Dr. Tracey Agnese, a pediatrician, joins the podcast to discuss newborn evaluations and what pediatricians look out for in a baby’s first appointments. Plus, she and Dr. Fox discuss her Youtube channel and Instagram account, @babydocmama, which she started to answer common questions from new parents.
“Newborns! Part A: From birth until you go home” – with Dr. Tracey Agnese
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
All right, I’m here with Dr. Tracey Agnese, who is a wonderful pediatrician on the west side of Manhattan in the practice called Pediatric and Adolescent Medicine, which is very descriptive.
Dr. Agnese: Yes. Not general at all.
Dr. Fox: Excellent. And Tracey, of course, is an FOM a friend of Melka, which is how we got connected. Thank you for coming in. Thank you for being on the podcast. How are you doing?
Dr. Agnese: Good. Thanks so much for having me. I’m so excited.
Dr. Fox: This is wonderful. So we were in touch before by email and we spoke. And we sort of had a very similar realization that there’s information that we want people to have. And so I started a podcast and you started doing stuff online with YouTube and Instagram and this is the confluence. This is where it all comes together.
Dr. Agnese: Perfect. Yeah.
Dr. Fox: Excellent. So tell us what exactly are you doing now online?
Dr. Agnese: Yeah. So I started with a YouTube channel where, basically, I just want to give information to new moms about how to take care of their newborn baby, but also really importantly is how to take care of themselves as a new mom because I really feel that that gets so overlooked.
And so it actually started with something that I had like six years ago, when after I had my first daughter, and my sister who I’m super close with was living on the other side of the country at the time. And she had her first about eight months after I had mine. And I wanted to give her advice, like as a pediatrician and as a new mom, but also as a sister and like, take care of yourself this way too. And so I never did anything with it until recently when COVID hit and I had a little more time on my hands.
And as a new mom, I had a harder time than I thought I would. As a pediatrician, I thought, “Okay, you know, it’s all gonna be fine.” I didn’t really think much of it, I guess. So I was pretty shocked by how hard it was to take care of a newborn baby and to try to still find and take care of yourself during that transition. So I focus on that.
Dr. Fox: Yeah, I was either smart enough or stupid enough to have all of our kids before I became an MFM so I didn’t really know anything, which is great. So I never thought it’d be anything. I don’t think I thought at all maybe ever, actually. So how do people find you? What is your YouTube channel?
Dr. Agnese: Yeah, so if you go to my website, traceymd.com, then it has a link to my Youtube channel and to my Instagram account. On Instagram I’m @babydocmama.
Dr. Fox: Tracey, MD. That’s it?
Dr. Agnese: Yeah, that’s it, traceymd.com.
Dr. Fox: You got in early.
Dr. Agnese: I know. And T-R-A-C-E-Y. And I said, “You know, maybe I should like buy the domain without the E too.”
Dr. Fox: Did you?
Dr. Agnese: I did, yeah.
Dr. Fox: Oh my God, that’s amazing. Just in case.
Dr. Agnese: Just in case.
Dr. Fox: All right. So and how have you found that so far because it’s a total change in paradigm for us. Like, we’re so used to doing it a certain way and everything’s through like, writing and reading and articles and books and stuff or talking to patients. And then, when we start doing something like this where you’re recording your voice or your face or a video, it’s like jarring in a way. How did you find it when you started?
Dr. Agnese: I find it so much more fun than I even thought. I just started recording and I just press record and said, “I’m not even gonna have to use this if I don’t want,” and to just let myself loosen up and start talking. But once I started doing a few of them, I just kind of pretend I’m talking to a friend or you know, a patient in the exam room. And it’ funny, I hear my voice differently now than I did before because now I’ve listened to myself when I’m editing these videos. And I feel like I hear myself so much that when I’m talking out loud in person, I hear it differently. And all my intonations and stuff I never really paid attention to, it’s very apparent now. But it’s fun. I’m having a lot of fun with it.
Dr. Fox: It’s also interesting when you podcast to listen to yourself on 1.5 speed.
Dr. Agnese: Oh, yes. I was on a podcast recently and I speak fast. I’m actually trying to slow things down in general. I’m a fast talker and I always listen to podcasts on 1.5 speed. And I listened to myself on 1.5 speed and I was like, whoa, you really have to slow down so it was ridiculous.
Dr. Fox: Yeah. When I hear myself on fast speed, it’s a little terrifying. Oh my God, this is [inaudible 00:04:11] speed. Excellent. So tell us a little about yourself.
Dr. Agnese: Sure.
Dr. Fox: Where are you from? How’d you get into medicine? How’d you get into pediatrics?
Dr. Agnese: Yeah, I’m from New Jersey and I did all my training in New York. I went to SUNY Downstate for medical school. That’s where I met Melka. And then I did my pediatrics residency at NYU and I’ve been practicing in the city for almost 10 years and as a private pediatrician.
I think I always thought I wanted to go into pediatrics. As a kid, I used to buy stuffed animals at garage sales with my mom saying, “I’ll put this in my Peds office one day.” But in medical school, I actually thought for a little while… When I started I thought I wanted to do OB but then I realized I’m not a surgeon. And I was really interested in the baby when the baby came out after delivery. So I did PEDs. I thought I wanted to do adolescent medicine in residency but then I quickly realized I wanted to do Gen PED that I liked from newborn until they’re, you know, the whole thing.
Dr. Fox: Right. You let [inaudible 00:04:59] do the adolescents.
Dr. Agnese: Absolutely. I know we reconnected recently actually. She came by the office and she was back in New York and she’s amazing at that.
Dr. Fox: [inaudible 00:05:07].
Dr. Agnese: So that’s a special thing there.
Dr. Fox: Half of my guests are the FOMs, the Friends Of Melka. She definitely hooks me up with all her friends. It’s great.
Dr. Agnese: That’s funny.
Dr. Fox: Now that you’re a pediatrician, you’re practicing in the city and I wanted to start… I guess we’ll start from the beginning to talk about, you know, newborn care because that’s really, obviously, people’s first, you know, experience as parents is when the baby’s born in the hospital. And so there’s a lot of confusion like what actually happens in the hospital after the baby’s born with the baby. Like, what do you do, and when do you come and see them?
Dr. Agnese: Yeah, sure. So when the baby’s born, of course, if there’s anything urgent, right, you’re calling the NICU doctors and the ICU in-house neonatologists are gonna be the ones coming and assessing the babies. So us, as the general pediatricians, the first time we’re meeting the baby is within 24 hours of birth and we usually do that you know in the morning and when we’re rounding in that next morning.
So we come in and, of course, we read you know all the prenatal history first. Things we look at that are important is any medicines or issues that the mother had during pregnancy. And we always like to know the GBS groupies strip status of the mom. And we like to look at the blood types of the mom and the baby to see if the baby is a setup for jaundice or not. Those are some of the key things in the chart that we’re looking at and what type of delivery it was and all that.
And when we check the baby, I think all of us kind of do it similarly, where we go from head to toe. I think that’s kind of how we all think about it. So, you know, we’re feeling the head and we’re feeling the fontanelles and the sutures, making sure everything’s in place. We’re looking at the baby first, actually, just making sure that everything looks symmetric and normal as well, making sure that the ears and the eyes and the nose, you know, that the nerves are patent and that everything looks like it should.
And in the mouth, oftentimes we’ll put a finger in the mouth of the baby, assess the baby’s suck, make sure that there’s the palate is okay, that there’s no cleft palate. We look at the tongue, underneath the tongue, the frenulums, make sure everything anatomically is okay there.
Then we will usually feel the clavicles and make sure that there’s, you know, nothing that feels that it’s broken, that the arms are moving symmetrically. We check the hands, of course, five fingers, five toes, and make sure everything looks correct there. Of course, we listen to the heart and the lungs, make sure the lungs are clear, make sure the heart sounds…that there’s you know, but no concerns there.
We feel the baby’s belly, make sure that there’s no, you know, masses or anything that we would be concerned about in the belly. We take a look at the umbilical cord. And we look at the number of vessels and make sure that it looks like it is already healing appropriately.
We take the baby’s diaper off. We look at the genitalia, make sure that it’s a normal male or normal female genitalia. We check the hips while we’re down there too. And we make sure that hips are moving correctly and that they’re not out of the hip sockets. That’s something that can be detected even in that first exam.
And then we always turn the baby over onto the baby’s tummy. We take a look at the back, make sure the spine looks straight, make sure that if there is a dimple in the…above the butt area, which is not uncommon, a sacral dimple, we like to look at it make sure that you could see the base of it. It doesn’t look like something that needs further evaluation.
And we are looking at the skin too of the baby. We’re looking for rashes. We’re looking at the color of the skin, making sure I see if there’s any signs of jaundice or anything else.
Dr. Fox: When this happens, you’re doing the newborn evaluation of day one babies, you know, born within the past day, for first-time moms, how often have you met the parents before this evaluation versus you’re the pediatrician who either they knew they were going to see you or the doctor had, you know, the OB had you come in? I’m just curious how often you know them before you evaluate the baby.
Dr. Agnese: Often, we do for a few reasons. One, it might be a second child of somebody who comes already to the practice and so that’s common where we will know them. And then some where we have done a prenatal visit. So I think most peds in New York City do this. I don’t know about the rest of the country, but we do prenatal visits. Now, during the pandemic, we do them virtually, but where we meet the parents beforehand. And that, though, doesn’t always mean that you’ll see that person because whoever’s doing the hospital rounds that day could be there but not all the time. For a lot of times, you haven’t met them before.
Dr. Fox: For those prenatal visits, is that more so for the parents to know who you are just sort of like, you know, get to meet, what’s the personality like, how does your office work, or is it something where there’s actually like something of substance that’s discussed in terms of the baby or the health or anything like that?
Dr. Agnese: Yeah. I always start off asking the parents, you know, what they want to talk about because some will come with a whole list of questions, mostly that they’ve googled and says, “Ask your pediatrician this.”
So if they do have that list. I kind of want to know at the beginning and we can go through it but most of the questions are really common. And most of the time, we’re just going through the way that the office works. And, you know, they commonly ask if there’s a well a waiting room and a sick although now post COVID the questions and the whole conversations are different.
We go over the setup of the office with questions, how to reach us if there’s questions, our hours when we’re open, walk-in hours, sick visits, that kind of stuff. I think it’s most important to just get a sense of the doctor and if you feel like it’s somebody that you’re going to trust, you know, with your baby because I think most of us probably all the practices in the city probably have the same answers to most of those questions. It’s just more of getting a feel for if there’s somebody that you’re comfortable with.
Dr. Fox: Yeah, I think a lot of parents find it helpful for that way just to sort of get a sense so this person or this practice won’t be a stranger when the baby’s here. But is it ever helpful on your end potentially, like, when you meet with the parents like you’ll take some notes when this baby’s here or is it mostly just like, all right, this is sort of what we do as part of like, you know, marketing, in a sense?
Dr. Agnese: It’s usually not so helpful for us, unless there’s issues with the baby, of course, but that’s not as common. There is some sort of issue that anybody’s concerned about with the baby that they know the baby will need immediate care, then it can be helpful to explain the process of if. The baby has to go to the NICU, or these are the things that, you know, might happen afterwards but mostly, it’s more of just to get to know you.
Dr. Fox: Right, which makes a lot of sense. I mean, you know, parents ask us all the time, you know, because they have to find a pediatrician, “Who do you recommend?” And I always tell them, like, I know so many really good pediatricians. It’s always hard to find a not good pediatrician, you know, who’s at a good hospital or in a good practice. And I say, it’s really so much more so like, “What are you looking for? You know, is it you want someone who’s close to where you live because it’s easy to get there, or do you want a big group, a small group?”
I mean, and so, in that we always encourage people to meet the pediatricians. If you like them, yeah, like, that’s great. That’s a really good, you know, system and a situation. And it’s not like, oh, this person’s the best doctor in the world. They know so much more than everybody else. It’s rarely that, unless there’s a specific condition or something like that.
Dr. Agnese: Yeah, I think being close is really important because you go to the doctor a lot in the beginning. That is something we usually always cover is parents ask about, and I like to go over is the frequency of the visits in that first year of life. You know, they like to know.
And it’s important to be close because you are going to be at the doctor a lot, especially in that first month of like you might be coming back in a day or two days, or, you know, often in the beginning. So it’s important to be close. And it’s important to feel like it’s somebody that you can ask these, you know, questions to that you might feel silly asking. You don’t want to feel silly asking so it’s somebody that you feel comfortable with.
Dr. Fox: Right. When my wife was pregnant with our twins, our first kids, we ended up using a pediatrician who I knew from medical school. He was one of my teachers is, you know, Dr. John Larson, a great guy. And we met with him and we’re like, “Oh, this is great. He’s a few blocks away from us. This is perfect.” And like, two months after our kids were born, their office moved into our building. First of all, we were like, “This it’s unbelievable.”
Dr. Agnese: That’s perfect.
Dr. Fox: You don’t have to like get them dressed. You can just take them down their diapers. It was unbelievable. Yeah, it’s very convenient to have a pediatrician close by.
Dr. Agnese: You don’t realize how important that is in the beginning, is to be very convenient to be located.
Dr. Fox: Okay, so you’re examining the baby [inaudible 00:12:38] how often. Again, the baby’s already been born and the nurse or the NICU team, someone’s looked at the baby at birth. And they’re already in the nursery by the time you see them and, obviously, the parents have probably spent some time with the baby already. How often is it that you’ll pick up something on that exam or assessment that is not even concerning, but something that has to be discussed with the parents or followed up? Is it like, 50% of the time, like it happens all the time, or is it like 5 to 10? What percentage of time do you find something even if it’s minor?
Dr. Agnese: Yeah, I mean, most babies are healthy. So most babies are healthy. So the things that we’re finding that we talk about commonly maybe in the beginning, it’s usually something that it’s just gonna be like, you’re reassuring the parents. For example, rash, like a very common newborn rash that you see in the first time is something called erythema Toxicon, which I always like to say, it’s a terrible name because it’s not toxic at all. It’s a normal newborn rash, but it looks like pimples on the body.
And the parents, even if they haven’t noticed it yet, they might notice it as soon as you leave the room or the next time they go to change the baby’s diaper and get really worried about it. So it’s more of that kind of preventative pointing things out that you are reassuring them about.
And yes, certainly other things that we pick up that we need to address more urgently, I mean, it’s not as common. It might be like hips if the hips feel a little loose. It might be a murmur. But a heart murmur is not uncommon in the first 24 hours. So we usually, actually, if you hear it in the first 24 hours, you just kind of wait and see if you still hear it the next day because a lot of these flow murmurs from the change of fetal cardiac circulation to the other, you know, newborn that just goes away.
So but that is something that we might, you know, pick up. And if it’s still there on day two or three, then we might have the cardiologist, you know, take a listen and further evaluate. And then the dimple, the sacral dimple, like I said, that’s another thing that we often will see and might need an ultrasound or something for. Those are the common things, but most of the time babies are totally healthy and you’re just kind of pointing out what to look for and reassuring.
Dr. Fox: So you do an exam, but there are certain tests that are done in every baby, or at least in New York City in newborns. What tests are done on them aside from an examination by one of you?
Dr. Agnese: Before they leave, the nurses will do a newborn screening test, which there’s a blood test. They prick the heel and they send that off to the [inaudible 0:14:54] and they taste test for, I don’t know, 40/50 different sorts of metabolic and all different congenital diseases and stuff. So that takes about two weeks to come back. So the nurses send that off.
Every baby gets some sort of assessment of the level of jaundice. So jaundice is a baby being yellow because there’s too much bilirubin that’s being built up in the blood. Bilirubin is normal in all of us because you have red blood cells that are constantly turning over and bilirubin is a byproduct of it. But there’s a lot of reasons why newborn babies in that first week of life have higher bilirubin because they have…their liver’s not just mature enough to get rid of everything yet. They also have shorter red blood cell lives and turnover. And they also have…sometimes they’re a little dehydrated, which we can talk about too because babies lose weight.
And so there’s reasons why their numbers go high. And there’s literally a nomogram of a per hour of life and every hour and what number would cross the threshold as being too high for that baby at that hour of life. So that’s a really big part of the beginning.
So the babies will either get assessed by…a there’s a screening tool, almost like a forehead temperature thermometer, the same kind of thing that the nurses will do to get an assessment of the bilirubin. If that crosses a threshold, then they might need to follow that up with a blood test. So some assessment of bilirubin.
A hearing screen is something that’s done by the nurses before as well making sure, you know, check for congenital hearing loss. Kind of newer, more recently in the last few years is a congenital heart disease screening where the nurses check the pulse oxygen. So the oxygen levels, you know, of the babies in the upper and the lower extremities to make sure there’s not a discrepancy that’s concerning for congenital heart disease.
Dr. Fox: Okay, so those tests are routine. I would say most of them are usually normal. The bilirubin’s one that frequently we’re chasing for a while.
Dr. Agnese: And the hearing screen is not infrequently abnormal because there’s so much debris in the ear canals, you know, and like stuff from just amniotic fluid that kind of stays there. So sometimes babies will, you know, not pass that in the nursery. And then that’s something that we actually…in our office we have the machine and we can test it, you know, again, in your first or second visit.
Dr. Fox: I like you said not pass instead of fail. My third failed her hearing test and she had loose hips.
Dr. Agnese: All the things, yeah.
Dr. Fox: She was a disaster but she’s amazing. Yeah, she now has one wonderful, wonderful attached hips and she hears beautifully. She even listens in addition to hearing. She’s a great kid. And then are there routine, either medications or vaccinations that are given to newborns in the hospital?
Dr. Agnese: The hepatitis B vaccine that’s given to babies in the hospital by the nurses. There’s the Vitamin K shot that’s given. There’s the [inaudible 00:17:26] that’s given for prophylaxis as well. I think that’s it. I know there’s no other vaccines that are given in the beginning.
Dr. Fox: Now, does everyone get the hepatitis B vaccine in the hospital?
Dr. Agnese: It’s offered to everyone but not required. So if you don’t get the hepatitis B in the hospital, then you can get the first dose at your pediatrician’s office.
Dr. Fox: Got it.
Dr. Agnese: So it is recommended by the academies that everybody gets it in the hospital.
Dr. Fox: Right. And what kind of things would delay a baby from going home at a normal time? Like what are the common things? Obviously, if the baby’s like ill and they know about this, but what are the types of things we’re like, oh, we have to keep the baby another day that, you know, parents should maybe be on the lookout for that it might happen, but it’s not always a big deal?
Dr. Agnese: Yeah, so that would be jaundice that might keep you there, because if that level does cross the threshold, the bilirubin, then the baby needs treatment, which is going to be phototherapy, which is lights like a tanning bed. So that would be a reason that the baby would stay.
And then if there’s any concern around about infection, you know, then the baby goes usually then to the NICU and might need a further workup or maybe two days of antibiotics while you wait, you know, to see. That’s it. I mean, most of the time, they’re not really staying longer for other reasons.
Dr. Fox: In my experience, the babies usually stay longer if the mommies stay longer.
Dr. Agnese: Yeah, exactly.
Dr. Fox: But they don’t discharge the babies without the mother. The baby can’t get home.
Dr. Agnese: Right. And then now, I mean, babies are going home soon now too just like the moms with COVID.
Dr. Fox: But they do stay 24 hours.
Dr. Agnese: Twenty four hours.
Dr. Fox: Yeah, yeah. And I always wonder, is that a hospital thing or is that a state thing? Is that just sort of the tradition of Mount Sinai? Like, why 24 hours?
Dr. Agnese: It’s not just Sinai. It’s kind of across the board at all. I think it’s just because, you know, we need to know at least 24 hours if the baby is gonna do anything funny, you know, where because as new parents, you don’t know what’s normal and not normal yet. So if there is any concern, you know, that the baby might need evaluation by the NICU, you’ll know in 24 hours.
Dr. Fox: So you evaluate the baby, all the tests are there, and you’re gonna see the parents obviously, you know, and talk to them say, “Hey, I met your baby. He or she’s beautiful,” you know, and go through everything you did. What are sort of the top five things you tell them, so you tell everybody automatically before they go home from the hospital? And let’s go through them one by one. What are the things you want them to know?
Dr. Agnese: Sure. Yeah. So the first thing is feeding. So feeding the baby is the focus of the first few weeks. And so I like to talk about that if they want to breastfeed, then we go over the frequency, you know, of feeding the baby. Once you leave the hospital, you want to do every two to three hours. I always like to tell them it’s from the beginning of one feed to the beginning of the next is how we count it. You want to feed both breasts each time. I usually tell them to do each breast for 15/20 minutes and then switch to the other one.
And I let them know that babies lose weight in the beginning and we expect that and that’s okay. So babies lose…we allow up to like 10% of birth weight, and we expect them to lose that. And then we like to see them to start gaining weight by about days three to five of life.
Besides feeding, we talk about pees and poops because that’s another way to know, besides the weight, if the baby is getting enough in is by what’s coming out. So we always go over what to expect. So on the first day of life on day one, you want one wet diaper in 24 hours. On day two, you want two wet diapers in 24 hours. Day three, three. Day four, four. Day five, five, and then after that you are having five or six wet diapers a day.
And the poops I always like to tell them it’s really not about the number but it’s more about the consistency, that it starts off as that, you know, that first poop is that thick meconium poop. And then after that, it starts to get a little more thin and runny and lighter. And what you would call it like diarrhea for an adult, ultimately, becomes very normal.
Dr. Fox: It’s like couscous.
Dr. Agnese: It’s like couscous. Yeah. We call it yellow mustard or, you know, CD mustard, but couscous is a good one too. I like that.
Dr. Fox: Yeah, that’s one of the things that stuck with me. I was like, couscous. All right. I had a hard time eating couscous for a while after that.
Dr. Agnese: Yeah. Yes. So we like to talk about what to expect with that, pees and poops for the baby. And I always like to talk about when to call the doctor if you’re concerned, which will be if there’s a fever in those first two months of life, you do want to call the doctor.
So I always tell them, though, you don’t have to go checking the baby’s temperature all the time. You’re holding the baby. And if the baby feels like super hot, like really burning up, or if the baby is really acting different, although when you’re first taking your baby home, you don’t know what different is because you don’t even know what your baby’s normal is.
But if you really if you can’t arouse that baby to feed for, you know, a feed or two, or there’s anything that you’re really concerned about, unclothe the baby, let the baby acclimate to room temperature for like 10 minutes, and then take a rectal temperature. And that’s the only accurate way to do that in the newborn period. And if it’s 100.4 or above, you certainly would want to call the doctor.
Dr. Fox: And when that happens, is it usually okay, and everything’s fine, or is it really alarming if there’s a fever
Dr. Agnese: Usually things are just fine but babies don’t have…you know, they can’t tell us if there’s a problem. It’s also hard to know if they’re sick and so that is really one of the actual signs that you have. Most of the time, it winds up being fine but while you’re waiting to make sure that it’s fine, you know, sometimes the baby might need more of a workup, you know, or not to see so.
Dr. Fox: And that’s one of the reasons that a lot of people are sort of squeamish about having a lot of visitors around their newborns. It’s not that they will necessarily get the baby sick but maybe they’ll give the baby something that will cause a slight fever, which will cause a whole cascade of tests to make sure the baby’s not really sick.
Dr. Agnese: Exactly.
Dr. Fox: Yeah. Yeah. Interesting.
Dr. Fox: Agnese: And the baby doesn’t have the immune system really yet at all to fight off anything and the baby doesn’t have, you know, the first set of shots, although it gets really more of exactly what you said. It’s that you don’t want to have to go through that whole workout for a little fever.
Dr. Fox: After they’re discharged, when is the first time you normally see them in the office in a usual situation? Is it like two days later or two weeks later? When is it normal?
Dr. Agnese: No, no, it’s usually a few days. So it can be anywhere from one, two, or three days is usually you know, maybe four days. It’s within those first few days.
Dr. Fox: And that’s to assess what when you see them? Just to check their weights and everything.
Dr. Agnese: Mostly, it’s the weight and the bilirubin and feeding, you know, making sure feedings going okay, make sure the baby is either, you know, not losing too much weight or gaining weight, and then checking in if you need to check the bilirubin. Those are the big things we look at in the first visit.
Dr. Fox: Wow, Tracey, that was an amazing review of care of the newborn from the time of birth through discharge from the hospital and the first visit. And I’m really looking forward to doing another podcast with you right away about newborn care from that point through the first few weeks and first few months of life. Thank you so much.
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