No Need to Worry, Mom. It’s Normal.


altOne steady source of business in the emergency department comes from a group described as the “worried well.” Anxious new parents are frequent members of this tribe and come into the ED at all hours to point out perceived abnormalities or areas of concern in their little ones.


10 common neonatal concerns that have non-threatening explanations

One steady source of business in the emergency department comes from a group described as the “worried well.” Anxious new parents are frequent members of this tribe and come into the ED at all hours to point out perceived abnormalities or areas of concern in their little ones. To be fair, neonates can be more than a little mysterious, and even emergency physicians can pick up on odd physicial findings and begin to worry unnecessarily. To assist in your care of the “worried well,” here is a list of ten findings that can be normal in infants:

Cutis marmorata – this is the elegant Latin term for that lattice-like mottling that infants can get due to vasomotor instability. While mottling can be pathologic, it is seen in normal infants with cooling, starting in the newborn period and persisting for several months. If the baby looks well otherwise, warm them up and then come back and re-examine them. It should resolve.

Acrocyanosis – blue hands and feet, also due to vasomotor instability and also generally benign. It is usually seen when the baby gets cold and can be dramatic after they are pulled out of the bathtub. It may be seen in the first few months of life. If the baby has pink lips and tongue, it is not concerning and should disappear with warming.

Peri-oral cyanosis – the parent will come in and report that the baby turned blue around the mouth. You may even witness this yourself in the exam room. If the lips and tongue remain pink while the area around the mouth turns blue, this is fine. It is due to engorgement of a venous plexus around the mouth and is normal.

Harlequin color change – this one is dramatic. It is uncommon and is not due to disease in the heart or the vessels. The neonate appears to be divided down the middle into a pale half and a red half starting at the forehead and going to the pubis. It is due to vasomotor instability and is normal in the newborn period. Sometimes, if you lay them on the pale side, the color change will shift and the dependent side will get red and the other side will get pale.

Breast enlargement – this can occur on both male and female infants. It is due to stimulation from maternal estrogen in utero. It can persist for several months after birth. Sometimes, the breasts become engorged and drain a white liquid known as “witches milk”. This is not pathologic and will go away after 1-2 weeks.

Vaginal discharge – female infants can have a milky vaginal discharge in the first few weeks of life that can even be blood-tinged. This is from exposure to high levels of maternal estrogen prior to birth and is normal.

Hyperpigmented genitalia – this can occur in both male and female infants. It is also due to maternal estrogen effect and will fade during the first year of life.

Myoclonus – course trembling of the jaw, arms, and ankles can occur in the neonatal period, usually during a period when the infant is active. It does not persist. Twitching due to a convulsion is more likely to happen when the infant is in a resting state and may last longer.

Palpable liver – the liver edge is frequently felt in normal newborns. It can be normal up to 2 cm below the costal margin.

Palpable spleen – a spleen tip can also be felt occasionally in normal newborns.

Amy Levine, MD, is an associate professor of pediatric emergency medicine at UNC Chapel Hill.


  1. I know this is a very late comment, but parents SERIOUSLY bring neonates in for this stuff? I know we have parents with low literacy issues, who may be kids themselves, but every single Mom gets sent home with a fairly thick handout on normal neonatal “funny looking things”.

    I guess if some of them were listening to the teaching instead of texting the world during their (too short) inpatient stay, they might have picked up on some of this already. Where is Dr. Google when you really NEED him?

  2. my baby is now one month old,she had an 2decho scan on her second week old when her gp heard a murmur in her heart.she told us that my bb have a hole in the middle of her her heartbthat causes pressure on her lungs.she also told us that the hole will closed on its own,and nothing is alarming.but recent i’ve noticed in bluish color at the bottom of her it possible sign of cyanosis?pls help…thanks

  3. I’m not surprised parents bring their babies in for these things. Especially if it’s their first child. It’s overwhelming to have a first baby and be inundated with information. And even if the new parents read that what they are seeing is normal, I can understand their asking their ped just for reassurance.

    I think the problem with Dr Google is that the average person doesn’t know how to tell if a source is legitimate. Pretty much no matter what is googled, you can come up with scary information as well as conflicting information.

    And isn’t it better to bring a baby in for an exam to find out it’s nothing serious than not bringing a baby, assuming it’s nothing, when it really isn’t? Should a parent with no medical training be trusted to differentiate between benign and serious conditions? For example, distinguishing acrocysnosis from general cyanosis?

    Even doctors can be wrong. My sister, now 25y, turned blue when she cried. My mom took her to the ped when she was a few days old, and the ped said she had a minor heart problem and they could see the ped cardiologist in a few days. Had my parents not refused to wait, she would have died that night. She has hypoplastic right ventricle , tricuspid and pulmonary atresia. When my own son was diagnosed with a murmur at 2 days old, our ped said it was a waste of time to see the cardiologist, despite the family history of congenital heart defects. At every well check she said the same thing, it would be a waste of time, it’s a classic PPS murmur. Finally when he was 7 months old , I was more persistent. I had found journal articles that said PPS murmurs are GONE by six months. Nearly 25 years to the day, since my sister saw the ped cardiologist for the first time (when my parents were told to immediately follow him to the hospital) , my son saw the same ped cardiologist who diagnosed mild pulmonic stenosis that needs to be monitored and may one day need to be repaired through a cath procedure. He certainly didn’t think it was a waste of time to do an echo!

    And not all these conditions in this article are included in take-home-info. My son had the harlequin color change as a newborn and the pediatrician didn’t know what it was. I only learned it was benign by asking Dr Google. I also don’t remember reading anything in the take-home pamphlets about any of the conditions in this article except mottling, breast enlargement, and vaginal discharge. And I read it all. More than once. I listened to doctors and nurses and lactation consultants without having my phone out. And I’m a veterinarian so I have a pretty good grasp of anatomy and physiology, and I know how to analyze sources for quality. And yet I still had questions about the harlequin color change and his palpable liver. After all, heart defects can cause an enlarged liver and how should I know how big a newborn human’s liver should be? I think better be safe than sorry, and see a dr for anything worrisome for peace of mind.

    Lol as a side note, as a vet, Dr Google typically causes more trouble than good. People look things up and conclude ridiculous ideas, such as that raw eggs cure parvovirus, and that Manuka Honey cures bladder cancer. I joke that I charge extra for people that consult Dr. Google. But I enjoy when people know how to analyze sources and ask intelligent questions and bring up intelligent ideas and solutions. For those that don’t know how to analyze sources, I do my best to educate them and steer them in the right direction to educate themselves. So many people get info from non-experts posting on bulletin boards and assume it’s fact. It can be frustrating for sure.

Leave A Reply