Class 4 - When to Worry About Your Baby

Bringing a new life into the world is incredibly thrilling, and equally terrifying. Quite suddenly, parents become entirely responsible for the safety and wellbeing of the person they love more than life itself. What’s more, that little person is completely helpless.

The good news, however, is that although your new baby looks complicated (lots of moving parts!), she is actually very simple and very resilient. Once you fully buy into this fact, taking care of your baby becomes much more straightforward. It doesn’t make it easy, by any means, but it does remove some of the terror.

This class is designed to teach you about the things you will notice in your baby that may worry you, and to help you differentiate the truly dangerous from things you can confidently handle on your own. The goal is to educate you ahead of time, so you don’t find yourself terrified in the middle of the night, unsure of whether or not you should be worried.

Always Concerning

When we answer messages from worried parents, there are a few things we always need to know to understand how dangerous the situation is. If these symptoms are not happening, your baby is usually safe to stay at home with supportive care from parents. If these symptoms are present, however, your child may require a trip to the emergency department for further evaluation and treatment.

1. Dehydration

  • You may read or hear about different ways you can monitor this (sunken fontanelle, not making tears, dry or cracked lips, dry mouth, dry skin). Unfortunately, interpreting these symptoms correctly is complicated and takes years of practice. For this reason, we do not recommend parents use these methods.
  • The good news, is there is one easy way to know if your child is hydrated or dehydrated: count the wet diapers.
  • Regardless of how old your child is, they should pee at least every 8 hours.
    • If they’re sick or acting differently, make a note of the time of day you see a wet diaper.
    • To count, it doesn’t have to be a whopping wet, soaked diaper either.
    • Any urine that’s enough to change the color strip indicator on the front of the diaper counts as a wet diaper.
  • If your child goes longer than 8 hours without making urine, AND is sick or acting differently, you should let us know so we can discuss.

2. Respiratory Distress

  • Respiratory distress is a medical term which means “working hard to breathe.” Another way to think about this is “labored breathing.”
  • The best way we’ve found to describe respiratory distress to parents is that it looks like the baby is out of breath, as though they just finished a work out.
  • It is difficult to see the breathing clearly with clothes on.
    • For this reason, you should always turn on the light and take of the shirt or onesie when evaluating for respiratory distress.

3. Inconsolability

  • We define a child as inconsolable if they are crying continuously without interruption for 30 minutes or longer, and you’ve done everything you can think of to console them.
    • Good ways to soothe your baby include:
      • Offer Breast Milk or Formula
        • We tell our families that a baby who is crying during the first 6 months of life is always hungry until proven otherwise.
          • Regardless of how recently, or how much you fed them last time, offer more food when fussy just to make sure.
          • New parents are usually surprised at how much and how frequently their baby needs to eats.
        • If your baby is crying so hard they won’t feed at the breast, offer pumped milk or formula from a bottle.
          • If your baby vigorously eats and finishes everything in the bottle, offer more.
        • You can’t overfeed a baby, because they will stop eating when full.
        • The crying and fussiness of a hungry baby are often incorrectly blamed on other things:
          • Gas pains
          • Indigestion
          • Constipation
          • Only wants to be held
          • Hates being on his back
          • Hates the bassinet or cradle
          • A recent change in formula, mixing and matching formula brands
          • Mom’s diet (as long as the food is healthy, research has shown us this is never the case)
          • Too hot
          • Too cold
      • There's nothing wrong with using pacifiers to soothe a fussy baby, but first make sure she isn't hungry.
      • Swaddling, swaying, singing, and shushing are other classic ways to soothe your baby, after you’ve tried offering more food.
      • If your child has fever, symptoms of infection, is teething, or received vaccines in the last 72 hours, offer acetaminophen to see if this helps.
        • If your baby is older than 6 months, you can offer ibuprofen as well. Both are equally effective.
  • If your baby has been crying continuously without stopping, for at least 30 minutes in a row, and you’ve tried everything discussed here, you should let us know so we can discuss.

4. Altered Mental Status

  • Put simply, altered mental status means the brain is not working correctly. Examples of altered mental status include a child who:
    • Has a seizure (whole body jerking movements alternating with whole body stiffening)
    • Does not recognize parents or surroundings.
    • Is truly lethargic
      • Luckily, when parents say their child is lethargic, they usually mean that, compared to normal, their child has less energy, or is more clingy, fussy or tired.
      • The medical definition of lethargic is an almost coma-like state. Essentially, the child responds very little or not at all, despite the caregivers best attempt to get them to do so.
      • True lethargy is a sign of serious illness, and usually warrants immediate evaluation in the emergency department.

Fever

  • Fevers in children seem to cause caregivers a great deal of anxiety.
  • This stems from two main factors:
    1. Fevers are frequently uncomfortable. If you can remember the last time you had a fever, I’m sure you would agree. You have no energy. Your muscles ache and your head hurts. You don’t want to eat or drink anything, and you can’t sleep. This happens with children as well, and it worries caregivers to see them so miserable.
    2. There are a great deal of myths surrounding fevers.
  • Myth
    • Fevers, especially very high ones, can permanently hurt a child. A high fever can, for example, damage the brain or other important organs.
  • Truth
    • A fever is defined as any temperature of 100.4ºF or higher.
    • Medically speaking, there is no such thing as “mild fever” or “high fever.”
    • Fever will not permanently hurt your child, regardless of how high it gets. The fever just tells us there is an infection. 
      • Fever is a symptom of an infection, just like cough, runny nose, or vomiting. 
    • What matters is that your child is not dehydrated, does not have respiratory distress, is consolable, and does not have altered mental status.
  • Myth 
    • A higher fever means the infection is more dangerous, or is more likely to be caused by a bacteria which requires antibiotics to fix.
  • Truth 
    • In children, the height of the fever does not indicate a more dangerous infection, nor does it imply a bacterial infection. 
    • Common viral infections that cause a simple runny nose and cough in adults, will frequently cause fevers as high as 105ºF or 106ºF in children.
    • What matters is that your child is not dehydrated, does not have respiratory distress, is consolable, and does not have altered mental status.
  • Myth
    • You should be more concerned if acetaminophen or ibuprofen don’t bring the fever down to normal, or the fever returns before the next dose can be given safely. 
  • Truth
    • This actually happens frequently, and does not mean the situation is more dangerous.
    • What matters is that your child is not dehydrated, does not have respiratory distress, is consolable, and does not have altered mental status.
  • Myth
    • Giving acetaminophen every 4 hours and/or ibuprofen every 6 hours (the way they are supposed to be taken) for many days in a row is not good for children.
  • Truth
    • What matters is that the dose is correct for your child’s weight, and that you don’t give two acetaminophen doses less than 4 hours apart or two ibuprofen doses less than 6 hours apart.
    • The number of days in a row is not medically important.
  • Myth
    • As long as my child is not dehydrated, does not have respiratory distress, does not have altered mental status., and can be consoled, I don’t ever need to worry about a fever, no matter how old my child is, how long the fever has been going on, or how high the temperature gets.
  • Truth - There are some fever situations where you should contact the pediatrician. Whether you need to contact the doctor immediately (day or night) or during regular business hours, depends on the situation.
    • Contact Immediately, Day or Night:
      • If your child is dehydrated, has respiratory distress, is inconsolable, and or has altered mental status,
        • Or, if you don’t know if these things are happening.
      • If your child is less than 90 days old, and has a rectal temperature of 100.4ºF and higher, or 96.9ºF and lower. 
        • In this age group the immune system is still immature, and more susceptible to dangerous, potentially life-threatening infections.
        • Although the fever is still not dangerous for these babies, and these dangerous infections are rare, you should still let us know right away to make sure you don’t need to go to the emergency department.
      • Your child, regardless of age, has a fever of 105ºF or higher.
        • Although a fever of 105ºF and higher is not dangerous by itself, you should let us know right away to make sure you don’t need to go to the emergency department for dehydration, respiratory distress, inconsolability, or altered mental status.
    • Contact During Regular Business Hours:
      • If a temperature of 100.4ºF has been present at some point during the day for 3 full days in a row.
        • The first time you notice a fever, we consider that day 0 of the fever.
        • The following day at the same time is 1 full day of fever.
        • If there are 3 full days of fever, you should contact the pediatrician during regular business hours to see if your child should be examined in person.
      • If your child has a fever, it goes away for at least 24 hours in a row, and then returns.
        • This could indicate that a bacterial infection (which requires antibiotics) developed on top of the original viral infection.
        • Usually, this is just just a second, overlapping viral infection, but we should discuss to see if your child should be examined in person.

Coughs and Colds

  • Pediatric research has shown that in the first two years of life children average 6-8 colds per year.
  • With that in mind, it’s not a question of if, but when, your child will catch a cold.
  • The good news is that these viral infections, while unpleasant for everyone involved, are rarely dangerous, and the symptoms can be confidently handled at home.
  • Symptoms:
    • Cough
      • the cough from a cold is frequent, occurs throughout the day, and there are usually several coughs in a row.
      • Many babies will have a cough here and there, or only at certain times of the day, for example right after feeding or when you lay them down.
        • These are not caused by viral infections.
    • Fever - see discussion on fevers above
    • Runny Nose
      • The nasal discharge from a virus is visible outside of the nose, and typically runs down the face and around the mouth.
      • It is clear at first, and then will change to green or yellow later in the infection.
        • Medically speaking, the color of the discharge does not matter whatsoever.
        • Although visually unappealing to parents, these runny noses will not bother your baby, and almost never cause difficulty with feeding.
  • Duration
    • Each viral infection typically lasts 10-14 days.
    • Unfortunately, children frequently catch a second, different cold virus on the tail end of the first.
      • When this happens, the 10-14 days of symptoms restarts.
      • As a result, cold symptoms can last for many weeks without going away.
        • Some parents worry this means the child is fighting a dangerous “super bug” which they won’t be able to beat, or perhaps there’s something wrong with the immune system.
        • In reality, the immune system is fighting and beating each individual virus beautifully, but there have been several in a row.
  • Contact Immediately, Day or Night:
    • Dehydration, respiratory distress, inconsolability, or altered mental status.
  • Contact During Regular Hours:
    • The same cold symptoms have been present every day (no days off!), without improvement, for 4 weeks in a row.

Nasal Congestion of the Newborn

  • Occurs between birth and 6 months of life
  • Unlike the runny nose caused by a cold virus, this congestion is something you hear in your baby, and is often accompanied with dried boogers in the nose you can see.
  • It’s important for you to know your baby does not have a cold when this occurs.
  • This is actually caused by silent reflux, which all babies and is completely normal.
  • The “boogers” you see and hear in the nose are actually dried breast milk or formula.
  • This is also the reason babies sneeze so much during the newborn period.
  • This congestion will not bother your baby, and almost never causes difficulty with feeding.

Spitting Up

  • In the first 6 months of life, most babies spit up 20-30 times per day. 
  • Most of the time they swallow it back down without you seeing it at all.
  • This occurs because the sphincter (think of a rubber band) that keeps food from leaving the stomach back to the mouth is loose in babies and gets tighter and stronger as they approach 6 months.
  • When caregivers do see the spit up, it can be alarming because it happens suddenly and always seems like “they spit up the entire feed.”
  • Normal Spit Up Includes:
    • A lot or a little
    • After every feed or just some of the feeds
    • 2 minutes or several hours after a feed
    • Clear, yellow, or the color of whatever they have been eating
    • Curdled or uncurdled
  • Spit Up is Not Caused By:
    • Eating too much (if you follow the hunger cues, you can’t overfeed a baby!)
    • Eating too fast
    • Not burping long enough, or the baby being a “bad burper”
    • Mom’s diet
    • Putting them down too fast after a feed
    • Indigestion
    • Gas
  • When To Worry
    • All babies have reflux, but a very small percentage of babies have painful reflux.
      • Babies with painful reflux are in pain when they eat.
      • They show signs of hunger, and feed for a few sucks when offered food, but then scream in pain while eating, and refuse to eat anymore.
      • Sometimes these babies will lose weight due to painful eating, and may need medicine to reduce the acid in their stomachs so eating isn’t painful.
  • What You Can Do
    • If your baby isn’t in pain while eating, this reflux is completely normal and should be ignored.
    • If you try to fix it, you won’t get the results you want, and you may create a new problem, such as feeding your baby less than she needs.
    • If it ain’t broke, don’t fix it!
  • Important
    • Your baby will not suffocate on their own spit up.
    • They will swallow it back down, or it will make a mess, but they will not choke to death if they spit up while lying on their back.

Poop

  • Parents pay a lot of attention to the poop, and place a great deal of weight on what they see. 
  • From a medical standpoint, poop is rarely important, and we often tell parents to ignore it entirely. 
  • That being said, there are a few things to look out for.
    • Concerning Poop Features
      • Color
        • All the colors of the rainbow are normal, except for bright red blood.
        • White or acholic (without color) poop indicates a dangerous problem in children under 2 months old.
          • If older than 2 months, this is not concerning.
      • Consistency
        • All consistencies are normal except for hard, little pellets/pebbles (think rabbit poop).
        • This is the way we define constipation in children.
      • Frequency
        • Many newborns poop every time they eat.
        • Some newborns don’t poop every day.
        • Around a month of life, a baby’s digestive system becomes more efficient, and they may go 10+ days without pooping. 
        • What’s important is that they are peeing and eating normally, and that they are not pooping pellets/pebbles.
        • Constipation is defined on what they poop (pellets/pebbles), not how often.

Eye Goop/Crust/Redness

  • The way to identify a true eye infection is that the white part of the eye is very red compared to normal.
  • If the whites of the eye(s) are not red, there is no infection.
  • A true eye infection can be caused by a cold virus or bacteria.
    • A cold virus usually involves other cold symptoms (cough, runny nose).
      • The eye symptoms (redness, tearing, itching, green/yellow discharge) are just another part of the virus.
      • These symptoms will stop when the virus goes away.
    • The redness and mucus from a bacterial eye infection usually show up in one eye first.
      • It can then spread to the other eye as well.
      • The drainage returns almost immediately after wiping it away, and happens all day, not at certain times (after naps).

Blocked Tear Duct

  • A blocked tear duct is a very common, non-infectious, cause of eye goop and crusting in the first ten months of life.
  • The tear duct normally drains tears when the eye makes them.
  • These ducts are small and easily blocked by debris during the first ten months of life.
  • When this happens, the tears don’t drain properly and accumulate into eye goop and crust.
  • The whites of the eye are not red because there is no infection.
    • Wiping away the goop should be done sparingly (for example, if they can’t open the eye because of the crusting).
    • Wiping should only be done with sterile products to avoid introducing bacteria from tap water or a “clean” washcloth on your shelf.
    • Saline water and gauze are good options for wiping the goop if you need to. 
  • The blocked tear ducts usually come and go, often including both eyes, throughout the first ten months of life.

Head Injury

  • As motor skills progress from sitting up to crawling, pulling to stand, walking, and running, head injuries become incredibly common. 
  • Try as you might to pad the sharp corners and edges in your home, kids always seem to find the one spot you missed. 
  • From the loud noise the impact makes, to the giant goose eggs that form, bumps to the head can be very scary for parents. 
  • Fortunately, they are very rarely dangerous, and there are just a few simple things you can look for to rule out a serious head injury:
    • Mechanism of Injury
      • This is the most important indicator of a dangerous head injury, and if the mechanism of injury is not dangerous, there is very low risk of danger for your baby.
      • Serious mechanisms of injury include the following:
        • High speed injury, for example from a bicycle or motor vehicle accident.
          • Your child is fast, but can’t run fast enough to be labeled “high speed.”
        • Injury from a hard projectile, such as a golf club or baseball bat.
        • Fall from a great height,
          • 3 feet or higher for a child under two years old.
          • 5 feet or higher for a  child older than two.
    • Persistent or Worsening Vomiting
      • Persistent and worsening is the key here, because children will often vomit once or twice after a fall, usually due to hard crying, or simply because kids vomit sometimes.
    • Loss of Consciousness
      • We always ask parents if the baby cried right away to make sure they did not lose consciousness.
      • If they cried right away, then we know there was no loss of consciousness.
    • Altered Mental Status
      • Examples of altered mental status include a child who:
        • Has a seizure after a head injury.
        • Does not recognize parents or surroundings.
        • Is clearly off balance compared to normal.
  • Size of the Bump
    • The size of the bump is not a good way to identify a dangerous head injury, and is not something we ask parents about.
    • The swelling increases over time, and may look much worse the following morning.
  • Management
    • If none of these dangerous mechanisms or symptoms are present, you can let them sleep and play normally without interrupting to check on them.
    • Ibuprofen (if older than 6 months) and acetaminophen are helpful if your child seems more fussy after then head injury.
    • Most children will resist a cold or ice pack on their injury, and you don’t need to fight them on this since the swelling will heal on its own with time.