Transitory conditions of neonates

Rounded Rectangle: A Skills Group 

J. Buinauskienė, V. Šulnienė

Flowchart: Alternate Process: This  chapter discusses the topic “transitory states in neonates”.   You are expected to identify and assess independently these conditions in clinical practice. Be  ready to explain to neonate‘s parents the causes of these transitory changes in neonates. 


Transitory conditions include the manifestations of various adaptive changes in a neonate’s body, which are noticeable during the early neonatal period and reflect the adaptation of a neonate to his/her new environment.

White spots (milia)
Milia are defined as small, yellow-white nodules, which are 1-2 mm in diametre, and manifest predominantly on the neonate’s nose, forehead and chin. Those are the result of active secretion from sebaceous glands, which cause obstructive processes in their canals. In the majority of cases, milia disappear, spontaneously two weeks after birth, but sometimes it may persist even up to 3 months. (Fig. 1).

milia grazi
                              Fig. 1. The presence of milia on the neonate’s forehead, nose and upper lip

Sweat Rash (miliaria)
Refers to the presence of  pruritic exanthema expressed by erythematous spots, predominantly found on the forehead but the disorder may involve the entire body (Fig. 2). Miliaria is associated with “overheating” followed by increased sweat production, which results in the presence of obstructive processes in sweat glands and possible ruptured sweat gland ducts. There  are two main types in neonates:

1. Miliaria crystalline.
This type is characterized by the presence of superficial vesicles, 1-2 mm in diameter, without the manifestation of perivesicular inflammatory reactions. Lesions are apruritic.

2. Miliaria rubra(also called "prickly heat").
It is the most common type characterized by the presence of red papules and pustules. It is important to ensure that the baby is not over-wrapped, and once the heat stress is removed the lesions usually resolve quickly.


miliarinis berimas
      Fig. 2. A neonate with miliaria

Toxic neonatal erythema (erythema toxicum neonatorum)
It is defined as irregular, erythematous spots with yellowish centers (Fig. 3).
These spots manifest 2-5 days after birth due to rearrangement of protein metabolism and appear on the neonate’s face and extremities. CBC shows eosinophilia, and accumulations of eosinophils in the centers of spots are found.
The  lesions are harmless, designated as reaction of the neonate’s immune system to proteins, which are present in breast milk and disappear within 2-3 weeks without treatment.

toks eritema
             Fig. 3. Toxic neonatal erythema


Neonatal erythema (erythema neonatorum)
Refers to erythematous spots (Fig. 4) and are assumed to be cutaneous reactions to the environment that manifest on the 1-2 day of life. The rash disappears spontaneously within the 4-7th day.











   Fig. 4. A neonate with erythema neonatorum


Mongolian Spots
This is a very common benign skin pigmentation characterized by the entrapement of melanocytes in the inferior part of the dermis resulting in the appereance bluish  discoloration (Fig. 5).
Distribution is seen on the face, shoulder, lumbosacral region and buttocks.
Less commonly,  the “congenital dermal melanocytosis” on the neonate’s extremities or trunk is observed. The prevalence is the highest (80%) in Afro-American, Asian, Indian and Roman neonates. Mongolian spots vanish within several weeks up to years.

    Fig. 5. Mongolian spot with bluish discoloration involving
the lumbosacral  area of a neonate

Spider Naevi  (Stork bite/Angel kiss birthmarks)
It is characterized by erythematous spot/macule, commonly on the forehead, as the result of vascular redistribution. Are the result of an expressed vascular network, which appear as an erythematous lesion in the neck / occipital region. Less often we find those on the forehead and eyelids  (Fig. 6).  The lesions disappear within several weeks or even months. 6 months.
In Lithuanian literature you will find the expression „Gandro žnybis“ – “A stork bite” as storks grabbed the babies by the neck and flew them to their new home.

gandro znybis
         Fig. 6. The “stork bite” in the neck region


Desquamation of neonate’s skin (Desquamatio neonatorum).
Refers to a state when the neonate’s skin starts to “peel off” (Fig. 7), which occurs predominantly on the 3-5th day of life. Affected skin areas include chest and abdomen as well as extremities.

deskvamacija 3
    Fig. 7.  Desquamation of neonate’s skin


Neonatal jaundice
It is a common phenomenon in neonatologic practice as 60-80% of neonates are affected by jaundice caused by differences in bilirubin metabolism during the first days of life.
In 70-90% of neonates physiologic jaundice, which involves the entire body, is expressed and manifestations occur always on the second day of life.
Please make a remark here (!): Physiologic jaundice manifests always on the second day of life in contrast to jaundice caused by Rh(D) or blood group incompatibility, which appears usually on the first day of life.  (Fig. 8). Jaundice affects the face, sclera and the entire body.
Physiological (normal)  jaundice results from an increased breakdown of erythrocytes - a state known as “hemolysis”. RBC life span of an adult is 120 days, while in neonate’s it is almost half shorter – only 70 days. During laboratory testing of blood sample the predominantion of indirect/unconjugated bilirubin is observed. 
The albumin’s binding capabilities for bilirubin are low and a lower protein concentration is present in every neonate’s blood during the first week of life.
Moreover, the hepatic enzymes (Glucuronyltransferase) are less active. Additionally, an increased β-Glucuronylreductase activity is observed, which results in an increased monoglucronylbilirubin concentration (enterohepatic bilirubin concentration).
The skin becomes yellow once the blood serum bilirubin concentration ≥ 85 μmol/l. The highest concentration in term neonate is present during the 3-5th day of life and includes 170–255 μmol/l. Jaundice disappears within the coming 2-3 weeks.


Picture 166
         Fig. 8.  Neonatal jaundice



Mastopathy in neonates
A swelling of the breast can be observed in females as well as in males during the first two weeks of life (Fig. 9). Mastopathy in neonates is caused by an increased concentration of estrogens obtained from the mother either via breast milk or during labour (placental penetration).
During the 7–10th day a swelling of breasts are observed, which is symmetric – the skin is not erythematous and non -tender. A “milk-like discharge” from the neonate’s nipple may be present. Neonatal mastopathy - as all the other transitory manifestations – disappears on its own and does not require any medical intervention.

mastitas 1 

Fig. 9.  Neonatal mastopathy


Is the result of an increased estrogen concentration in male neonates (Fig. 10) and must be clinically differentiated from testicular torsion. Hydrocele disappears within 2 weeks.

  Fig. 10. Hydrocele


Desquamative vulvovaginitis
Refers to the discharge of transparent, white mucous secretions with possible bloody streaks/impurity from the vagina in girls (Fig. 11).
Desquamative vulvovaginitis also referred to  “pseudomenstruation” disappears within two weeks. Possible appearance of blood (0.5-1 ml) on the 5-8th day of life may occur and last for 1-3 days.

Fig. 11. Desquamative vulvovaginitis


Physiological weight loss
During the first days of life a neonate may lose up to 10% of its initial body weight – physiological weight loss - due to dehydration.
The neonate is expected to regain the lost weight within the coming 2 weeks.


Transitory  hyperthermia
It is caused by the process of overheating and dehydration, which is common during the
3-5th day of life, characterized by an elevated body temperature till ≥ 38.5–39.5 oC.


Passage of meconium
The neonate is expected to pass meconium (dark green-brown-sticky feces without an odor) within the first 48h after birth. Starting from the 4-5th day of life the “phase of transitory defecation” is present and the neonate defecates 6-7x/day for 2-4 days. From the 6-7 day of life the phase of “maternal milk feces” begins.

Physiological diarrhea starts 10-14 days after birth and may last for 4-6 weeks. Feces are of liquid consistency, have a high content of mucous and contain greenish-white, undigested proteins. We find 30 leucocytes in the field of investigation. Perianal skin irritation is common.


Physiologic oliguria
Neonates void rarely during the first days of life. The first urination is by 48 hours of life and then six diaper-soaking urinations per 24 hours therefter. Normal daily urine output is considered to be 40–60 ml/kg.


Uric acid crystals
During the first week after birth the excretion of uric acid with the urine is excessive. Increased uric acid concentrations are the result of purine and pyrimidine compounds, which are formed in the presence of leucocyte lysis.
The urine color appears yellowih-red due to the presence of uric acid crystals and an orange -colored sediment in the diapers are seen (Fig. 12).

Fig. 12. Neonate’ s urine stain –note the color caused
by the presence of uric acid crystals


Rounded Rectangle: It is very important to recognize and understand the manifestations of the transitory conditions in neonates and not to confuse physiological findings with pathological ones. The neonate‘s parents must be informed about the manifestations, which were discussed in this chapter. 



1.McKee-Garrett TM Assessment of the newborn infant[žiūrėta 2012-05-18]. Access to Internet :