Newborn Care – PediaCast 441

Show Notes


  • The Pediatrics in Plain Language Panel returns to the studio as we consider newborn care. We explore all things new parents need to know, including infant sleeping, feeding, growing, peeing, pooping, spitting up and bathing. We also cover fussiness, colic, jaundice, rashes, cradle cap, belly buttons and baby shots. We hope you can join us!


  • Newborn Care
  • Sleeping
  • Feeding
  • Growing
  • Peeing
  • Pooping
  • Spitting Up
  • Bathing
  • Fussiness
  • Colic
  • Jaundice
  • Baby Acne
  • Cradle Cap
  • Diaper Rash
  • Belly Buttons
  • Baby Shots



Other Pediatrics in Plain Language Episodes


Announcer 1: This is PediaCast.


Announcer 1: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio. 

It is Episode 441 for September 12th, 2019. We're calling this one "Newborn Care." I want to welcome all of you to the program.

So this week we are covering a very important topic, especially for those who are expecting the arrival of a brand new baby at home. Or for those with recent additions of one of these little creatures, trust me, your life is about to change if it hasn't already done so.


Regardless of if it is your first baby or the latest in a long line of previous newborns in your house, there are lots of details you need to know. And even if you are a pro in the baby department, it does not take long to forget what to expect in the do's and don'ts of caring for the youngest and littlest of children.    

Now, we have covered a newborn topics on PediaCast many times in the past but it has been a while and the older shows do tend to get lost in the depths of our increasingly massive archive. Plus recommendations do change somewhat over time as the newest evidence is added to our collective pediatric knowledge base.


Additionally, we have never covered newborn care in the context of one of our Pediatrics in Plain Language episodes. So we're going to add that aspect today, as I'm joined by two very talented primary care pediatricians from Nationwide Children's Hospital, Dr. Mary Ann Abrams and Dr. Alex Rakowsky.

You'll recall when the Pediatrics in Plain Language Panel is in the house, we double our efforts to avoid medical jargon. Or at the very least, we make an effort to really explain exactly what we mean in Plain Language. So that everyone can understand and perhaps, some can learn new terminology as we go along, if we do use some of that jargon on accident.

Or sometimes it's unavoidable because those are really... The terms that everyone in the medical field uses, there may not be equivalent plain language terms. We want to explain those things as we move on.

However, we also do not intend to dumb down the science. After all, understanding what's going on is an important component of health literacy.


But of course, to understand complex concepts and reasons behind the recommendations, it's important for parents to also understand the words we are using. So that's what we'll do today. It's just an attempt to speak in plain language as we consider the care of newborn infants who have freshly arrived in the home.

We plan on covering sleeping, bathing, feeding, growing, spitting up, peeing and pooping, fuzziness, colic, jaundice or yellow skin, baby acne, cradle cap, diaper rash, belly buttons, and of course, we'll mention shots and immunizations. 

So as you can see, we plan on exploring many topics during our hour or so together. And we do have to pick and choose. There are newborn topics I'm sure that we are not covering but we had to figure out which ones were the most important, and this was the list we came up with.

Please do consider sharing this episode with your friends and family especially if they are expecting a new baby and perhaps  they have not heard of PediaCast before this. This would make a terrific introduction to the program for first-time moms and dads and experienced parents as well.


It's difficult to recall what to expect and what you're supposed to do when it's been several months or more likely several  
years between little bundles of joy.

One easy way to share the program is by connecting with us on social media. We are on Facebook, Twitter, LinkedIn and Instagram. Just search for PediaCast. 

And reviews are helpful, too, wherever you listen to podcast. It doesn't take long to write down a thought or two regarding our program. We really appreciate it when you do that.  

We also have a Contact link over at, so it's easy for you to get in touch if there is a question that you have about pediatrics or parenting, health care for kids, or if you would like to suggest a topic for the program.

Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.


If you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at

So, let's take a quick break. We'll get our Pediatrics in Plain Language Panel settled into the studio and then we will back to talk about newborn care. That's coming up, right after this.


Dr. Mike Patrick: Our Pediatrics in Plain Language Panel joins us again this week. You will recall that Dr. Mary Ann Abrams is an assistant professor of pediatrics at the Ohio State University College of Medicine and a pediatrician with the Hilltop Primary Care Center at Nationwide Children's Hospital.


Dr. Alex Rakowsky also an assistant professor of pediatrics at Ohio State and the pediatrician with Olentangy Primary Care at Nationwide Children's. Really appreciate both of you joining us again today.

Dr. Alex Rakowsky: Thanks, Mike.

Dr. Mary Ann Abrams: Happy to be here.

Dr. Mike Patrick: So let's get right into an introduction to plain language. We mention this with each of this special podcast that we do. But Dr. Abrams, explain to us what is plain language and why is it important?

Dr. Mary Ann Abrams: Plain language is important because it helps people focus on what they really need to know and what  they need to do. And we use it in all parts of our life. If we're not an automobile expert or a lawyer, for those of us who are doctors, we need that kind of information in plain language.


So in medicine, because we tend to get the habit of talking a certain way, it's important for us to remember to use plain language when we're talking to patients and families who really do need to understand, to be able to focus on what they need to know and do. Not try to figure out what the Latin term is or the jargon or the technical term is that we use.

Dr. Mike Patrick: Sometimes there is not a plain language equivalent for a particular word and then, it's going to be even more important to explain exactly what we mean by that word. But in doing so, we're kind of adding to someone's vocabulary.

Dr. Mary Ann Abrams: Absolutely. And then, we can say now that we've explained what this is, you'll hear us use that term going forward. And as you said, that builds their knowledge and their understanding, too.

Dr. Mike Patrick: Speaking of plain language, there is a book that we're loosely following with our Pediatrics in Plain Language series called What To Do When Your Child Get Sick, published by the Institute for Healthcare Advancement which is non-profit organization. 

And in fact, they're offering their book to our listeners for 40% off the cover rate simply by using the discount code pod719. And we'll put that discount code in a link to that particular book in the show notes for this episode, 441, over at


But just give us a brief example what the stuff, what does that book look like? What can parents get out of that?

Dr. Mary Ann Abrams: This is one of several books that the Institute for Healthcare Advancement has available and they're all called the What To Do books. They have several titles, What To Do When Your Child Is Heavy, What To Do When Your Child Gets Sick, What To Do for Dental and Oral Health, What To Do for Seniors.

So they're all written in a very easy-to-read, easy-to-use format that really, again, give you the information you need to know. There some places to take note, places to write down important phone numbers or websites. And they're very, very accessible and highly appreciated by people who've used them.


Dr. Mike Patrick: Really good information and easy to understand. And then we have our Pediatrics in Plain Language survey that we're encouraging our listeners to take. It's easily available. If you go to have and click on the Survey tab, it will be right there for you. Also in the show notes for this episode, 441, over at 

Why are we surveying our audience?

Dr. Mary Ann Abrams: Because we want to hear from you. We are putting together what we try to think is really valuable information. But we want to make sure we're hitting all the important topics, things that are important to you. We want to be able to start answering questions that you may have on this podcast. And we want to know how to make it better.

So we are really welcoming people's responses and inputs. We really appreciate all the people that have answered and responded so far. And we're taking their comments into account.

Dr. Mike Patrick: One of the comments was sometimes we're explaining things that maybe we don't need to explain. But that because particular people have different experiences and you may have bigger vocabulary. But there's going to be other people who may not have as big of a vocabulary. 

And so, we're just trying our best to kind of pick and choose which words we should and shouldn't be using and we're going to be imperfect to that, right?


Dr. Mary Ann Abrams: Absolutely. We're all continuing to learn. And it may give you the listener another way to explain something if somebody asks you about something. So it helps all of us.

Dr. Mike Patrick: So we really appreciate if you just take a couple of minutes to fill up that survey. Again, it's easy to find. At, just click on the Survey tab.

And you can actually evaluate not only this episode but any of our Pediatrics in Plain Language podcast episodes that we've done in the past. So, we did one early in the summer with the Keeping Kids Safe. We've done it on Outdoor Fun and Spring Injuries. We talked about family literacy and books, fitness facts and ideas. 

Wintertime blues was another one. We've talked about the flu before. So you can kind of look there. If there's one or other of those podcasts you've listened to and want to do a survey, that would be fantastic.


All right, so let's move on into our information this week because we have a lot of it coming your way, if you have a newborn at home, you're expecting one. Maybe you have had three other kids and this is your fourth time around and you're thinking you're a pro. But if months or couple of years go by when you have not had a newborn at home, it's really easy to forget these things if you're not thinking about them every day.

So we really wanted to hit on the most important topics for having a baby. Babies, especially newborns, they don't really do a lot, right? They sleep, you give them a bath, they feed. So we're going to just start with sort of those basic activities.

Dr. Rakowsky, we're going to start with you. What do parents need to know about newborn babies and sleep?

Dr. Alex Rakowsky: So speaking as a dad of a big family here, the sleep would be off-kilter for probably four to six weeks minimum. And sort of an expectation that when I see families in clinic is to kind of let them know that having a normal day-night schedule is not going to be in the cards until at least the second month of life for most children.


So sleeping is important that when the baby lays down for a nap, mom should take a nap also. Try to start teaching night time routines, but it may take up to four weeks for the baby to just kind of even get into that. And the first months really is for that baby to kind of adjust to life and the parents adjust to the baby as far as sleeping is concerned.

As far as bathing, the rule of thumb tends to be if there's anything open with the umbilical stump or umbilical cord area to not bathe in direct water. Parents can sponge bathe and that's perfectly fine. But once the umbilical cord falls off and then heals up completely, then you can start to immersing or putting the child in a small baby bathtub and clean from there.


I just want to add that a lot of babies will have dry skin. That's just natural as they lived inside a water environment inside of mom. So that skin's going to sort of peel off and then you have more of a outside-of-water skin layer. So you will have a lot of what looks like flaky dead skin on a baby. 

There's no need to wash that off. It just going to naturally come off. And I have a lot of families who just sort of upset about the fact that they can't take it off. They want to bathe the child, get that off, and then that's fine.         

And when in doubt, you can always ask a doc or a nurse some cleaning techniques.

Dr. Mike Patrick: Yeah, absolutely. Let's head back to sleep for just a moment. A lot of families will compare babies with one another. And you'll find, "Oh, my baby sleeps all the time." "Mine never sleeps." "Mine, after a week, already slept more at night than during the day."

There's no real rules, right? I mean each baby is going to be different. You just have to sort of go with the flow, so to speak.

Dr. Alex Rakowsky: It is all lot of old wives' tale that if your child's born at night, they'll be a night owl. If they're born in the morning, they'll be a better sleeper. But none of that has ever been proven correct.

And our own experience has been that the ones who slept really well in the first month of life ended up being some of the more difficult sleepers later on in life.


So there really is very little rhyme or reason. You may have a baby who sleeps... They shouldn't sleep more than four hours because you really want to feed them every four hours even through the night in the first months to six weeks of life. But you may have a baby who sleep in pretty well at night early on.

I think the expectation should be that for the first four to six weeks, sleep schedules will be difficult. And that's where you need help around the house and that's where just getting a lot of support for mom is really important.

Dr. Mike Patrick: And I love what you said, try to get some sleep when the baby is sleeping. Although that is an easy thing to say but not an easy thing to do because of our own rhythms in our brain and sleep-wake cycle. And sometimes...

Dr. Mary Ann Abrams: And I want to get everything done while baby is sleeping. Then you're like, "Oh!"

Dr. Mike Patrick: And the flight of ideas like then you can't stop thinking about this and that. And what do I do for, you  know so.


Dr. Alex Rakowsky: We have a lot of families in our clinic that have several children. And it's a hard when you have the kids at home, especially if you have a summer baby because you will schedule around the house. But it's perfectly fine for the first four to six weeks to have laundry build up and have frozen meals that people bring over because you really need to get that sleep just for the mom's own safety.

Dr. Mike Patrick: Yeah, that totally make sense. And then, we wouldn't be complete talking about sleep without mentioning safe sleep. That the ABCs should be sleep alone, on their back and in a close container like a crib. Some other thing that is going to be safe for babies.

And when we say alone, that means that they just have their sleeping clothes on and no blankets, no pillows, no stuff animals, no bumper pads, nothing in the bed that they could suffocate on, correct?

Dr. Alex Rakowsky: Yeah. The rule of thumb tends to be that whatever you're wearing maybe a similar extra layer of that material on the baby. There's this almost like false assumption that babies need a wool blanket on them in dead of summer. So you have grandparents, for example, put stuff into the crib just because a baby needs to be ball heated.


But the data seems to show the most babies, if you have a thin pajama or a T-shirt on, the baby will be fine with these two T-shirts. So don't feel compelled to get something into that crib. And I think if parents are aware of the fact that their child is not freezing to death without something thick on top of them, it helps the other parents then sort to say, "Okay, I can keep stuff out of the crib".

It's easy to say keep stuff out of the crib, but then they come home and say, "I don't know what you're thinking because my child if freezing," and comes the wall blanket.
Dr. Mary Ann Abrams: And it's nice to have the baby wearing, if it's winter time, you can have him have a little sleeper on. Or in the summer, like you said, a little onesie t-shirt or a sleep sack where the clothes actually serve the function of a blanket if it's needed. So that they're not tangled up in something else.


And then also, there's some research to show that sometimes overheating can be a problem for safe sleep. Also, the other part of being alone is all the stuff and then the other people. 

So not co-sleeping, not sleeping with mom or dad or grandma and not even laying on the couch on someone's chest. A lot of people take a little nap and have the baby right there. They think it's all going to be fine and, unfortunately, it isn't always fine.

Dr. Alex Rakowsky: One of the residents couple of years ago mentioned the eclair rule. So would you fall asleep with a stuffed donut or eclair in bed? And the parents would say, "No because it roll over and the eclair will get all over my shirt."  Well, the baby has as much mobility as an eclair or stuffed donuts. So if you're afraid to roll over on a donut in your bed, then you shouldn't have a baby in there either.  


I've used that analogy probably like two dozen times since this resident came up with it. It works great. Parents would go, "Oh, you're right, that baby doesn't move a whole lot."

Dr. Mike Patrick: And working in an emergency department, I see babies come in who have been suffocated because a parent rolled over him on a couch or a bed, in a chair. And it's a tragedy. And those parents would wish they could  take that back, for sure.

Also, in terms of bathing, some safety things to think about -- water temperature's going to be important. Constant supervision at all times. Even though babies don't move around a lot, you should be there with them every second. 

Dr. Alex Rakowsky: And then, don't use your hand for the temperature. Use your elbow. Use a knee. Use some other more sensitive part  of your body because for a lot of parents, especially if we do a lot of physical labor, your hands may be a lot more immuned to a sensitive temperature. And the baby's skin is very thin compared to what we have.

Dr. Mike Patrick: Absolutely. And then soaps and shampoos, the baby's stuff, the No More Tears, right?


Dr. Alex Rakowsky: Yeah. I have my own ideas about baby things. I don't feel compel that every child needs to have a baby's specific scented, soap, shampoo, et cetera.

Dr. Mary Ann Abrams: Unscented.

Dr. Alex Rakowsky: Yeah. In fact, I'm a big believer and I've seen it over and over again that the scented materials tend to flare up a lot of kids when they come from a house that has eczema, unfortunately. 

So I like unscented, gentle soaps. You can do a non-baby gentle soap but there's some good brands out there that have infant products. But when it comes to detergents, since we're kind of going to this realm, use the unscented baby specifics.

So it's like you're dealing with a body with a thin skin. So you don't want to use something harsh. And for a lot of kids, that scent even though it reminds people of babies may be something that irritates that skin more than it would irritate us.

Dr. Mike Patrick: Yeah, absolutely.


Dr. Mary Ann Abrams: Because they make scents or smells out of chemicals. And those aren't the normal chemicals that are around people's bodies. So think of it that way. It's almost like an extra something unnatural that's being introduced  to the baby's sensitive skin.

Dr. Mike Patrick: On the other hand, if you're using a scent that you like and your baby's not having any sort of an issue, it's not necessarily harmful, either.

Dr. Alex Rakowsky: That's fine. 

Dr. Mary Ann Abrams: Don't worry about it.

Dr. Alex Rakowsky: You can always try. I think a lot of parents are obligated to use a specific brand that we all know. 

Dr. Mike Patrick: Yeah, and it cut the price as much.

Dr. Alex Rakowsky: But you don't have to. I mean, some parents "Well, that's the only..." There's a lot of unscented baby products that one, are a lot to cheaper, and two, may work better for your child.

Dr. Mary Ann Abrams: Generic brand is fine.

Dr. Mike Patrick: Let's move on to feeding. So babies, they sleep, you give them bath, they're going to eat.  

Tell us Mary Ann, what do we need to know about feeding our newborns?

Dr. Mary Ann Abrams: So feeding can be of source of a lot of concerns and worry and also satisfaction and happiness. And feeding ties in with some of sleep issues, too. And the baby's finally sleeping and then, oh my goodness, they grow, so they need more calories. So suddenly they're waking up more often because they need to eat more. Or drink more, I should say.


So starting at the very beginning, hopefully, before the baby's born, parents will think strongly about breastfeeding the baby. We do believe the breastfeeding is the healthiest way to feed your baby. It's healthy for the baby, it's healthy for mom, it's natural. 

You don't have to have a lot of gear, you don't have to lug things around. You can breast feed them anywhere, anytime, any place. And it's less expensive because you don't have that buy all the formula and everything. Mom needs to eat a little bit more than usual. But otherwise, it's very convenient.   

That being said, it's not always the choice that everyone makes. And I think maybe one of the least fortunate things is people who do really really want to breastfeed kind of get started after the baby is born. And then, it doesn't go smoothly. And often, with the first baby it doesn't. 

And they end up stopping breastfeeding because they don't have the support they need. They're worried about their baby. Other people aren't helping them or they're telling them what's the problem and just give him a bottle type thing.


So back to the basics, if you're breastfeeding, starting to feed the baby as soon as possible after they're born. And kind of understanding that normal cycle that it takes a while for the mother's milk to come in. And to stimulate that milk to come in, putting the baby to the breast and having them suckle so that that helps stimulate the production of the milk. And that may take a couple of days.

So you do want to keep a close eye on the baby, make sure that they're still active, that they're not maybe getting dehydrated or not having enough liquid in their body because they're not getting enough to feed. And checking with your doctor about whether you should do anything differently in that regard.


But then, once the milk comes in, baby's tend to do well and there's a learning curve that, you know, what's the best to hold  them? How do I get them to latch on or to suckle the way that works best for us? And then, after a week or two, it often kicks in quite seamlessly and quite well. 

Until they grow again and then suddenly you're like, "Oh my gosh." So then, they have to rob up the frequency of feeding to get more milk production.

With formula, there's several good formulas and we recommend you start with just normal basic formulas. They'll take a  bottle every -- it varies -- maybe every two and a half, just three and a half hours in the beginning. And maybe every three to four. And maybe anywhere from two to three or four ounces depending on the baby themselves, the time of day and their activity level, and how old they are.


I think one the important things when giving a bottle whether it's formula or pumped breast milk is not to feel like they have  to clean their plate. Not having a bottle and say, "Oh, there's only a couple more swallows, let's finish that up." Because you want the baby to learn how to sort of say, "Hey, I'm full. I'm finished," and not to get either overfed or get used to having to kind of take in more than they really need.

Dr. Alex Rakowsky: If I can just add a couple things about feeding. The first is the infants can cluster feed. And so, there may be situations... We tend to think as kids like little machines. Like every three hours, we're going to load them up with gas and off they go. 

But in all honesty, we have days where we eat more and we have days that we eat less. They're human and they're going to have days where they need to cluster feed. And it's perfectly normal to have an infant that's going to feed every hour on the hour for the next two days and then go back to every three hours. We don't know why these happens but it happens commonly.


And then, a second is a lot of clinics have lactation specialist or something like lactation training. We just got one in our clinic in Olentangy. And she has been a lifesaver. 

Breastfeeding is natural but it's not inherently simple. So it's not something parents can just kind of go into. There's some tricks that you have to learn how to breastfeed successfully. So ask your pediatrician, do you have a breastfeeding lactation consultant? They add like five minutes to the visit.

Or is there somebody I can call? A lot of the birthing hospitals in the country will have lactation people there. And they're more than happy to have helped. But parents should not feel like this is something that I should know how to do because it's not simple to do the first couple of times. 

Dr. Mary Ann Abrams: Don't be afraid in the hospital before you go to ask, to talk to a lactation consultant. They may have them and ask for them. And then again, as you pointed out, it's going to be day 3 or day 5 when you have another question. So how  do you touch base with them down the road when things change or something comes up in that regard? 


Dr. Mike Patrick: And there's no silly questions. There's no problem that you have that thousands of other mothers also experienced. And the lactation consultants are very good at dealing with each of those problems and that's something that they see over and over again.

Having said all of that, and truly believing that breast milk is best, and we want to do everything that we can to encourage that to be successful, and we want to plug folks into lactation consultants, sometimes it doesn't work. And we can also make the mistake of then keeping on guilt and shame. The mental health of a mom is also extremely important on how well you are parenting. 

And so, when it doesn't work out, we also want to support those moms. It's a natural instinct to sort of feel like a failure when something that you really want to happen isn't able to happen. But realize that anxiety and guilt and shame can also interfere with our ability be a good parent. And so, sometimes if it doesn't work out, then we have to move on, right?


Dr. Mary Ann Abrams: Absolutely. And I've known more than one mom who found herself in that situation. Everyone loves  their baby and they want to do what's best for their baby. Sometimes that may involve making that decision -- or that you try as hard as you could -- that's ultimately, it's what's best for the baby and our family.

Dr. Mike Patrick: Absolutely. So we feed to grow. So Dr. Abrams what do new parents need to know about infant growth, especially during that first month or two?

Dr. Mary Ann Abrams: Well, the first couple of weeks are kind of interesting because most babies, at least healthy full-term babies lose a little weight in the first several few days, about 10% of their weight when they were born. But they should have kind of gotten back to that birth weight at least by two weeks.


So, they've kind of lost whatever extra baggage they were carrying when they were born. And then, they've kicked in and learned how succeed that pattern going, so then they regain that weight. 

And then, they should continue to gain about roughly an ounce a day over the next several months. So that's why we'd like  to see them depending when they go home after being born anywhere from two to four or five days after they go home. And if they're doing okay, we can see them again at two weeks or one month or at their two-month well check. 

We always keep track at their growth. We look at how their head is growing because that reflects how their brain is growing and that's critical to their development. We look at how long they are and we look at, obviously, their weight.

Dr. Mike Patrick: One of the things that pediatric provider will share is, "Okay, you're at tenth percentile for your weight and fifteenth percentile for length." What does that mean? What are those percentiles that get reported out in terms of the growth chart?


Dr. Mary Ann Abrams: There's a whole world of science about growth chart, right, that you could do a three PediaCasts, I bet. To make it short, the World Health Organization and the Centers for Disease Control have growth charts where they've looked at thousands of children. And there's a discussion whether they should all be breastfed children or combination of breast milk and formula. 

But using all of these data, they looked at how these children grow overtime. They established averages for each age and for boys and girls. And then, they looked at the variation. What's considered sort of normal variation versus concerning variation being how far off they are from sort of that average.

And what we really look for, in the beginning, the first few months, sometimes, they'll kind of bounce around. But we really hope, ultimately, that a child will sort of find their pattern of growth and they'll stay out following that pattern.


So if they are a small person, they're going to be on the lower side of this chart over time. The bigger person will be on the higher side. But if they start changing, if they drop off for or if they get to out of balance there too -- getting too high -- those are the kinds of things that we look for when we see the babies over time and use these growth charts.

In general, we'd like them to be proportional. So if you're at a 30th percentile for your weight, it should be that for your  
height and ultimately the head, too.

Dr. Mike Patrick: Really with growth, family patterns come into play, your ethnicity, what race you belong to. Some groups of people are shorter, some groups of people are larger. And so, really kind of taking all of that data into account, that's what your pediatrician is trained to do. And to explain what it means and how you're following your curve over time is going to be what's important.


And then, taking things into account like certain diseases like Down syndrome, for example. There's a special growth chart for them. Premature babies, things are going to look a little bit different. So there are some special growth charts that some pediatricians use. 

Dr. Alex Rakowsky: And just to throw out a fun fact that babies weigh doubles by four months. So a lot of parents like, "My baby eats all the time." But I'm about 200 pounds. So for me, to weigh 400 pounds by Christmas, I have to be chomping down an awful lot. 

So it's the same thing here where parents are like, "He eats," or "She eats every two hours." But they're doubling him. It's just, if you think about it... 

Dr. Mary Ann Abrams: A lot of growing. 

Dr. Alex Rakowsky: It's a lot of growing in four months. So if they're eating every two hours and they seem hungry, that's why. 

Dr. Mike Patrick: So that is a great segue into our next topic, which is infant spitting up because if you're eating a lot, you're likely to also spit up quite a bit. And so, we each took some topics that we sort of primarily prepared for this program. And I did a couple of them myself, and spitting up is one of them. 

Our thoughts on spitting up really have kind of changed over time, I think. As I explained this to parents, because we do see a lot of kids in our urgent cares and emergency department come in with spitting up, is that the stomach is not very smart. Its main job is to break down food with the acid and to squeeze and churn things. 

And so, as the stomach squeezes, the food's got to go in one or two directions because there are only two holes that it can go out of. One of the top of the stomach where it enters in at the end of the esophagus which goes from the back of the throat down to the stomach. And then, there's another opening that goes into the small intestine.

So it's got to go in one of those directions. And there are bowels, one on top, one on the bottom. And so, when the stomach squeezes, what you hope happens is the valve on top closes and the valve on the bottom opens, so the food goes in that direction.


But we know in a lot of babies that the valve on top is kind of loose and maybe a little immature and doesn't close with a lot of strength. And so, when the stomach squeezes, some of the food is going to come back up. Actually, the majority of it is going to go on in the small intestine. 

And one way that you can tell that enough is going into the small intestine is by following a baby's growth because you are feeding to grow. And so, if they're growing well, then we know that even if they're spitting up, that they're keeping enough in. 

Some warning signs for spitting up, if it's what we call projectile. Oftentimes, pediatric providers and parents have a different idea what a projectile is. Projectile is really with a lot of force, across-the-room kind of vomiting. Whereas, spitting up is often out like a fountain out of arm's length. But I could see how a lot of parents would think that's projectile, but isn't truly. There's a lot of force involved with projectile vomiting.


And that just happens when there's an obstruction. So, pressure builds up, and that's the reason that it comes out in a projectile. 

Dr. Alex Rakowsky: Obstruction meaning blockage. 

Dr. Mike Patrick: Oh, yes, I should... We should... 

[Gong Sound Effect]

Dr. Mike Patrick: Okay, yeah, obstruction is blockage. So if you had a blockage at any point in the intestinal tract, especially early on, right at the stomach level, where the stomach goes into the small intestine or at some point in that first part of the small intestine. 

Other things red could indicate blood. Green can indicate bio. Again, these are things that we would not expect to be there and are a little bit more of a concern. 

Babies who are losing weight despite all these spitting up. And then, any airway problems since we have something coming up, if they're choking, gagging, seems like they're having difficulty with breathing or any color changes, coughing, wheezing, anything abnormal with the airways, someone ought at least take a look at the baby and see if that's a problem. 


I think we used to be quicker to treat spitting up babies. And when you combine spitting up with colic which we're going to talk about, then you can start to say, "Well, is the spitting up hurting and do we need to use medicine for that?" I think we're trying to get more toward saying, "Look, this is as..." 

Many moons ago, one of my own preceptors when I was a resident, still a pediatrician in our primary care system, Dr. Cheryl Pippin, and she would say that this is laundry problem, not a baby problem. And I used that terminology for parents for many, many years after my residency.

But really thinking that, normalizing this idea that babies do spit up, and as long as there aren't any of those warning signs going that not a breathing problem, they're growing okay, we're probably better off just sort of letting this be. 


When it is more of a problems, some things we can do, one of the first things parents want to do is change the formula. But when you think about what causes babies to spit up, it's more an issue with the tank, not with what you're putting in the tank. And so, changing formula often does not make a difference. But it's an easy thing to try.

One thing we did a lot in the past was thicken the formula with cereal, and that leads to weight gain because there's more calories now. And we can have some obese babies that can turn into obese toddlers and have weight issues on in that can start early.  

So there's definitely a role for that still in some cases, especially if kids are losing weight or they're having the airway kind of problems. But I think we're less quick to thicken feeds compared to maybe ten years ago or so. 

And then, the acid-reducing medicines, if babies are really fussy, you try something like a Ranitidine or Zantac that people have heard of. There's other medicines as well to kind of reduce stomach acid. That's not really going to prevent them from spitting up. It just makes their spit-up maybe more comfortable. But their crying could also be from colic. 


Now, there are some studies showing that there can be some bad effects possibly of those medications. So again, there's a role for them but we shouldn't necessarily jump too quickly. That's something that each individual family has to talk about with their pediatrician to figure out, is it time to do that or not do that? 

And then, of course, there are surgical procedures that can be done when spitting up is really bad and definitely an airway issue and you want to make sure it's not something wrong with the plumbing, that there's not connections where they're not supposed to be and things like that. 

So overall, I would say spitting up is very common, but there are some warning signs. That projectile nature, red blood, green bile, losing weight, airway problems are going to be the big... Did I cover that fairly well?

Dr. Alex Rakowsky: I want to add a couple of things. So there are pictures on the internet as far as how big a baby's stomach is. Essentially, your stomach is the size of your fist. And it can expand in about twice the size. So a typical baby is going to have a three to four ounce capacity or size that you can squeeze things into in their stomach.


And there's been some nice studies looking how much air is swallowed during a feed. And kids who eat normally or swallowing about an ounce of air for every two ounces of formula or two ounces of breast milk. And kids who are quick feeders or have a bad latch can have an ounce of air for every ounce of formula. 

So if you have a three ounce bottle or three ounce breastfeed, then you're adding two to three ounces of air. That stomach can only hold four ounces. It's got to go somewhere. 

So a couple of tricks is to feed, stop in the middle of the feed. Get some of the air. You don't have to burp. Just hold the baby, it will get some of that air out. 

The first few times, the baby's not going to be happy about you breaking their sort of suck You're eating lunch, somebody takes your lunch away. But it comes back. Eventually, you'll learn that your lunch comes back.

But that's a really easy thing to do, to get some of that air out of there. The second is after a feed, hold the baby upright for about ten minutes just to get that air, just to bubble up. It doesn't have to be burping or hitting their back. It's just a matter of holding the baby upright.


And some kids just can't tolerate that. They just don't get a good latch and those are kids you're going to feed every two hours, which it's hard for parents but they will get larger. The stomach gets larger and it just makes it easier for spitting up.

I also want to add that there are real cases of blockages. So when in doubt, just come see one of us. 

Dr. Mike Patrick: Yeah, absolutely. Very, very important.

Dr. Mary Ann Abrams: The other thing I would add is for most babies who are spitting up, it really is just spitting up. And that can be scary, even though it's just spitting up and without any of the warning signs, but that you should still put the baby to sleep alone, on their back, in the crib. So they're not going to choke on that spitting up. 

A lot of people, I think that's a reason they put the babies to sleep on their stomach.


Dr. Alex Rakowsky: It's a really good point. 

Dr. Mary Ann Abrams: But if you actually look at the way the airway and the swallowing tube, the esophagus are laid out, the spitting up isn't going to cause that kind of a problem.

Dr. Mike Patrick: Yeah, very good point. So we've talked about feeding, we've talked about spitting up. The other direction that food goes is on out. So we're going to talk about pooping and peeing. 

I don't want to spend too much time on these. Peeing, kids, if you're well hydrated, your body's making urine, we'd like to see at least -- if you have to put a number on it -- about six wet diapers in 24 hours. 

Is it important to count every single one and get a number? Probably not, but your child should be making urine on a fairly regular basis. 

Sometimes, it can be difficult with these really super absorbent diapers. It can be hard to tell if they're having urine or not. If you have a healthy baby, really, not something you need to count and worry about. But if the kid is sick and there really is vomiting and diarrhea, and there's concern that they're not making enough urine, you can always put a couple of cotton balls in the front of the diaper and just check them on a periodic basis and see if they got a little moisture to them, just like they're smear. 


Dr. Alex Rakowsky: If I may just add, make sure that the baby urinates before they go home. I mean, it sounds silly but just make sure that the baby feed before going home. And that's a question we're going to ask if a child comes in and he probably hasn't peed since birth. It's like, "Is there a real blockage down there or is this child really dehydrated?" 

And the second is, that the first couple days of life, you may urinate, you may pee less. So at least two to three diapers a day in the first couple of days and then it peaks up. 

And a lot of breastfeeding moms may not have breast milk coming in, but they at least have some volume. So it's not thick milk, but there's at least thin milk, but the volume's there. So you work your way through it. But if they're peeing well, that means that the volume is being given. 


Dr. Mary Ann Abrams: And also, look at the urinary stream, especially little boys, make sure that urine comes out and...

Dr. Alex Rakowsky: And we try to avoid the various streams. 

Dr. Mary Ann Abrams: You want to at least see where it might go. Again, if it doesn't, if it just really dribbles out in that little boy, that can be a suggestion of a blockage internally there where the urine comes out. But you always want to check if it's a hit in the face, if it's a hit in the wall. 

Dr. Mike Patrick: Yes. And it seems like for pediatrician, you learn pretty quickly to jump out of the way, right, when you open a diaper... 

Dr. Alex Rakowsky: I have an extra shirt in my trunk and I've had it for 30 years. And I take it out about once a year. 

Dr. Mary Ann Abrams: And wash it. 

Dr. Alex Rakowsky: I used it when hit. 

Dr. Mike Patrick: In terms of bowel movements, the first bowel movement is going to be that black tarry what we would call meconium stools. So it's just a function of swallowing amniotic fluid and it's getting processed in the digestive tract and that's normal. But that should very quickly give way to just some loose, yellow, seedy, mustard like stools. 


Although, the color can really vary. We worry if it returns to that black tarry stools, could there be some blood in the intestine? Red can be a concern for the possibility of blood. So the big things to watch for is back to the black tarry once that's not there anymore. And if anything looks like there could be blood, you'd want to bring that to someone's attention. 

Dr. Alex Rakowsky: Or white stools. 

Dr. Mike Patrick: And white is the other one, yes, absolutely.

So we're going to talk about jaundice in just a little bit. But a lack of bile in the bowel movement... Bile is something that helps us break down fats, a substance in the intestine that the liver makes. And so, if that is absent, it could indicate a liver problem. So white stools would also be a concern.


But other than that, the colors from yellows to greens to browns and tans and all sorts of colors in between really depend on the mix of micro-organisms, bacteria, and such in the intestine. So it really can vary quite a bit from one child to another. 

Dr. Mary Ann Abrams: And that's also affected by what they're feeding. Breastfed babies tend to have more yellowish stools versus the formula-fed. They have more colors. 

Dr. Mike Patrick: Yes, absolutely. And then, the consistency really, again, can range from pretty loose but not like lots of water. But pretty loose to formed and it can vary from one bowel movement to another. If it's consistently very hard and seems difficult to pass, you'd want to let your pediatric provider know about that. Your baby may or may not need help depending on the exact situation. 

And then, frequency of bowel movements can also really range to "I make a bowel movement every time I eat" to "It's every two or three days." And some babies can go several days, especially early on because a lot of our stool is bacteria. And if you don't have a lot of bacteria in your intestine yet, that can affect the amount of stool that you're making. 


And some babies' guts do a better job of absorbing the nutrients that are there and you have less residual. And so some babies can go once every few days. But it's still okay if your baby goes every time you breastfeed. 

You hear both, like breastfeed babies stool more often. But you also hear they stool less often. And I'm not sure there's really good like a study with evidence to show one breastfed versus formula-fed go more often, less often. 

Dr. Mary Ann Abrams: Sometimes, the answer is what's normal for your baby is what's normal for your baby. 

Dr. Mike Patrick: Yes, yes. And changes, pay attention to those changes and let someone know. And they may provide reassurance and say, yeah, those changes are fine. But at least give them that opportunity to evaluate. 


Dr. Alex Rakowsky: I just want to add, you mentioned seedy stools. These aren't like evil people hanging out at the 7-11. So these are little white, almost like dots, in the stool. I've had parents freaked out about this. 

And they are essentially extra fats that the body just gets rid of. So if you see a white globules or little white seeds that are about the size of a sesame seed, that's normal. That usually means that you're producing enough fat in your breast milk or the formula. That's a good sign.

Dr. Mike Patrick: Yeah, very good. So let's move on to colic and fussiness. 

Dr. Alex Rakowsky: Tough topic.

Dr. Mike Patrick: Yeah. So what do you got for us here? 

Dr. Alex Rakowsky: Let me just start off for colic to begin with. So as both a parent and a pediatrician, I find this one as one of the most frustrating things that we do or encounter. And I'll start off with just the statement, like Mary Ann said, that parents love their kids and they want to do what's best for their kids. 


And colic is just sort of unexplained fussiness or screaming, as we'll get in a second. And it's hard to explain it, do something about it, and to get rid of it. 

So colic usually means that a child is unusually upset or screaming more than they should. The official definition is three hours or more at least for days a week for three weeks. Nobody is going to wait that to go see you, but it's an unusually fussy child. 

Usually, starting around four weeks of age. Most of it ends by around four months of age, but it can go for about two to three months. And parents can't find the reason. 

It can be associated after a feed. Then you think about more sort of they're digesting funny. It could be in the evening and that's a common finding in colicky kids, that they get a little more upset in the evening. 

It can be for change in the house, like the lighting in the house. Or there can be no reason at all. 


So colic is to this day not really well understood. But there are certain things that parents can do for it. So, as far as therapy for colic, I start at reassurance. And it's about 10% of all kids are going to have colic. And our job as pediatricians or nurse practitioners is to just to go and make sure that the baby is fine. 

And reassurance number one is that 10% of kids have this, and almost all of them outgrow it. Reassurance number two is that most kids are going to outgrow it in about three or four weeks. Some will go up to three months but by four months of age, almost every child has kind of outgrown it. 

Reassurance number three is there's always somebody you can go see. So if you're really worried about your child being upset, then definitely come on in and be seen. 

And then, there are some things that parents can try. And the couple of tricks that people have tried is like shooshing noises, making like white noise in the background or playing Barry Manilow or something in the background, something soothing. 


Having a... 

Dr. Mike Patrick: Some would not find Barry Manilow soothing.

Dr. Alex Rakowsky: I know, yeah. I guess I do. You can have certain lighting that the child may appreciate. You may have a child who's upset in the evening that you increase the lighting because it may be the shadow affected their seeing. You can take a child and just carry them around. Rub their belly, do some bicycle, and kind of moves the legs up and down. Do belly rubs. 

My personal theory is that kids can't move a whole lot. So imagine lying on the couch and somebody gave you a medicine that you really can't move your body. And you get a back ache or a butt cramp and you're just lying there, so you're going to get upset. All you can do is scream. 

So I think a lot of the colic is because the child also can't communicate any other way. And once they get rolling, they get upset quickly, and if you can't figure out what's going on, they get upset even more quickly and off goes the whole screaming fest. 


So it's a matter sometimes of just taking the child, walk around the house. 

And then, formula changes people have tried. The data for that is really, really mixed and majority of people have noticed that if applied doesn't help a whole lot. There are some data for like the restful, or gentle, or sensitive formulas for kids that haven't had colic for awhile. That if you switch for one of those formulas, they tend to do better. 

Dr. Mike Patrick: Although if they've had it for awhile, then...

Dr. Alex Rakowsky: It's probably going to clear up...

Dr. Mary Ann Abrams: They might be out throwing it, exactly. 

Dr. Alex Rakowsky: People have tried Mylicon which is essentially a soap which breaks up bubbles. I mean, it's really what it is. And for kids who are gassy, I'll try Mylicon. 

People have tried grape water. We have a lot of immigrant families in our clinic and grape water is very common in Hispanic population. Make sure you get from a legitimate source, like a local pharmacy, a local supermarket. And that seems to have some soothing effect. 


But I usually try to avoid some of the more naturopathic things because I'm not sure what those ingredients are in addition to the one herbs, or whatever they have in there. 

But a lot of it is just tincture of time. Time, as in T-I-M-E. Just letting the baby kind of outgrow this. 

Dr. Mary Ann Abrams: I think on top of what you just said, two other points. And you've said it but I think making sure like if I'm the physician, that after seeing them, is to really express our understanding that yes, you are exhausted. And it's so hard to see your baby appear to be so uncomfortable. 

So you're hurting for your child and you're also exhausted, and somebody in your house has to go to work tomorrow. Maybe you have to go to work tomorrow. When you aren't getting enough sleep, everything seems worse. So to really acknowledge that and to be empathetic and understanding. 


And the second part that matches that is "I know it seems impossible right now, but this will go away." By four months, almost all of it is usually gone. So try to keep that long-term view. 

We checked your baby. The ears are fine. He or she is growing and developing beautifully, gaining weight. You have a healthy baby, so it will get better over time. 

And last, to give people the permission to say, "I am just so exhausted or so stressed that I can lay my baby down again, alone, on their back, in a safe crib-like setting or a space." And close the door or walk away. You know they're safe and it gives you a break. That can be hard, but I think telling people that upfront, hearing it helps parents to do that, if that will do what they need to do. 

Dr. Alex Rakowsky: I don't think you can say that enough times. This is probably the most frustrating thing parents are going to go through. 

Dr. Mike Patrick: And you're going through it sleep deprived. 


Dr. Alex Rakowsky: And you're already beat up from delivering a baby or having a baby at home. And it's just a difficult thing for parents to go through. And acknowledging it and then giving them the reassurance, but also giving them the pass that you can go away for a couple of hours and have somebody else watch the baby. 

I mean, if grandma's around, grandpa's around, have them help out because this is frustrating. We have a child with colic, and it's so frustrating because really, you feel like you're failing your child. And just the reassurance that we got from our pediatrician that you guys are still doing a good job and this will pass. And they do pass.

Dr. Mary Ann Abrams: And make sure that whoever that person kind of understands it, too. That the baby has been checked, the baby is okay, and it's okay to let him cry. You want to make sure that you trust them to keep the baby on their back and that they won't be frustrated. 


Dr. Alex Rakowsky: It's perfectly fine if all the pediatricians say, I want to see you again. And we have a family who their first child -- and I've seen this baby and I think seven times now and eight weeks for colic -- and he's finally outgrown it. But it's one of those thing where mom just need a reassurance to say he's fine, he's fine. And it's just like, "Next baby, I'll know what this is," but it's hard, it's very hard. 

Dr. Mike Patrick: And when, the pattern changes in some way that makes your parent radar go off, like "This is not right," definitely have your child looked at. Because there are other things that can make kids very fussy and really difficult to console if they're in constant pain. 

And so, if something is out of character and this is different than their normal fussiness, just have someone take a look. 

Dr. Alex Rakowsky: I mean, the poop changes, if they have a fever, they have a part of the body's not moving or moving normally, you notice a rash, come on in. Because that's the things that can look just like colic. 


Dr. Mary Ann Abrams: And if they haven't been colicky, and suddenly, they're crying continuously, that's...

Dr. Alex Rakowsky: Yeah, come on in. 

Dr. Mary Ann Abrams: And even with colic, they're not usually crying continuously. They're... 

Dr. Mike Patrick: By the time they come in, they're usually fine, right? 

Dr. Alex Rakowsky: Colic's definition is three hours a day, three days a week so it's not that much. But most colicky kids can be like four or five hours a day every day. 

Dr. Mike Patrick: But the car ride to your office, usually they like that, then they're smiling. And then, the parents are apologizing. But parents should not apologize ever for having a concern and seeking the counsel of their pediatric providers. 

Dr. Alex Rakowsky: They only smiled when mom played Barry Manilow in the car. 


Dr. Mike Patrick: Yes, that's right. Just put that on a loop in the nursery. 

Dr. Alex Rakowsky: I only know two songs, so I'm not really sure on the loops. 

Dr. Mike Patrick: I kind of figured that this basic information would take us quite awhile to get through because we wanted to explain it really well and make this useful for folks with brand new babies at home. 

What we're going to do now is kind of rapid fire go through some common problems that you see and just give you some basic points on those. 


So the first one is actually a complex issue and that is newborn jaundice. It means that the skin is kind of a yellowish color. This is one that might take a little bit longer, but I want to try to explain sort of the science behind what's happening with jaundice. And it's caused by an increase in the chemical in the blood called bilirubin. 

That bilirubin in the blood results in discoloration in the skin. Also, the white parts of the eyes, you can see it. Typically yellow, although depending on what pigment that you have on your skin, it may have a little bit of a different hue to it. 

So babies born with African parents, Asian parents, when there's already pigment in the skin, it's going to be a change. 

Dr. Mary Ann Abrams: Pigment means... 

Dr. Mike Patrick: Pigment meaning a coloration. So this could be yellowish, orange. Something different that you're concerned about, have someone take a look at it. 


Usually begins around two to four days of age and usually last about a week, when we're talking about normal baby jaundice. And why does it happen? We have to remember that we have red blood cells in our blood. And the job of the red blood cells is to carry oxygen. The chemical in the red blood cells that helps the body carry oxygen is called hemoglobin. So keep that in mind. 

And then, red blood cells that are carrying the hemoglobin which is carrying the oxygen, they have a limited lifespan. So our bodies are taking apart old red blood cells and making new ones all the time. 

One of the by-products of breaking down the hemoglobin that's in red blood cells is a product called bilirubin. So that's how it sorts of gets into the blood. 

Now, bilirubin is processed by the liver and largely eliminated as bile, which then aids in the digestion of fat. So it's kind of a cool system. We got this waste product. We can do something with it. And so, the liver is going to break that down and get rid of it. 


Now, why do young babies have an excess of this bilirubin? Well, it's because they have too many red blood cells. And the reason that they have too many red blood cells is that they used to have blood vessels that went to mom through the placenta. And so, they had more roads for the blood to travel. And so, you get rid of that part of the circulation. And now, you've got extra amount of red blood cells and the body is breaking those down, it doesn't need them anymore. 

So, we have increased amount of bilirubin. Combine that with the fact that newborn livers may not be quite as good at processing the bilirubin. We do know that breastfed babies are more likely to get jaundice, whether that's a hydration issue, or maybe there's something about breast milk that changes the liver's ability to break down the bilirubin. We know that's still not really well understood. 


And then, something more concerning is is there liver disease? Or is there a blockage with the release of bile from the liver? Also, babies can be somewhat dehydrated. Some of them, if they're not feeding really well, that can also contribute to less blood but still the same amount of bilirubin in it. So the concentration is more. 

There's a lot of little factors in young babies that can create more bilirubin in the blood and we see this jaundice. 

The concern with the bilirubin in the blood is not just that their skin is this color, but very high levels of bilirubin can actually harm the brain. And that's something that we call Kernicterus.

And so, we do worry when the bilirubin is going up too high. So if you do notice that there's discolorization, make sure you see your pediatric provider. They'll probably do a test to see what the bilirubin level is. 

If it is high, there are some things that can be done, feeding babies more often which will help keep them hydrated. It also helps with the bile production, which is how you're eliminating it. So that can be helpful. 


Bilirubin lights, so may have seen a baby that gets a blanket with ultraviolet lights in it. The ultraviolet kind of helps process the bilirubin in the skin, kind of takes over what the liver was trying to do.

Having said that, that's something that ought to be watched over by your doctor. Don't put baby in the sunlight, next to a window and try to do this yourself at home. This should all be done in a controlled environment with your doctor. Understanding what's going on, seeing your baby, and deciding what we need to do. 

Some babies need IV fluids. You can even, when it's really high, take baby's blood out that has the bilirubin in it, and put fresh blood in that doesn't have bilirubin. And, of course,, if they do have a blockage in their liver, then that would need to be, sometimes they have to have surgery for that or if there's other liver disease, you have to deal with that. 

Dr. Alex Rakowsky: Mary Ann already mentioned the importance of a two or three-day-after-birth visit. And this is when a lot of bilirubin problems show up. And so, this is really an opportunity to kind of stress the fact that there's some serious things that can show up on that visit. 


So a heart problem can show up. Just make sure that you get seen two to three days after birth or two days after your leave the hospital. 

Dr. Mike Patrick: Yeah, good point. Warning signs for this, if it's getting worse, if the color is getting more intense, changing over time, you want to let someone know about that right away. 

If it's lasting more than a week, if your child's not making enough wet diapers, or if they have a fever, they're sleeping all the time and seem to be difficult to wake up, those would all be warning signs for baby jaundice. 

Anything else we need to say about that? 

Dr. Alex Rakowsky: It can run in the family. So if you had a child who had jaundice or needed treatment for jaundice in the past, that may be a child that may need a couple of visits to a pediatrician. Just expect that, before we figure out what to do with anything. 


So we've talked about yellow skin. Let's talked about some other skin problems. I like that you mentioned that babies have that flaky skin when they first come home. Everyone says, "Oh, skin like a baby." But baby's skin is not always perfect. 

And one of the things that can happen is sort of the equivalent of an acne that babies can have. And it's because mom's hormones pass through the placenta into the baby's body. Even boys get some of mom's hormones. 

And those can contribute to skin changes that result in acne just like in puberty. So you get increased production of skin oils. The way that the skin sort of sloughs off can break those oil glands. 

So the same thing that causes acne can happen in little babies. And so, often we see that on the face, but it can happen in some other places. Your baby's not making those hormones unless they have a disease process that would cause that to happen. 

So, the mom's hormones are slowly going away. So usually, by the time they're about four months old, definitely by six months, those things should be going away. And if it's lasting longer than that, you want to let your doctor know.


Also, look for skin infections. So if there's increasing redness or firm tender skin that just doesn't look right to you or again lasting longer that you'd expect, have a pediatric provider look. Just leave it alone. Don't try to pop it or pick it. Just kind of wash the skin as you normally would with just some general soap and water. 

But if you are worried about increasing infection, have someone take a peek. And then, Alex, you're going to talk about another common skin issue cradle cap. 

Dr. Alex Rakowsky: So cradle cap is like this thickened skin on the top of the skull. It can be either mixed in with the hair, to the side of the hair. It's very common in infants. It's essentially sort of almost like a greasy dandruff. Is it a form of psoriasis? Potentially, sort of seems to be in the same family. 

Best therapy for that is just put some oil on it, like a baby oil. I'm actually a bigger fan of -- a lot of families do this -- olive oil or something like a nice filtered unscented oil. Let it soak in for a little bit and jus scrub it off with a soft scrub, like a brush a lot of babies get in the hospital. 


If it gets a little bit more hard to clear, what we do actually is use a little bit of Selsun Blue. So we'll put Selsun Blue to a cup and froth it off. So a squirt, froth it off, get that little blue froth. Put that on the head, let that sit there for about a minute or two, it will loosen it up sometimes. Wash it off, then do the oil and then do the scrubbing. 

And if that doesn't work, sometimes, you have to use steroids that you put on the cradle cap. Again, talk to a pediatrician or pediatric provider about that. 

Dr. Mike Patrick: And just using the Selsun or the oil one time isn't going to make it go away. So don't be concerned that it may help it and then it may kind of come back. And those things help to kind of dissolve that scaly oily... That's why the oil works, it helps to dissolve another oil. 


Dr. Alex Rakowsky: And that's a great point. It can take weeks to get rid of it. But as long as it's slowly coming off, it's okay. 

Dr. Mike Patrick: And watch for signs of infection, if there's redness.

Dr. Alex Rakowsky: It will not go bald in that area if you get rid of it successfully.

Dr. Mary Ann Abrams: And it doesn't mean that you're not taking care of your baby or washing them the way you should. 

Dr. Mike Patrick: It's also probably there's a hormonal component to it of some sort and kids typically outgrow it with time, with a few months. As you're using any of the Selsun type shampoos, those are more tears, not "No More Tears". So if it gets in the baby's eyes, it's going to sting. 

Dr. Alex Rakowsky: Yeah, definitely. 

Dr. Mike Patrick: It's not going to hurt them, but just watch out for that. They won't be happy.

Dr. Alex Rakowsky: Yeah, definitely use a froth only and then cover the eyes just to.... 

Dr. Mary Ann Abrams: Sometimes, the Selsun shampoo can be hard to find so you may have to ask when you go to the drugstore or the groceries to try to find it. 

Dr. Alex Rakowsky: The regular one, not the menthol one. 

Dr. Mary Ann Abrams: They're not going to be right there at eye level. Just don't be afraid to ask. 

Dr. Mike Patrick: And probably not in the baby aisle. 

Dr. Mary Ann Abrams: No. 

Dr. Mike Patrick: And then, diaper rashes, very common?


Dr. Mary Ann Abrams: Yeah, diaper rashes are pretty common. They can kind of come and go. Your little baby's bottom can be looking great and then with another diaper change, "Oh, my goodness!" 

And most of them have a common underlying cause. And it's basically, that skin is being irritated. And whether it's being irritated by a lot of urine, a lot of pee, or a lot of pooping. Or maybe the diaper has stayed on too long. Or maybe somebody tried to clean extra hard. They're using products that are irritating to that baby's sensitive skin. All those things can lead toward a diaper rash. 

So the best thing, and sometimes they can get infected later. A diaper rash can make the skin a little bit more tender and open to a yeast infection, or even a bacterial infection that does need more treatment. 


But generally, the best approach is to prevent it. And to do that, kind of things that you might take for granted. Try to change the diapers frequently. Especially if they poop or have a bowel movement, try to change that diaper really quickly after that, so that it doesn't stay on and irritate the skin.

Use a nice kind of thick barrier ointment or diaper cream or even petroleum jelly, just to kind of give it extra little coating to prevent that irritation, especially the diaper may stay on a little bit longer. And if possible, let that baby's bottom be open to air, even if it's 15 minutes. 

But if they have a bad diaper rash, try to do that for a little bit longer period of time. And as long as you're with them, they can be on their tummy with their bottom up in the air. But don't put them like that and then walk out of the room. 


The other thing is sometimes, if their bottoms are really irritated, Mike talked earlier about seeing blood in the stools. Sometimes, parents saw the baby's been okay, they have a little diaper rash, and they see a little blood in the stool, and that's very alarming. 

So sometimes, if that bottom is really irritated, there might be a fleck or two of blood. Or sometimes, that can even cause a little crack in the skin right where the poop comes out. 

So obviously, you can call a doc and have them checked. But you can also take a little gentle look and see if you see a little, kind of a little tear in the skin. And that's very reassuring, that there's not some other bleeding problem going on. And then, you can clean that. 

We prefer you clean with just warm water and a washcloth or a baby wipe that doesn't a lot of extra scents and chemicals. Don't scrub and brush hard. And then put a little extra of your diaper ointment or petroleum gel right around the bottom there where the poop comes out and then over the areas that are exposed to the diaper.


Dr. Alex Rakowsky: I'll add two things here. The first is don't use cornstarch. So cornstarch actually has starch and fungus loves starch. So this is a great setup to get a yeast infection down there, a fungal infection down there. 

And then, the second thing is if you see little red dots, what we call satellite lesions, so you see the rash and then you see dots in different places, that means that there's most likely a fungus involved or yeast involved. Get seen, but while you're waiting to get seen, you can always start like an antifungal, like athlete's foot cream. 

It's water-based so it peed off easily, so put it down and put thick things that Mary Ann talked about on top of it. And I guess out of everything, it's okay to use the thick cream like a petroleum jelly, whichever you like because it's cheap and it work great, every diaper change. Because you really wanted to sort of protect that skin from the harshness. 


Dr. Mike Patrick: Kind of create a barrier. 

Dr. Alex Rakowsky: You create a barrier, yeah. 

Dr. Mike Patrick: Between the pee and the poop and the diaper and the skin.

Dr. Alex Rakowsky: And there's nothing special by any of them. We have people use Desitin, Butt Paste, you name it, they tried it. And they will work about the same. And for parents who really struggle with finances, you can get a big jar of just Vaseline or petroleum jelly for like a dollar. 

Dr. Mary Ann Abrams: When you mention cornstarch, a lot of people think about baby powder or talcum powder. That again does nothing to help any diaper rash and it can also be a hazard if it gets poofed up in the air or knocked over and the baby can actually breathe that in. And that can cause serious problems, too.

So keep the powder away and kind of prevent it with those simple but straightforward approaches. 

Dr. Mike Patrick: Good. Okay, a couple more topics we're going to cover very quickly -- belly buttons, most babies are going to go home with kind of a stalk and the clip still on there. And it's going to dry out over time, just separate on its own.


And the majority of babies, you can just leave this alone and just let it fall off naturally. It's going to take a few days to a couple of weeks, but it's going to happen. Some folks would say if you want to hurry off, you can use some rubbing alcohol and a Q-tip or a cotton ball with each diaper change just to kind of hurry it up drying. 

But there's no evidence that you have to do that. Some people say do it, and some people don't. And the recommendations go back and forth on that. 

Things to worry about with the belly button -- redness, tenderness, drainage. Anything that looks like an infection can be an issue. After the stalks separates sometimes, you can get some persistent yellow tissue with just sort of overzealous healing. And sometimes that needs to be treated. 

We've called that an umbilical granuloma. Big word, just means belly button and kind of some scarish tissue that the body is making. So if you do see persistent yellow after the cord has come off, then you'd want to bring that to someone's attention. Of course, bleeding as well. 


Sometimes, you can get a hernia around the belly button. So if there's a bulging there, you want to make sure that it's soft and you can sort of push it back down, but you don't have to constantly push it down. 

Don't tape a quarter or a 50-cent piece over to try to keep it down, but just let your provider take a look at it and give you some reassurance there. Those kind of hernias usually go away on their own as the abdominal muscles continue to grow and mature. But sometimes, they can be there for a long time and might have to do something about it, but most of the time, you don't. 

Things to worry about with that is if it's very hard, tender. It's not soft. You can't push it down, you'd want to let someone know about that right away. But that's unusual. 

And then delayed separation where it does take the stalk longer to come off. We're talking like a month of age, it's still there. So definitely, let your doctor know about that because it can be associated with some other medical conditions. 

Anything else with belly buttons? 


Dr. Alex Rakowsky: Yeah, belly button hernias or what we call umbilical hernias are really common. So we'll put a finger in there to see how deep they are inside. It doesn't matter what's coming out, it's how big the hole is inside. And most will clear up on their own. 

Dr. Mike Patrick: Don't tape quarters and 50-cent pieces. Sometimes, we see folks... 

Dr. Alex Rakowsky: We see that less and less now.

Dr. Mike Patrick: Yeah, yeah, I'm showing my age. Although I have mentioned it before and parents still sometimes go, "Okay, yeah, yeah." 

Dr. Alex Rakowsky: You still see it, yeah.

Dr. Mike Patrick: And then, Mary Ann, very quickly -- immunizations. So as babies are at the hospital right after birth, there's a couple potential shots they could get, one's not really an immunization. And then, also, the two-month visit, what can you expect there? 

Dr. Mary Ann Abrams: Yeah, I think there's just a couple of key points since we're covering a lot of newborn topics today. Clearly, we could do a whole session on vaccinations and hopefully, we will. 

But in the newborn period close to birth, they'll probably get two shots. One is called vitamin K which is not a vaccination. But interestingly enough, babies are born with the ability of their blood to clot isn't as developed as it should be. And they don't have the vitamin K that they need.


Vitamin K is important for blood clotting. And without it, babies can be at risk for bleeding right after they're born and later, up to four to six weeks. And we're not talking about just a little oozing crack in their skin that can cause bleeding into their brain. It can cause bleeding into their intestine and their gut. And babies can actually die. 

So what we know and learned over time is that giving them that shot of vitamin K. And a shot works far better than any other way of giving that vitamin K as soon after they're born as we can helps prevent that, and basically saves a lot of babies' lives and also prevents potentially severe damage to their brain. 

So that's why vitamin K is given. I think it's good to think about that. You may think it's a little bit uncomfortable for your baby to get a shot soon after they're born but the benefits and the risks are clearly in favor of doing that vitamin K. 


The other vaccination shot they get after they're born in the hospital is for hepatitis B. And that is given because we want to make sure that if a baby is born of a mom with hepatitis B or exposed to hepatitis B right at that time, they have a very high chance of getting hepatitis B. And hepatitis B, when you get it at an early age is much more likely to lead to having it the rest of your life and even leading to liver cancer. 

So to make sure that babies don't slip through the cracks or somehow don't get that or wait till they come back and then they don't come back, every baby is given a shot against hepatitis B when they're born. Because we know it works very, very well at that time to prevent hepatitis B becoming active at an infection in that baby.


So they get those two vaccines or those two shots and then they're kind of good. And then, obviously, when they come back, usually at their two-month visit, that's when they will start their regular vaccination series. 

And we have such a wonderful vaccine program in our country based on really good science and research to really protect children, older children, families, everyone in the community and the population against a lot of very serious life-threatening diseases. 

And the science that goes into why we are giving all these shots to these two-month-old baby, that research has shown that there's a perfect balance between when their immune system starts to be strong enough to respond to the vaccination, to build the antibodies and the immunity to these conditions. 

It's far enough out that any antibodies they might have from their mother have started to go away. So it doesn't interfere with the vaccine. And we also want to provide them with the protection as early as possible. 


So take just one quick example, whooping cough can kill babies. So that's why we want to jump on that at the first opportunity when it starts to work well for them. That's why they need a couple of boosters because each one of those boosters helps protect them even more. 

So yes, they'll get vaccinations about eight different diseases. That doesn't mean they get eight shots because we combine a lot of those and one of them is actually by mouth. But it's a very important visit and it's one of the important things we do at that two months visit. 

Dr. Mike Patrick: For those who are interested in hearing a lot more about immunizations, back in Episode 351 and 352 of PediaCast, we actually have two-part series with Dr. Mike Brady, who is a Nationwide Children's Hospital infectious disease expert, who also has worked with the CDC and the AAP in terms of coming up with immunization schedules. He's one of the top immunization infectious disease docs in the country. 


He was on PediaCast. The first one, 351, we basically just went through all the childhood shots, the diseases that they protect against and we look at real risks of shot. Because we're not going to say that they're 0% risk but certainly the benefit far outweighs the risk. And we try to illustrate that as best we could.

The first episode, we talked about hepatitis B, diphtheria, tetanus, pertussis, polio, Hib, pneumococcal, rotavirus. And then the second one, 352, we talked about the flu vaccine, MMR, chicken pox, hepatitis A, meningitis, and HPV vaccine. So pretty much all of them. And those were really great episodes. I felt like it was a really good discussion that we had. And so, I would encourage folks to take a listen to those if you're interested. And I'll put links to both of those episodes in the show notes for this one, 441, over at


Lots of links for you this week, including the book that we had talked about. The Plain Language, What to Do When Your Child Gets Sick and the 40% discount. It's already not that expensive a book. Like $12 I think and you get 40% off that. So it almost doesn't cover your postage though with the price that they're offering. 

So we'd really encourage to get that book, very easy to read. We'll have links to primary care pediatrics here at Nationwide Hospital, which both of you represent that division here with our system and all of the many primary care centers we have around town.

And then, of course, our Pediatrics in Plain Language survey, we really would love to hear your comments and your thoughts on these programs. And we'll also have links to all of the past Pediatrics In Plain Language episodes. We do about one a quarter or so, and we'll have links to all of those. 

We also have the SoundCloud playlist which has all of our Pediatrics In Plain Language episodes and I'll put a link to it in the show notes for you for that as well. 


So our time has come to an end. I just want to say once again to Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both primary care pediatrics at Nationwide Children's, thanks so much once again to both of you for stopping by. 

Dr. Alex Rakowsky: It's a great topic. We can probably do this a couple of times. 

Dr. Mike Patrick: Oh yeah, absolutely. There's more, there's a lot we didn't talk about, and we're already an hour and 15 minutes in. But parents want to know about this stuff. And baby books are thick because there's a lot to talk about. 

Dr. Mary Ann Abrams: So send us your questions, what we didn't touch on or what we could touch on next time. And it's always fun for us. 

Dr. Alex Rakowsky: Thanks.



Dr. Mike Patrick: We are back with just enough time to say thanks to all of you once again for taking time out of your day and making PediaCast a part of it. Really do appreciate that. 

Also, thanks to our guests this week, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both primary care pediatrics here at Nationwide Children's Hospital.

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Those episodes are also available in Apple Podcasts, iTunes, Google Play, iHeart Radio, Spotify, and most mobile podcast apps. Simply search for PediaCast CME.

Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.


Announcer 1: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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