Preparing for Baby
You and your pediatrician will know a great deal of information about your newborn’s health even before he emerges from the womb. With all the cool technology that's out there and because the medical system is fraught with lawsuits, obstetricians will frequently check (and over-check) a baby’s health via sonograms, blood tests, and health screens on mom for things such as Rubella, HIV, Hepatitis B, and Group B strep, to name just a few. Pediatricians also examine the actual birth, noting the length of labor and details such as whether mom had a fever. All this will affect how we view your newborn’s risk of infection and guide our management.
While the first few days with baby are filled with endless joy and utter amazement for parents, it’s the pediatrician’s job to keep an eye out for danger. Newborns can get sick very easily, but it’s also true that most issues can be resolved with minimal intervention.
Your baby’s respiratory rate is much faster than mine or yours. Adults breathe 16 times a minute, and we do it effortlessly unless we are sick or exercising. A baby’s breathing rate is about 50 times a minute, and it’s normal for it to be abnormal! For example, your baby will often breathe a bit faster and deeper, only to relax and then even hold their breath for a few seconds.
So when should you worry? When there is an increased effort, or he is working at breathing. You should not see the ribs pulling in or the nose flaring, and if you know how to check the respiratory rate, it shouldn’t be above 60 times a minute.
Many babies are born with upper airway congestion. It’s not a cold; it’s a shift in hormones such as progesterone. And those noses are just so tiny—any congestion will seem to make your little one suffer. Short of some saline drops and bulb suction, there is not much that you can—or need—to do. Just look for the signs of distress mentioned above, and 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 itself as your baby gets older.
The birth of your baby is a time of utter joy and celebration. Friends, family, and even complete strangers on the street are want to see and even touch your beautiful little one. The problem is that your baby does not yet have a developed immune system. Even if you breastfeed your baby and pass some of your immunity, there are a plethora of illnesses that are just too easy to catch.
Germs are spread either by touch or by respiratory droplets. We are all aware of the need to wash hands thoroughly and frequently. But even if you have clean hands, you can still spread a virus or bacteria by coughing, sneezing or even breathing on a baby.
You will hear slightly different advice from different doctors (and different grandmas), but I think the happy medium would include being extra careful in terms of visitors during the first 2 months. If you have adult family or close friends who want to visit, take a quick medical history first. Are they sick, or even starting to feel sick? Do they have a family member, especially a child at home who is now sick? If an adult is definitely healthy, and promises to wash their hands often and not necessarily kiss the baby near the mouth, then it is ok in my book to have them visit. Anyone who is sick should be kept away from your newborn until they are older.
Hopefully all adults who come near your baby have been immunized against all preventable germs. Most adults have had all the basic childhood vaccines. But the two that adults should ideally have as a booster or reminder when caring for babies are the Pertussis vaccine (Tdap) and the flu shot. What to do if a loved one or nanny just won't get a vaccine? I have to leave it up to you. But as long as an adult is not coughing, and isn't feeling under the weather at all, you can usually assume they are not contagious. And even if they have every vaccine in the world, they can still bring a germ over, as vaccines don't cover all the germs out there. So I'll encourage and empower each family to draw their own lines and choose their own battles as each family needs to make their own decisions when it comes to the health and safety of their newborn.
In terms of choosing your battles, I really would not want any toddlers touching your newborn. Those guys are rarely without a runny nose! They are also notoriously putting their hands in their mouth or noses, so hand-washing becomes “a wash” itself after a minute! Now if there is another baby who comes, that is ok – because they won’t touch your baby. As for those older kids, perhaps 7 or 8 years old, they can usually be trusted to wash their hands and look at the baby, but not necessarily handle him or her.
Now some of you are going to be saying, “C’mon Dr. G – you sound a bit over-protective. You know everyone wants to see my new baby now!” So let me explain where I am coming from.
First of all, it is just not worth seeing your newborn catch even a little cold if you can avoid it. They won’t eat well, and often gag or even throw up when they are congested. They will sleep even worse and cry even more, and they will honestly suffer for 3-7 days even from a common cold.
Furthermore, and perhaps more importantly, your newborn will have very little clinical or behavioral cues to allow us doctors to NOT worry when they are sick. Whereas an older child is more like an adult – and can verbalize and localize their pains – a newborn is going to just act very irritable and even lethargic. On top of that, they respond with a fever quite easily, and any fever in a newborn is an emergency until proven otherwise.
Babies and Fever
Each and every pediatrician will treat the newborn with a true fever the same way. We must assume the worst, and search for signs of infection, especially dangerous bacteria, in the blood, urine and even spinal fluid. Then we must actually admit the baby into the hospital for 2 to 3 days and administer antibiotics through an IV until the cultures prove whether there is a bacterial infection or not. The reason for doctors being so aggressive in our approach to newborns who are sick is in the statistics. Babies who have high fevers can get sick very quickly. With an adult with a serious infection you often have many days to catch and treat an illness. But there have been too many cases (and I have unfortunately seen this) where a baby is critically ill, or even dead in hours as a result of an overwhelming bacterial infection.
So, while the vast majority of fevers are going to be viral colds in origin, and the majority of colds are actually going to pass in a few days even in a newborn, it just isn’t a good thing to have your little one catch a fever. If you are concerned, measure your baby’s temperature using the most accurate method - rectally. You don’t have to check it daily, or really ever – but check it any time they feel warm or are acting sick. Any fever over 100.4, (or 38.0 Celsius) is an immediate trip to emergency room. Call us while you are on the way or when you are there so we can help. Certainly, don’t give Tylenol and wait until the morning.
Past two to three months of age things start to change, and we don’t have to be as aggressive. Now, the immune system is improving and hopefully the first vaccines are on board. Perhaps more importantly, there are now clinical cues appearing in the baby such as how interactive they are, how well they are eating, smiling, sleeping, and even playing.
Taking Baby Outside
In the old days, the above concerns sometimes led to parents waiting inside for a month or two with their newborn. After all, since there are indeed tons of germs outside, that might seem a valid option. But I think once again we need to balance fear with reality (and mom’s sanity) and find that middle road.
Although there are germs and sick people outside, the only way your newborn is going to catch those germs is if people cough on or touch your baby. So as long as you are quick with a stiff arm and strong glance (or loud shout, perhaps even with a bull horn), you should be ok taking your baby for a quick walk after a few days of life. Indeed, we want to see all newborns for a full physical exam on day 3, 4 or 5 at the doctor’s office, so all babies will come out at least once that first week. But it also should be ok to take a quick walk (weather permitting) down the promenade, in the park, or even to get a coffee (decaf please!).
Now when your neighbor or best friend, or absolute random, well-meaning brooklynite starts approaching the stroller you need to start the explanation (you can blame the pediatrician) and prevent anyone coming within five feet. They can look for a moment from far away, but they really can’t come close or touch your baby.
As your child gets older, you’ll likely relax a bit about germs. You’ll still wash their hands often, but the truth is that kids at the playground will share their puffs, goldfish and their germs. You choose your battles and do the best you can. But with those newborns, it’s always best to be over-protective, and to err on the side of caution.
When to travel is a very common question, and there is no easy answer. There is always a pro and a con, a risk and a benefit, and the same principles of germs coming from people apply. The bus or train or even plane themselves don't make a baby sick, but the germs from people in enclosed crowded spaces can. I feel absolutely safe with a four month old, with two sets of vaccines, traveling by plane, but if there is a good enough reason to travel with a younger baby, it may indeed be well worth the small risk of acquiring a germ.
Most infants receive their shots 2,4 and 6 month olds, and each round help to make your baby stronger and more resilient. But more importantly, the older your baby is, the stronger they are, and clinically it is easier to check whether they are happy with a mild cold or low fever, or truly lethargic and fussy with a high fever. You can "read" them better, and can tell easier whether it is just a cold they are battling, or is it something more serious. The newborn is so vulnerable and fragile, and it is difficult to be assured that they are fully happy and acting well, so best to play it safe when they are less than 2 months old. We can always discuss a specific situation in person, but I really empower the families I work with to make those decisions based on my general advice, and the circumstances around travel such as visiting family who can't wait to meet your baby! If your baby ever did get sick after travel, we would work quickly to figure out whether it was a virus, and therefore self-limiting, or is it a scary bacterial germ that needs treatment.
So try to travel - I want you to! But just be careful. There is no wrong or right, and my personality is to really encourage, and even insist that parents make the ultimate decisions. If you ask, “Can we travel?” I will say yes. If you say, “Is it possible our baby will get sick, I will have to say yes. More people, more germs. IF just one visitor comes with a germ, they can make your baby sick. Some will call it the 5 feet rule. If someone is 5 feet away, even if they have a germ, it won’t spread to your baby. They have to cough on, or touch your baby. So if you think someone may be sick, just stay away from them. Travel in a subway, car or plane doesn’t mean your baby will get sick, but just be extra careful when you are around a lot of people.
If you do travel somewhere domestic there will always be somewhere there you can trust for that “just in case” moment, or for that bad cold or fever that may develop. International travel isn’t dangerous, but analyze where you are going and where you would go if your child got sick. That is being extra cautious and being well prepared. I admire families that travel a lot, and I don’t like to set any type of rules for the families that I work with, although some pressure me to give my vote. I can vote on many things, but my personality and my beliefs as a doctor who insists on not being paternalistic is to empower you with the knowledge of the germs that are out there, and how they could spread, but to encourage you as a family to make the best decision. I hope that feels right for you, as I know it sometimes feels as if we should get “the answer” from the pediatrician. I just feel strongly that if there is a right or wrong, I would tell you, but these decisions, although difficult, are best made by parents.
About 80% of babies will experience spit up. Their gastroesophageal junction is very loose, and their stomach is quite small, so a little milk will often make a reappearance. If your baby spits up often, keep her upright for a little while after each feeding (I know that’s easier said than done at 3 a.m.!).
Only when there is a failure to gain weight or significant symptoms, such as crying and back-arching, should treatment be considered. You should also report continuous projectile vomiting, which is a sign of pyloric stenosis, or an upper airway obstruction. This condition requires an emergency visit to your doctor’s office.
I could talk for days about rashes. Most are normal, common, and benign, although names like erythema toxicum (which is completely harmless) sound scary for sure.
Pediatricians are always on the lookout for infectious rashes, such as staph or strep, which are very serious and do require immediate care. Always report any pus or spreading redness, but baby acne, cradle cap, and atopic dermatitis are all easily managed with mild medicines or the tincture of time.