Evaluation and Care of the Normal Neonate
Hand washing is critical for all personnel to prevent transmission of infection.
Active participation in the birth by the mother and her partner helps them adapt to parenting.
Immediately at delivery, the neonate’s respiratory effort, heart rate, color, tone, and reflex irritability should be assessed; all are key components of the Apgar score assigned at 1 min and 5 min after birth (see Table: Apgar Score). Apgar scores between 8 and 10 indicate that the neonate is making a smooth transition to extrauterine life; scores ≤ 7 at 5 min (particularly if sustained beyond 10 min) are linked to higher neonatal morbidity and mortality rates. Many normal neonates have cyanosis 1 min after birth that clears by 5 min. Cyanosis that does not clear may indicate congenital cardiopulmonary anomalies or CNS depression.
In addition to Apgar scoring, neonates should be evaluated for gross deformities (eg, clubfoot, polydactyly) and other important abnormalities (eg, heart murmurs). The evaluation should ideally be done under a radiant warmer with the family close by.
Preventive interventions include administration into both eyes of an antimicrobial agent (eg, 0.5% erythromycin 1 cm ribbon, 1% tetracycline 1 cm ribbon, 1% silver nitrate solution 2 drops; in some countries, 2.5% povidone iodine drops) to prevent gonococcal and chlamydial ophthalmia and administration of vitamin K 1 mg IM to prevent hemorrhagic disease of the newborn (see Vitamin K Deficiency).
Subsequently, the neonate is bathed, wrapped, and brought to the family. The head should be covered with a cap to prevent heat loss. Rooming-in and early breastfeeding should be encouraged so the family can get to know the infant and can receive guidance from staff members during the hospital stay. Breastfeeding is more likely to be successful when the family is given frequent and adequate support.
A thorough physical examination should be done within 24 h. Doing the examination with the mother and other family members present allows them to ask questions and the clinician to point out physical findings and provide anticipatory guidance.
Basic measurements include length, weight, and head circumference (see also Growth Parameters in Neonates). Length is measured from crown to heel; normal values are based on gestational age and should be plotted on a standard growth chart. When gestational age is uncertain or when the infant seems large for gestational age or small for gestational age, the gestational age can be precisely determined using physical and neuromuscular findings (see Figure: Assessment of gestational age—new Ballard score.). These methods are typically accurate to ± 2 wk.
Assessment of gestational age—new Ballard score.
Many clinicians begin with examination of the heart and lungs, followed by a systematic head-to-toe examination, looking particularly for signs of birth trauma and congenital abnormalities.
(See also Congenital Cardiovascular Anomalies.)
The heart and lungs are evaluated when the infant is quiet.
The clinician should identify where the heart sounds are loudest to exclude dextrocardia. Heart rate (normal: 100 to 160 beats/min) and rhythm are checked. Rhythm should be regular, although an irregular rhythm from premature atrial or ventricular contractions is not uncommon. A murmur heard in the first 24 h is most commonly caused by a patent ductus arteriosus. Daily heart examination confirms the disappearance of this murmur, usually within 3 days.
Femoral pulses are checked and compared with brachial pulses. A weak or delayed femoral pulse suggests aortic coarctation or other left ventricular outflow tract obstruction. Central cyanosis suggests congenital heart disease, pulmonary disease, or sepsis.
The respiratory system is evaluated by counting respirations over a full minute because breathing in neonates is irregular; normal rate is 40 to 60 breaths/min. The chest wall should be examined for symmetry, and lung sounds should be equal throughout. Grunting, nasal flaring, and retractions are signs of respiratory distress.
In a vertex delivery, the head is commonly molded with overriding of the cranial bones at the sutures and some swelling and ecchymosis of the scalp (caput succedaneum). In a breech delivery, the head has less molding, with swelling and ecchymosis occurring in the presenting part (ie, buttocks, genitals, or feet). The fontanelles vary in diameter from a fingertip breadth to several centimeters. A large anterior fontanelle may be a sign of hypothyroidism.
A cephalohematoma is a common finding; blood accumulates between the periosteum and the bone, producing a swelling that does not cross suture lines. It may occur over one or both parietal bones and occasionally over the occiput. Cephalohematomas usually are not evident until soft-tissue edema subsides; they gradually disappear over several months.
Head size and shape are inspected to detect congenital hydrocephalus.
Numerous genetic syndromes cause craniofacial abnormalities. The face is inspected for symmetry and normal development, particularly of the mandible, palate, pinnae, and external auditory canals.
The eyes may be easier to examine the day after birth because the birth process causes swelling around the eyelids. Eyes should be examined for the red reflex; its absence may indicate glaucoma, cataracts, or retinoblastoma. Subconjunctival hemorrhages are common and caused by forces exerted during delivery.
Low-set ears may indicate genetic anomalies, including trisomy 21 (Down syndrome). Malformed ears, external auditory canals, or both may be present in many genetic syndromes. Clinicians should look for external ear pits or tags, which are sometimes associated with hearing loss and kidney abnormalities.
The clinician should inspect and palpate the palate to check for soft or hard palate defects. Orofacial clefts are among the most common congenital defects. Some neonates are born with an epulis (a benign hamartoma of the gum), which, if large enough, can cause feeding difficulties and may obstruct the airway. These lesions can be removed; they do not recur. Some neonates are born with primary or natal teeth. Natal teeth do not have roots and may need to be removed to prevent them from falling out and being aspirated. Inclusion cysts called Epstein pearls may occur on the roof of the mouth.
The abdomen should be round and symmetric. A scaphoid abdomen may indicate a diaphragmatic hernia, allowing the intestine to migrate through it to the chest cavity in utero; pulmonary hypoplasia and postnatal respiratory distress may result. An asymmetric abdomen suggests an abdominal mass.
Splenomegaly suggests congenital infection or hemolytic anemia.
The kidneys may be palpable with deep palpation; the left is more easily palpated than the right. Large kidneys may indicate obstruction, tumor, or cystic disease.
The liver is normally palpable 1 to 2 cm below the costal margin. An umbilical hernia, due to a weakness of the umbilical ring musculature, is common but rarely significant. The presence of a normally placed, patent anus should be confirmed.
In boys, the penis should be examined for hypospadias or epispadias. In term boys, the testes should be in the scrotum (see Cryptorchidism). Scrotal swelling may signify hydrocele, inguinal hernia, or, more rarely, testicular torsion. With hydrocele, the scrotum transilluminates. Torsion, a surgical emergency, causes ecchymosis and firmness.
In term girls, the labia are prominent. Mucoid vaginal and serosanguineous secretions (pseudomenses) are normal; they result from exposure to maternal hormones in utero and withdrawal at birth. A small tag of hymenal tissue at the posterior fourchette, believed to be due to maternal hormonal stimulation, is sometimes present but disappears over a few weeks.
Ambiguous genitals (intersex) may indicate several uncommon disorders (eg, congenital adrenal hyperplasia; 5-alpha-reductase deficiency; Klinefelter syndrome, Turner syndrome, or Swyer syndrome). Referral to an endocrinologist is indicated for evaluation as is a discussion with the family about benefits and risks of immediate vs delayed sex assignment.
The extremities are examined for deformities, amputations (incomplete or missing limbs), contractures, and maldevelopment. Brachial nerve palsy due to birth trauma may manifest as limited or no spontaneous arm movement on the affected side, sometimes with adduction and internal rotation of the shoulder and pronation of the forearm.
The spine is inspected for signs of spina bifida, particularly exposure of the meninges, spinal cord, or both (meningomyelocele).
Orthopedic examination includes palpation of long bones for birth trauma (particularly clavicle fracture) but focuses on detection of hip dysplasia. Risk factors for dysplasia include female sex, breech position in utero, twin gestation, and family history. The Barlow and Ortolani maneuvers are used to check for dysplasia. These maneuvers must be done when neonates are quiet. The starting position is the same for both: Neonates are placed on their back with their hips and knees flexed to 90° (the feet will be off the bed), feet facing the clinician, who places an index finger on the greater trochanter and a thumb on the lesser trochanter.
For the Barlow maneuver, the clinician adducts the hip (ie, the knee is drawn across the body) while pushing the thigh posteriorly. A clunk indicates that the head of the femur has moved out of the acetabulum; the Ortolani maneuver then relocates it and confirms the diagnosis.
For the Ortolani maneuver, the hip is returned to the starting position; then the hip being tested is abducted (ie, the knee is moved away from the midline toward the examining table into a frog-leg position) and gently pulled anteriorly. A palpable clunk of the femoral head with abduction signifies movement of an already dislocated femoral head into the acetabulum and constitutes a positive test for hip dysplasia.
The maneuvers may be falsely negative in infants > 3 mo because of tighter hip muscles and ligaments. If the examination is equivocal or the infant is at high risk (eg, girls who were in the breech position), hip ultrasonography should be done at 4 to 6 wk; some experts recommend screening ultrasonography at 4 to 6 wk for all infants with risk factors.
The neonate’s tone, level of alertness, movement of extremities, and reflexes are evaluated. Typically, neonatal reflexes, including the Moro, suck, and rooting reflexes, are elicited:
Moro reflex: The neonate’s response to startle is elicited by pulling the arms slightly off the bed and releasing suddenly. In response, the neonate extends the arms with fingers extended, flexes the hips, and cries.
Rooting reflex: Stroking the neonate’s cheek or lateral lip prompts the neonate to turn the head toward the touch and open the mouth.
Suck reflex: A pacifier or gloved finger is used to elicit this reflex.
These reflexes are present for several months after birth and are markers of a normal peripheral nervous system.
A neonate’s skin is usually ruddy; cyanosis of fingers and toes is common in the first few hours. Vernix caseosa covers most neonates > 24 wk gestation. Dryness and peeling often develop within days, especially at wrist and ankle creases.
Petechiae may occur in areas traumatized during delivery, such as the face when the face is the presenting part; however, neonates with diffuse petechiae should be evaluated for thrombocytopenia.
Many neonates have erythema toxicum, a benign rash with an erythematous base and a white or yellow papule. This rash, which usually appears 24 h after birth, is scattered over the body and can last for up to 2 wk.
Screening recommendations vary by clinical context and state requirements.
Blood typing is indicated when the mother has type O or Rh-negative blood or when minor blood antigens are present because hemolytic disease of the newborn (see Erythroblastosis Fetalis) is a risk.
All neonates are evaluated for jaundice throughout the hospital stay and before discharge. The risk of hyperbilirubinemia is assessed using risk criteria, measurement of bilirubin, or both. Bilirubin can be measured transcutaneously or in serum. Many hospitals screen all neonates and use a predictive nomogram to determine the risk of extreme hyperbilirubinemia. Follow-up is based on age at discharge, predischarge bilirubin level, and risk of developing jaundice.
Most states test for specific inherited diseases, including phenylketonuria, tyrosinemia, biotinidase deficiency, homocystinuria, maple syrup urine disease, galactosemia, congenital adrenal hyperplasia, sickle cell disease, and hypothyroidism. Some states also include testing for cystic fibrosis, disorders of fatty acid oxidation, other organic acidemias, and severe combined immunodeficiency.
HIV screening is required by some states and is indicated for children of mothers known to be HIV-positive or those engaging in HIV high-risk behaviors.
Toxicology screening is indicated when any of the following are present: maternal history of drug use, unexplained placental abruption, unexplained premature labor, poor prenatal care, or evidence of drug withdrawal in the neonate.
Screening for critical congenital heart disease (CCHD) using pulse oximetry is now part of routine newborn assessment. Previously, newborns were screened for CCHD by prenatal ultrasonography and by physical examination, but this approach failed to identify many cases of CCHD, which led to increased morbidity and mortality. The screening is done when infants are ≥ 24 h old and is considered positive if
Any oxygen saturation measurement is < 90%.
The oxygen saturation measurements in both the right hand and foot are < 95% on 3 separate measurements taken 1 h apart.
There is > 3% absolute difference between the oxygen saturation in the right hand (preductal) and foot (postductal) on 3 separate measurements taken 1 h apart.
Any infant with a positive screen should have additional testing, including chest x-ray, ECG, and echocardiography. The infant’s pediatrician should be notified, and the infant may need to be evaluated by a cardiologist.
Hearing screening varies by state. Hearing loss is one of the most frequently occurring birth defects. About 3/1000 infants are born with moderate, profound, or severe hearing loss. Hearing loss is even more common among infants admitted to ICUs at birth. Currently, some states screen only high-risk neonates (see Table: High-Risk Factors for Hearing Deficits in Neonates); others screen all neonates. Initial screening often involves using a handheld device to test for echoes produced by healthy ears in response to soft clicks (otoacoustic emissions); if this test is abnormal, auditory brain stem response (ABR) testing is done. Some institutions use ABR testing as an initial screening test. Further testing by an audiologist may be needed.
High-Risk Factors for Hearing Deficits in Neonates
< 1500 g
≤ 7 at 5 min
> 22 mg/dL (> 376 μmol/L) in neonate whose birth weight is >2000 g
> 17 mg/dL (> 290 μmol/L) in neonate whose birth weight is <2000 g
Perinatal anoxia or hypoxia
Seizures or apneic spells
Early hearing loss in a parent or close relative
Neonates can be bathed (if the parents wish) once their temperature has stabilized at 37° C for 2 h.
The umbilical cord clamp can be removed when the cord appears dry, usually at 24 h. Umbilical cord care is aimed at reducing the risk of umbilical infection (omphalitis). The umbilical stump should be kept clean and dry; other care varies depending on the birth setting. In a hospital delivery (or properly managed home birth), where the cord is clamped and cut aseptically, dry cord care or cleansing with soap and water is adequate; topical agents do not decrease risk of infection. However, when cord clamping and/or cutting is not aseptic (eg, in some developing countries, precipitous out-of-hospital deliveries), applying a topical antiseptic (eg, chlorhexidine) to the cord reduces the risk of omphalitis and neonatal mortality. The cord should be observed daily for redness or drainage.
Circumcision, if desired by the family, can be safely done, using a local anesthetic, within the first few days of life. Circumcision should be delayed if the mother has taken anticoagulants or aspirin, if there is a family history of bleeding disorders, or if the neonate has displacement of the urethral meatus, hypospadias, or any other abnormality of the glans or penis (because the prepuce may be used later in plastic surgical repair). Circumcision should not be done if the neonate has hemophilia or another bleeding disorder.
Most neonates lose 5 to 7% of their birth weight during the first few days of life, primarily because fluid is lost in urine and insensibly and secondarily because meconium is passed, vernix caseosa is lost, and the umbilical cord dries.
In the first 2 days, urine may stain the diaper orange or pink because of urate crystals, which are a normal result of urine concentration. Most neonates void within 24 h after birth; the average time of first void is 7 to 9 h after birth, and most void at least 2 times in the 2nd 24 h of life. A delay in voiding is more common among male neonates and may result from a tight foreskin; a male neonate’s inability to void may indicate posterior urethral valves. Circumcision is usually delayed until at least after the first void; not voiding within 12 h of the procedure may indicate a complication.
Neonates discharged within 48 h should be evaluated within 2 to 3 days to assess feeding success (breast or formula), hydration, and jaundice (for those at increased risk). Follow-up for neonates discharged after 48 h should be based on risk factors, including those for jaundice and for breastfeeding difficulties, and any identified problems.