type of reflux.  The gastro-esophageal junction is just very loose, and their stomachs are quite small – so a little milk will often return to you as a present.  If your baby spits up often, try to keep them upright after a feed (I know – impossible at that 3am feed!).  Only when there is a failure to gain weight or significant symptoms (such as crying and arching) will treatment be considered.  What we don’t want to see is continuous projectile emesis – a sign of pyloric stenosis, or an upper airway obstruction.  This would mean an urgent trip to your doc.

Rashes
We could talk for days about rashes.  Most are normal, common and benign – although some harmless ones, such as erythema toxicum sound scary for sure.  We are always on the lookout for infectious rashes, such as staph or strep, and unfortunately these are definite emergencies.  So stay on the look out for pus or spreading redness.  But baby acne, cradle cap and atopic dermatitis are all easily managed with mild medicines, or tincture of time.

Jaundice
A wonderful midwife once asked me how I felt about jaundice. Of course, what she meant was how much of an interventionalist I was and how patient I was willing to be. The vast majority of jaundice is normal, or physiologic.  The immature liver and some normal low levels of red blood cell breakdown lead to an increase in bilirubin – and this yellowness of the skin is called Jaundice. While the lower levels of Jaundice (usually anything less than 20) are really harmless, the higher levels (definitely more than 25) can be damaging to the nervous system.  It’s the avoidance of this rare condition called kernicterus that lead to a lot of doctors recommending special lights and rarely the supplementation of formula to a breastfed baby.
The decision making actually involves some complex factors – such as gestational age, blood types of mom and baby, and the rate of rise coupled with the age of the baby down to the hour. As with most issues in your newborn’s health – finding that pediatrician who is an expert in newborn care AND can balance the small but real risk of pathology with the risks of intervention (the bili lights can affect the eyes and interfere with breastfeeding and bonding) is the key.

Fevers
As we mentioned in the last article – fever in an older child by itself is rarely an emergency.  Well that is NOT true with a newborn.  While it is true that most fevers are still caused by viruses that can be contained by the immune system, the risk of a bacteria is just too great.  Bacteria that are normal for a woman to harbor (such as E. Coli and Group B Strep) can be deadly for a baby.  In most scientific studies a dangerous fever is at or above 100.4 Fahrenheit, or 38.0 Celsius.  If your baby is less than 60-90 days old, this means an emergent trip to the ER and not a dose of Tylenol and call us in the morning.
How to avoid fevers?
As mellow as you once were, having a newborn gives you a license to be anal, neurotic (and sleep deprived, but that’s another story!).  The hygiene hypothesis debates the value of exposure to germs, to build our defenses.  That’s an interesting idea – but NOT for a newborn!  Everyone must wash their hands or just refrain from touching and kissing the baby, and that includes your doctor, your partner, and that random stranger on the street who will try to touch your baby!
You CAN go outside with your baby, but not to a one year olds birthday party, and not to the mall.  If mommy gets sick, what should you do?  Breastfeed often and love your baby.  It’s just not realistic to separate mom from baby.  But if your best friend’s two year old has a runny nose, it’s just not worth it to see them this week.  After the third month, your baby’s immune system is much stronger, and specifically able to localize an infection.  But these first two to three months are an intense mix of the most joyous, and nerve-wracking experiences.  Please remember, that your pediatrician is there for you during these times – and there is no such thing as a dumb or bad question.  We have 24 hour on call systems and walk in visits daily exactly for these reasons – to help care for you and your newborn.

Look out for Part II as Dr.Gilgoff explains colic, nutrition, and sleep.

(PHOTO: Willow and I at the Critical Care Unit at NY Presbyterian.  We were next to a bili machine so that is why the light is so blue).

Related Posts:

1. Germs, visitors and going outside with new babies (February 25th, 2010)
2. Dr. Gilgoff (January 19th, 2009)
3. Vaccines- Thoughts from Dr. Gilgoff (January 12th, 2009)
4. Colic and Nutrition for Your Baby from Dr. Gilgoff (December 5th, 2008)
5. Carters, Baby Gap and Circo labels causing skin rash and burn (November 7th, 2008)