24.2 Care of Common Problems in the Newborn

Care of the Newborn with Hyperbilirubinemia

Many normal and healthy babies develop jaundice, or hyperbilirubinemia, which is an increase in the concentration of bilirubin in the serum, the amber-colored, protein-rich liquid that separates out when blood coagulates. With jaundice, the skin and sclera of the eyes of the newborn may appear noticeably yellow due to the breakdown of fetal red blood cells. Mild jaundice is harmless. However, if the bilirubin level continues to rise and is not treated, it can lead to kernicterus, a type of brain injury. Jaundice tends to be more common in breast-feeding infants, particularly in those that are not feeding well. Therefore, breast-feeding parents should nurse their newborns at least 8 to 12 times per day (or every 2 to 3 hours), which will help produce enough milk and keep bilirubin levels low.

Pathophysiology of Neonatal Jaundice

The primary source of bilirubin is the breakdown of hemoglobin, leading to the formation of unconjugated bilirubin and related substances. Unconjugated bilirubin then binds to albumin in the bloodstream to facilitate its journey to the liver. Once in the liver, hepatocytes take up bilirubin and, through the action of the enzyme uridine diphosphogluconurate glucuronosyltransferase (UGT), conjugate it with glucuronic acid, making it water-soluble.

Due to the common occurrence of temporary jaundice in healthy infants, hyperbilirubinemia can be classified as either physiologic or pathologic. It can also be classified based on whether the hyperbilirubinemia is unconjugated, conjugated, or a combination. Additionally, classification by the underlying mechanism is another method. Most cases of neonatal jaundice involve unconjugated hyperbilirubinemia. Among the most common factors contributing to neonatal jaundice are physiologic hyperbilirubinemia, breast-feeding–related jaundice, breast milk–induced jaundice, and pathologic hyperbilirubinemia associated with hemolytic diseases. Dysfunction or disease of the liver may result in conjugated or mixed hyperbilirubinemia (e.g., parenteral alimentation causing cholestasis, neonatal sepsis, neonatal hepatitis) (Dysart, 2022).

Jaundice first appears on the face, then the chest and abdomen, and finally the arms and legs in some instances. The whites of the infant’s eyes may also turn yellow. At the present time, most newborns are routinely screened for jaundice in the skin 24 hours before leaving the hospital, using a painless handheld light meter called a transcutaneous bilirubin (TCB) monitor. If jaundice is suspected in the newborn based on skin color, age, and other factors, the pediatrician may order a blood test to make an accurate diagnosis. If parents notice a sudden increase in jaundice once they are home, they should call their health-care provider. The specific blood tests that may be ordered are as follows: (Cedars Sinai, 2023)

• Direct and indirect bilirubin levels—This test will show if bilirubin is bound with other substances by the infant’s liver. The level of indirect bilirubin is increased in normal physiologic jaundice. High levels of either type of bilirubin are seen with jaundice caused by more serious problems.
• Red blood cell counts—This test is important because jaundice occurs as a result of the breakdown of fetal RBCs.
• Blood type and testing for Rh incompatibility (the Coombs test or direct antiglobulin test [DAT])

One major differentiating factor between the four types of newborn jaundice is the timing of when the jaundice first starts. Treatment will depend on the degree of jaundice, the bilirubin level, and the age and weight of the infant (Cedars Sinai, 2023; Kemper et al., 2022).

• Jaundice that develops after the first 24 hours of life in term infants is called developmental jaundice or physiologic jaundice. It is considered normal. The bilirubin peaks between the 2nd and 4th days of life and falls to normal levels by 57 days. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL (Cedars Sinai, 2023).
• Jaundice that develops in the first 24 hours of life is called pathologic jaundice or nonphysiologic jaundice. When bilirubin rises higher than expected or remains elevated longer than expected, earlier treatment is needed to prevent severe hyperbilirubinemia. Abnormalities that cause excessive destruction of RBCs or problems in bilirubin conjugation result in nonphysiologic jaundice (Cedars Sinai, 2023; Kemper et al., 2022). These can include incompatibilities between the birthing parent’s and infant’s blood types, metabolic disorders, and infections. Phototherapy is often the treatment for nonphysiologic jaundice (Figure 24.11.)
• Jaundice that develops in breast-fed infants within the first week after birth is called breast-feeding jaundice or early-onset jaundice. It involves bilirubin levels of >12 mg/dL and develops in 13 percent of breast-fed infants by 1 week of life (Kemper et al., 2022). The most common cause of jaundice this early in breast-fed infants is insufficient milk intake, dehydration, or low caloric intake. Serum bilirubin may reach dangerous levels if intake is not increased. An increase in enterohepatic circulation may also result from reduced bacteria in the intestine that act to convert bilirubin to nonresorbed metabolites (Dysart, 2022). Babies who are sleepy, have a poor suck, or nurse infrequently do not get sufficient colostrum. Colostrum has a normal laxative effect in eliminating bilirubin-rich meconium. When meconium is not eliminated, bilirubin may be deconjugated in the intestine, absorbed, and recirculated to the liver for conjugation again. Lack of suckling decreases production of breast milk and further increases the problem.
• Jaundice that occurs after the first 5 to 7 days of life and lasts 3 weeks to as long as 3 months, peaking at about 2 weeks of age for some infants is considered true breast milk jaundice or late-onset breast milk jaundice. Bilirubin usually peaks at levels of 5 to 10 mg/dL and gradually decreases over several months, but for some infants, levels get as high as 20 to 30 mg/dL. Although the exact cause is unknown, true breast milk jaundice is thought to be caused by an increased concentration of beta-glucuronidase in the breast milk, which causes an increase in the deconjugation and reabsorption of bilirubin (Dysart, 2022). Infants show no signs of illness. Treatment consists of 8 to 12 feedings per 24 hours. If levels of bilirubin become too high, phototherapy may begin while the nursing parent continues to breast-feed. Interruption of breast-feeding is not usually recommended (Cedars Sinai, 2023; Kemper et al., 2022). This type of jaundice generally resolves without further morbidity concerns.

Nursing Care Plan for the Jaundiced Newborn

Subjective data may come from the parents who may report or the nurse who may observe that the newborn is having difficulty with breast-feeding or is not taking the bottle well. The problem may be infant fussiness related to feedings or lethargy and difficulty in waking to feed. The problem could be an issue with latch or positioning or with suck and swallow. To accurately assess what is happening, the nurse must become more involved with feedings in general. A loss of color in the stool also warrants investigation.

When assessing the infant in daylight, the nurse will most likely observe yellowing of the skin all over the body and in the sclera of the eyes. In newborns with dark skin, yellowing may not be visible, so jaundice should be confirmed with TCB (Ansong-Assoku, et al., 2023). Weight loss will be greater than expected (>10 percent). The infant will be difficult to awaken and, when awake, will be very fussy with a high-pitched cry.

The nurse assesses the infant’s skin for abnormalities, noting the color (yellowing) of skin or eyes. When determining yellowing of the skin, the nurse lightly presses on the skin of the baby’s forehead. If the skin looks yellow where pressed, the baby is likely jaundiced.

When assessing the infant for neurologic involvement, the nurse should keep in mind expected infant development. Infants experiencing hyperbilirubinemia are likely to be very fussy when awake and difficult to arouse when asleep. Consequently, many parents inadvertently delay waking their babies to feed them. More advanced stages of neurologic sequelae include hyperreflexia (twitching, overexcitability, sensitive reflexes, and convulsions). Symptoms can also include a high-pitched cry. An infant’s change in feeding patterns is neurologically significant as well.

Obtaining a good history, including a review of the pregnancy and delivery, may show a stressful delivery. When assistive devices such as vacuum or forceps have been used, they can increase infant trauma and, therefore, the risk of neonatal jaundice. The nurse is aware of high-risk disorders or diseases that may affect the infant (i.e., spleen or liver disease or hypothyroidism). As part of the physical assessment of the newborn, the nurse should obtain serum or transcutaneous bilirubin (TCB) values. TCB is preferred because of the noninvasive nature of the test. Any level greater than 12 mg/dL usually requires treatment, and the nurse should follow the provider’s orders and hospital policy and protocol. If a serum bilirubin level is required, it is usually obtained by heel stick, per facility protocol. If the newborn is breast-feeding, the nurse should observe and offer assistance to improve latch, suck, and swallow. The nurse will encourage frequent feedings, every 2 hours, and may suggest that the parent supplement with formula as appropriate/or needed.

Jaundice may be present if infants are having difficulty with breast-feeding, are dehydrated, or are taking in insufficient calories. Frequent feedings promote good hydration of the infant and help to boost the milk supply in the nursing parent. If breast milk is insufficient, even temporarily, infants may require additional calories and nutrients from formula.

The nurse initiates phototherapy per facility protocol and health-care provider order. The newborn is placed under the bili lights in an incubator or thermoregulated environment or in an open crib wrapped in a bili blanket. Phototherapy helps improve the solubility of bilirubin for faster secretion through the stool and urine. This is a noninvasive treatment. The infant wears only a diaper, covering the genital area, and eye patches covering their eyes to allow maximum skin exposure to the phototherapy lights while protecting the genitals and eyes. The nurse assesses the skin and eyes every 2 hours when the infant comes out from under the lights for feeding. The nurse also monitors the infant’s temperature for elevations or fever every 2 hours while phototherapy continues. Phototherapy can elevate an infant’s body temperature to dangerous levels. Therefore, close monitoring of temperature is necessary during treatment. Additionally, the nurse notes any signs of infection or sepsis.

Hyperbilirubinemia related to Rh incompatibility with the birthing person or severe anemia may require a blood transfusion. As for medication, the infant may require the administration of acetaminophen for fever or may be given phenobarbital, which acts to stimulate the liver to metabolize bilirubin more quickly (Dysart, 2022)

Because much of this treatment and phototherapy itself can be done at home, particularly if parents use a bili blanket, it is essential that the newborn’s caregivers receive thorough education about monitoring the infant’s skin, the need for skin surfaces to be exposed, monitoring temperature, and encouraging feedings every 2 hours. It is also very important that they keep scheduled appointments with their care provider because the infant’s blood will need to be monitored closely and frequently for bilirubin levels if it is not done by a visiting nurse. Infants who are receiving phototherapy, whether at home or in the hospital, can have brief periods outside the phototherapy lights. Ideally, this could be timed to occur every 2 hours when assessments and feedings occur. This is necessary so that the infants can be cuddled and held and so that they can bond with their parents and breast-feed if that is desired. Eye covers can be removed for parent-baby interaction and eye contact but must be replaced when the baby is returned to phototherapy. Also, the nurse must ensure that phototherapy is turned off during the collection of blood for serum bilirubin levels because both conjugated and unconjugated bilirubin are photo-oxidized when exposed to white or ultraviolet light (Wang et al., 2021).

Figure 24.11 Jaundiced Newborn Receiving Treatment under a Bili Light. Treatment for hyperbilirubinemia may include the use of bili lights with both ultraviolet and blue light. The newborn should not wear more than a diaper and eye protection to ensure effective treatment. (credit: “Light Therapy for Nonphysiologic Jaundice” by Robyn Alvarez/Flickr, CC BY 4.0)

Care of the Newborn with Hypoglycemia

In the term newborn, hypoglycemia refers to a blood glucose level below 40 mg/dL. It is a common transient occurrence in the immediate postpartum period; therefore, it is not necessary to routinely monitor the blood glucose of all term newborns. Most hospitals and birthing centers have policies and procedures that require monitoring of at-risk newborns rather than waiting for them to become symptomatic. The most common cause of hypoglycemia in infants is hyperinsulinism, typically occurring right after birth. Newborns at risk include the following:

• small for gestational age (SGA)
• large for gestational age (LGA)
• fetal growth–restricted (FGR) infants
• infants of a diabetic mother (IDM) (Stanford Medicine, 2023b)

See Chapter 23 Newborn Assessment for a full discussion of gestational age.

Other causes of hypoglycemia in the newborn are poor nutrition of the pregnant parent, incompatible blood types between birthing parent and baby (Rh incompatibility), neonatal pancreatic tumor, birth asphyxia or stressful birth, cold stress, liver disease, preterm birth, being born to a birthing parent treated with terbutaline, and infection (Stanford Medicine, 2023b).

Hospitals, birthing centers, and nurses can help prevent or significantly reduce hypoglycemia in infants by:

• encouraging breast-feeding initiation within the first 30 to 60 minutes after birth
• promoting skin-to-skin contact between birthing parent and baby to prevent cold stress, which depletes the infant’s glucose stores
• encouraging breast-feeding 8 to 12 times a day
• encouraging breast-feeding in response to infant feeding cues rather than a set schedule
• teaching that crying is a late cue for hunger; instructing parents not to let the newborn cry for prolonged periods because crying rapidly depletes glycogen stores and can contribute to rapid drops in blood sugar levels
• promoting continuous parent-baby rooming-in.

Pathophysiology of Neonatal Hypoglycemia

Neonatal hypoglycemia may present as transient or persistent. The developing fetus relies on maternal metabolism and placental circulation to obtain vital energy sources like glucose, ketones, free fatty acids, and amino acids to meet their energy demands. The placenta serves as a direct supplier of glucose to the fetal circulation. However, when the umbilical cord is clamped immediately after birth, it abruptly interrupts this continuous glucose supply, resulting in a rapid drop in the infant’s blood glucose levels during the first 2 to 3 hours of life (Abramowski et al., 2023).

Low blood glucose levels trigger the release of insulin and other hormones, including catecholamines, glucagon, and corticosteroids. These hormones stimulate the production of glucose through processes like glucogenesis and glycogenolysis while also enhancing the oxidation of fatty acids. This creates an internal source of glucose and other necessary energy substrates for the infant’s metabolic requirements. As a result, blood glucose levels gradually increase over the next several hours to days. Disrupting the established sequence of these physiologic changes can pose a heightened risk of more severe or extended periods of low glucose in the infant. The highest likelihood of hypoglycemia occurs within the initial hours after birth (Abramowski et al., 2023). Persistent hypoglycemia may arise due to overproduction of insulin, insufficient cortisol or growth hormone, or inherent metabolic disorders (Abramowski et al., 2023).

The signs of hypoglycemia are not always noticeable in the newborn, but those infants who are at risk should be tested per protocol regardless of the presence of symptoms. The diagnosis is made with a simple test on blood obtained by a heel stick. The most common symptoms of hypoglycemia in the newborn include shakiness or jitteriness, hypothermia (low body temperature), poor muscle tone (floppy muscles), lethargy (lack of movement and energy, out-of-the-ordinary sleepiness), seizures, and possibly cyanosis (blue tint to skin and lips) and apnea (stopping breathing) (Stanford Medicine, 2023b).

Treatment of neonatal hypoglycemia depends on the baby’s age and overall health and well-being. Depending on the facility’s protocol, treatment usually includes giving the baby a fast-acting source of glucose. This may be as simple as an oral glucose gel (“Standard-Dose Oral Dextrose Gel for Neonatal Hypoglycemia,” 2022), a glucose and water mixture, formula as an early feeding, or putting the baby to the breast if the infant nurses well. The baby’s glucose level is checked after the treatment to see if the hypoglycemia has improved. The baby may need glucose given through an IV as further treatment (Stanford Medicine, 2023b). Because the brain needs glucose to function, severe hypoglycemia, or not enough glucose for a prolonged period, can impair the function of the infant’s brain, causing seizures and brain injury. Thus, identifying and treating hypoglycemia as early as possible after birth. with the goal of stabilizing and maintaining a normal blood glucose level in the newborn, is optimal.

Umbilical Cord Granuloma

An umbilical cord granuloma is a small nodule of tissue, which can measure up to 1 cm, that may become evident after the separation of the umbilical cord (Poenaru, 2001). For some infants, after the cord has fallen off, a small granuloma will form. It will stay on the umbilicus and drain a light yellowish fluid. This condition will usually go away on its own in about a week, but if it does not, the pediatrician may choose to cauterize the area to burn off the granulomatous tissue (AAP, 2021a). Another treatment option for small granulomas may be an application of topical silver nitrate. These procedures are commonly treated in the pediatrician’s office. For larger granulomas or those unresponsive to silver nitrate, surgical resection may be indicated (Poenaru, 2001).

Umbilical Hernia

An umbilical hernia is present when the baby’s umbilical cord area appears to push outward when the baby cries. It is caused by a small hole in the muscular part of the abdominal wall that allows the tissue to bulge out when there is increased abdominal pressure (e.g., crying) (see Figure 23.9). It is not a serious condition and will usually heal itself in the first 12 to 18 months of life (AAP, 2021a). The healing process may take longer in infants of color for unknown reasons (AAP, 2021a). If the hole does not heal by the age of 3 to 5 years, it may require surgery.

Umbilical Cord Infection

After birth and until the umbilical cord naturally separates, bacteria can invade the umbilical stump and cause infection called omphalitis. While caring for the infant, the nurse’s main priority in preventing umbilical cord infection is to keep the cord clean and dry and to teach the parents to do so as well. No dressing is necessary. When changing diapers, the diaper is folded below the umbilical area to avoid urine-induced infection. As part of the discharge instructions, the nurse instructs the parents that once the umbilical cord has separated, they should maintain clean and dry precautions until the base of the umbilicus is dry without secretions. If the area still presents with a large amount of discharge after more than 1 week, they should consult the baby’s health-care provider.

The umbilical cord of the newborn is a direct line into the circulatory system. Therefore, if it becomes infected, the infection can quickly spread systemically and become very serious. When an infection enters the bloodstream, it is called sepsis, and it can damage the body’s organs and tissues. For up to 15 percent of newborns who get an umbilical cord infection, it is fatal, so it is considered a medical emergency (Healthline, 2019). A culture of the infected area will be taken to determine which antibiotic is best, which will largely depend on the extent of the infection.

If the cord infection is minor, the health-care provider may recommend application of an antibiotic cream to the area a few times daily to fight the infection (Healthline, 2019). If it is more serious, the baby will most likely need to be hospitalized to receive IV antibiotics for a course of 10 days (Healthline, 2019). This may be followed by oral antibiotics. How long the baby is hospitalized is up to the health-care provider, but usually it is for the duration of the IV antibiotic treatment. In some severe cases, the infection may need surgical intervention. Frequently, the infection causes cells to die at the base of the umbilicus, and these dead cells may need to be removed surgically (Healthline, 2019).

Milia

Tiny white bumps or cysts on the newborn’s skin, usually on the face around the cheek, nose, or chin area are called milia (Mount Sinai, 2021) (see Table 23.2). Occasionally, there may be a narrow red halo around the base of the milia. Milia form when dead skin cells get trapped in small pockets near the surface of the skin. The protein in those cells, called keratin, hardens into tiny cysts that present as small raised white bumps on the skin (Mount Sinai, 2021). No treatment is needed for milia because they will disappear on their own in the first few weeks of life.

Baby Acne

The common short-term skin condition that causes acne breakouts (papules and pustules) on a baby’s face, chest, or scalp is called baby acne (Cleveland Clinic, 2022e) (Figure 24.12). It occurs on average at about 2 weeks of age, although some babies are born with it. It resolves within weeks. Infantile acne occurs after 2 months of age and is different from baby acne, lasting up to a year. If an infant develops acne after 2 months of age, parents should see their pediatrician for intervention. Baby acne can develop slowly or suddenly. The cause is varied and may be related to clogged pores, oily skin, maternal or placental hormones, or other causes. The acne starts as red dots and turns into raised pustules, but not blackheads, disappearing in a few days to a couple of weeks. Generally, this acne resolves without treatment other than washing the area gently with mild soap and water, keeping the area clean and dry, and not using lotions or oils on the baby’s skin. An antifungal cream or low-potency topical steroid may be prescribed in serious cases (Cleveland Clinic, 2022e).

Figure 24.12 Baby Acne Baby acne consists of pustules, not blackheads, and usually resolves on its own. (credit: “Babyakne” by “selbst erstellt (Fragegeist)”/Wikimedia Commons, Public Domain)

Erythema Toxicum

The skin condition in newborns that causes a red rash and small, fluid-filled bumps on the infant’s face and/or limbs is called erythema toxicum neonatorum (ETN) (Cleveland Clinic, 2022d) (see Table 23.2). ETN is not dangerous, it does not itch, and it is not uncomfortable for the baby. It does not have any long-term effects and may go away within 5 to 14 days after forming. The condition may come back and once again resolve in a week or two. Although often confused with baby acne, ETN is different. It can be differentiated by the fact that the bumps disappear and form in new areas over a few hours. Between the bumps, the skin has what appears to be a red rash or red patches. Symptoms usually show up only on parts of the body that have hair follicles, such as the arms, legs, chest, or face (Cleveland Clinic, 2022d). The bumps and rash will get paler when pressure is applied to them. No specific treatment is needed for ETN, and parents should be instructed not to squeeze or pick at pustules because that may cause infection or scarring.

Pustular melanosis

The normal and harmless skin condition that affects term newborns and presents with skin bumps, pustules, or blisters anywhere on the infant’s body is called transient neonatal pustular melanosis (TNPM) (Cleveland Clinic, 2022a). The pus-filled bumps are noticeable at birth and will rupture, causing white-encircled dark spots on the skin. The darkened skin will fade in 3 to 4 weeks (Cleveland Clinic, 2022a). Because blisters rupture easily, care must be taken to avoid infection. TNPM affects boys and girls equally and affects infants of color more than white infants. TNPM is benign, and it does not itch or cause scarring. The condition resolves without treatment.

Management of Common Newborn Skin Ailments

Most common skin ailments in the newborn are benign and require little management. It is important to understand the expected and pathophysiologic findings in the skin. Nurses can differentiate between normal variations and abnormal conditions and can educate parents about both. Appropriate care and management approaches are discussed to address issues effectively.

Management of Common Newborn Viral Illnesses

Some common viral agents in the newborn include herpes simplex viruses, HIV, cytomegalovirus (CMV), and hepatitis B. Intrapartum infection with HIV or hepatitis B can occur as the newborn passes through an infected birth canal or by ascending infection if delivery is delayed after rupture of membranes (Tesini, 2022). It is possible for these viruses to also be transmitted transplacentally, which commonly occurs. Specifically, CMV (cytomegalovirus) is commonly transmitted in this manner.

Management of Common Newborn Bacterial Infections

Bacterial infections are any illness or condition caused by bacterial growth or toxins. Harmful bacteria can attack the skin, gastrointestinal (GI) system, lungs, heart, brain, blood, or anywhere in the body. Most bacteria are not harmful, and many are helpful. Many of the vaccines that infants and children receive are meant to prevent serious bacterial infections.

Commonly seen bacterial agents affecting newborns include group B streptococci, enteric gram-negative organisms (primarily Escherichia coli or E. coli), Listeria monocytogenes, gonococci, and chlamydia (Tesini, 2022).

With bacterial infections:

• Symptoms tend to persist longer than the 10 to 14 days that a virus usually lasts.
• Fever is usually higher than expected from a virus.
• Rather than improving, the fever and symptoms get worse a few days into the illness.

Antibiotics can treat most bacterial infections, but only a few viral infections have medications that can treat them. The primary treatment for neonatal bacterial infections is prompt empiric antimicrobial therapy with drugs such as ampicillin and gentamicin or ampicillin and cefotaxime (Tesini, 2022). Once culture results are returned, the drug, dose, and frequency will be adjusted to best fight the identified organism.

Bacteria in the blood, or sepsis, and a bacterial infection in the lining of the brain and spinal cord, or bacterial meningitis, are two serious and concerning kinds of bacterial infections. Infants have few subjective symptoms. Diagnostic tests are required to ascertain that bacterial infections are part of their current or presenting illness.

Helping Parents Recognize and Respond to Signs of Illness in a Newborn

Having a newborn is both exciting and stressful for new parents for many reasons. One of these is concern for the baby’s health. How does a new parent know if their baby is getting sick? They may not know what their baby’s normal behavior is, and that makes it difficult to determine if their newborn’s behavior is not normal. Changes in newborn behavior can be subtle, so they are not always easy for new parents to spot. The best advice the nurse can give a new parent is to have them note any behavior that seems abnormal to them. Use the following list to teach new parents about signs of illness in newborns. New parents should watch for:

• any suspicion of illness, such as crying more than usual, irritability, coughing, diarrhea, or vomiting (if vomit is green, which means bile, notify the health-care provider immediately)
• changes in feeding patterns, such as having to wake the baby for feedings or if the baby no longer finishes their feedings, which could indicate illness
• a fever of greater than 100.4° F (38° C), which warrants a call to the health-care provider
• low body temperature, less than 96.8° F (36° C), which warrants a call to the health-care provider
• changes in the baby’s cry—if the cry becomes weak, sounds strange, or becomes frantic or inconsolable
• weak suckling or not being able to suck for very long
• sweating while eating
• sleeping more than usual
• decreased muscle tone, floppy limbs, floppy neck when the infant previously could hold head up
• moaning or grunting noises when breathing, with or without flaring of nostrils
• decreased urination (fewer wet diapers) and dry mouth (dehydration)
• any color change, such as pale, bluish, or gray arms and legs

Any of these signs and symptoms of infant illness can occur independently or in combination. Babies do not often get sick, but when they do, they can deteriorate quickly (Kliegman et al., 2020).

Forceps Marks

If forceps were used to assist in the delivery, they can often leave bruised, red marks or even superficial scrapes or scratches on the newborn’s face and head. These marks may not appear immediately after birth and may first appear as redness or puffiness of the face (Figure 24.13). It may take a few hours for bruising and forceps marks to become visible. These marks will generally disappear within a few days of birth. Sometimes, a firm, flat lump develops in one of these areas due to damage of the tissue under the skin and bleeding in that area. Parents could, and should, bring this to the attention of their newborn’s care provider, who will likely tell them that this will go away within 2 months (AAP, 2021a).

Figure 24.13 Marks from Forceps Delivery If forceps were used to assist in the delivery, they can often leave bruised, red marks, or even superficial scrapes or scratches on the newborn’s face and head. (credit: “Forceps Marks” by Joanne Lee/Flickr, CC BY 4.0)