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 minute and 5 minutes after birth (see Table: Apgar Score Apgar Score 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... read more ). Apgar scores between 8 and 10 indicate that the neonate is making a smooth transition to extrauterine life; scores ≤ 7 at 5 minutes (particularly if sustained beyond 10 minutes) are linked to higher neonatal morbidity and mortality rates. Many normal neonates have cyanosis 1 minute after birth that clears by 5 minutes. Cyanosis that does not clear may indicate congenital cardiopulmonary anomalies or central nervous system (CNS) depression.
In addition to Apgar scoring, neonates should be evaluated for gross deformities (eg, clubfoot Talipes Equinovarus (Clubfoot) and Other Foot Abnormalities Talipes equinovarus, sometimes called clubfoot, is characterized by plantar flexion, inward tilting of the heel (from the midline of the leg), and adduction of the forefoot (medial deviation... read more , polydactyly Polydactyly Congenital limb defects involve missing, incomplete, supernumerary, or abnormally developed limbs present at birth. (See also Introduction to Congenital Craniofacial and Musculoskeletal Disorders... read more ) and other important abnormalities (eg, heart murmurs Murmurs Congenital heart disease is the most common congenital anomaly, occurring in almost 1% of live births (1). Among birth defects, congenital heart disease is the leading cause of infant mortality... read more ). 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 Neonatal Conjunctivitis Neonatal conjunctivitis is watery or purulent ocular drainage due to a chemical irritant or a pathogenic organism. Prevention with antigonococcal topical treatment at birth is routine. Diagnosis... read more and administration of vitamin K 1 mg IM to prevent hemorrhagic disease of the newborn (see Vitamin K Deficiency Vitamin K Deficiency Vitamin K deficiency results from extremely inadequate intake, fat malabsorption, or use of coumarin anticoagulants. Deficiency is particularly common among breastfed infants. It impairs clotting... read more ).
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 hours. 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 Length Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more , weight Weight Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more , and head circumference Head Circumference Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more (see also Growth Parameters in Neonates Growth Parameters in Neonates Growth parameters and gestational age help identify the risk of neonatal pathology. Growth is influenced by genetic and nutritional factors as well as intrauterine conditions. Growth parameters... read more ). Length is measured from crown to heel; normal values are based on gestational age and should be plotted on a standard growth chart Physical Growth of Infants and Children Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more . When gestational age is uncertain or when the infant seems large for gestational age Large-for-Gestational-Age (LGA) Infant Infants whose weight is > the 90th percentile for gestational age are classified as large for gestational age. Macrosomia is birthweight > 4000 g in a term infant. The predominant cause is maternal... read more or small for gestational age Small-for-Gestational-Age (SGA) Infant Infants whose weight is the 10th percentile for gestational age are classified as small for gestational age. Complications include perinatal asphyxia, meconium aspiration, polycythemia, and... read more , the gestational age can be more precisely determined using physical and neuromuscular findings (see Figure: Assessment of gestational age—new Ballard score Assessment of gestational age—new Ballard score 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... read more ). These methods are typically accurate to ± 2 weeks; however, in the sick neonate these methods are less reliable.
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 Birth Injuries The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more and congenital abnormalities.
(See also Congenital Cardiovascular Anomalies Overview of Congenital Cardiovascular Anomalies Congenital heart disease is the most common congenital anomaly, occurring in almost 1% of live births (1). Among birth defects, congenital heart disease is the leading cause of infant mortality... read more .)
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/minute) 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 hours is most commonly caused by a patent ductus arteriosus Patent Ductus Arteriosus (PDA) Patent ductus arteriosus (PDA) is a persistence of the fetal connection (ductus arteriosus) between the aorta and pulmonary artery after birth. In the absence of other structural heart abnormalities... read more . 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 Coarctation of the Aorta Coarctation of the aorta is a localized narrowing of the aortic lumen that results in upper-extremity hypertension, left ventricular hypertrophy, and malperfusion of the abdominal organs and... read more or other left ventricular outflow tract obstruction. Central cyanosis suggests congenital heart disease, pulmonary disease, or sepsis Neonatal Sepsis Neonatal sepsis is invasive infection, usually bacterial, occurring during the neonatal period. Signs are multiple, nonspecific, and include diminished spontaneous activity, less vigorous sucking... read more .
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/minute. 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 Overview of Perinatal Respiratory Disorders Extensive physiologic changes accompany the birth process (see also Neonatal Pulmonary Function), sometimes unmasking conditions that posed no problem during intrauterine life. For that reason... read more .
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 Caput succedaneum The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more ). In a breech delivery Breech presentation Fetal dystocia is abnormal fetal size or position resulting in difficult delivery. Diagnosis is by examination, ultrasonography, or response to augmentation of labor. Treatment is with physical... read more , 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 and anything more than a fingertip breadth posterior fontanelle may be signs of hypothyroidism Hypothyroidism in Infants and Children Hypothyroidism is thyroid hormone deficiency. Symptoms in infants include poor feeding and growth failure; symptoms in older children and adolescents are similar to those of adults but also... read more .
A cephalohematoma Cephalhematoma The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more 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 Hydrocephalus Hydrocephalus is accumulation of excessive amounts of CSF, causing cerebral ventricular enlargement and/or increased intracranial pressure. Manifestations can include enlarged head, bulging... read more .
Numerous genetic syndromes cause craniofacial abnormalities Overview of Congenital Craniofacial Abnormalities Congenital craniofacial abnormalities are a group of defects caused by abnormal growth and/or development of the head and facial soft-tissue structures and/or bones. (See also Introduction to... read more . 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 Primary Infantile Glaucoma Primary infantile glaucoma is a rare developmental defect in the iridocorneal filtration angle of the anterior chamber that prevents aqueous fluid from properly draining from the eye. This obstruction... read more , cataracts Congenital Cataract Congenital cataract is a lens opacity that is present at birth or shortly after birth. (See also Cataracts in adults.) Congenital cataracts may be sporadic, or they may be caused by chromosomal... read more , or retinoblastoma Retinoblastoma Retinoblastoma is a cancer arising from the immature retina. Symptoms and signs commonly include leukocoria (a white reflex in the pupil), strabismus, and, less often, inflammation and impaired... read more . Subconjunctival hemorrhages are common and caused by forces exerted during delivery.
Low-set ears may indicate genetic anomalies Overview of Chromosomal Anomalies Chromosomal anomalies cause various disorders. Anomalies that affect autosomes (the 22 paired chromosomes that are alike in males and females) are more common than those that affect sex chromosomes... read more , including trisomy 21 Down Syndrome (Trisomy 21) Down syndrome is an anomaly of chromosome 21 that can cause intellectual disability, microcephaly, short stature, and characteristic facies. Diagnosis is suggested by physical anomalies and... read more (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 Cleft Lip and Cleft Palate Cleft lip, cleft lip and palate, and isolated cleft palate, are collectively termed oral clefts (OCs). OCs are the most common congenital anomalies of the head and the neck with a total prevalence... read more 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.
When examining the neck, the clinician must lift the chin to look for abnormalities such as cystic hygromas Lymphatic Malformations Lymphatic vascular malformations are elevated lesions composed of dilated lymphatic vessels. This photo shows a cystic hygroma, or lymphatic malformation, on the neck of a 2-year-old girl. This... read more , goiters Congenital Goiter Congenital goiter is a diffuse or nodular enlargement of the thyroid gland present at birth. Thyroid hormone secretion may be decreased, increased, or normal. Diagnosis is by confirming thyroid... read more , and branchial arch remnants. Torticollis Congenital torticollis Neck and back abnormalities can be caused by soft-tissue or bony injuries or by vertebral anomalies. (See also Introduction to Congenital Craniofacial and Musculoskeletal Disorders.) Vertebral... read more can be caused by a sternocleidomastoid hematoma due to birth trauma.
The abdomen should be round and symmetric. A scaphoid abdomen may indicate a diaphragmatic hernia Diaphragmatic Hernia Diaphragmatic hernia is protrusion of abdominal contents into the thorax through a defect in the diaphragm. Lung compression may cause persistent pulmonary hypertension. Diagnosis is by chest... read more , 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 Classification of Abdominal Hernias A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become... read more , 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 Hypospadias Congenital anomalies of the urethra in boys usually involve anatomic abnormalities of the penis and vice versa. In girls, urethral anomalies may exist without other external genital abnormalities... read more or epispadias Epispadias Congenital anomalies of the urethra in boys usually involve anatomic abnormalities of the penis and vice versa. In girls, urethral anomalies may exist without other external genital abnormalities... read more . In term boys, the testes should be in the scrotum (see Cryptorchidism Cryptorchidism Cryptorchidism is failure of one or both testes to descend into the scrotum; in younger children, it is typically accompanied by inguinal hernia. Diagnosis is by testicular examination, sometimes... read more ). Scrotal swelling may signify hydrocele Congenital hydrocele The most common testicular and scrotal anomalies are Congenital hydrocele Undescended testes (cryptorchidism) Testicular torsion Rare anomalies include scrotal agenesis, hypoplasia, ectopia... read more , inguinal hernia Inguinal hernia in neonates Inguinal hernias develop most often in male neonates, particularly if they are premature (in which case the incidence is about 10%). The right side is affected most commonly, and about 10% of... read more , or, more rarely, testicular torsion Testicular Torsion Testicular torsion is an emergency condition due to rotation of the testis and consequent strangulation of its blood supply. Symptoms are acute scrotal pain and swelling, nausea, and vomiting... read more . 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 Overview of Congenital Adrenal Hyperplasia Congenital adrenal hyperplasia is a group of genetic disorders, each characterized by inadequate synthesis of cortisol, aldosterone, or both. In the most common forms, accumulated hormone precursors... read more ; 5-alpha-reductase deficiency; Klinefelter syndrome Klinefelter Syndrome (47,XXY) Klinefelter syndrome is the presence of two or more X chromosomes plus one Y, resulting in a phenotypic male. Diagnosis is based on clinical findings and is confirmed by cytogenetic analysis... read more , Turner syndrome Turner Syndrome In Turner syndrome, girls are born with one of their two X chromosomes partly or completely missing. Diagnosis is based on clinical findings and is confirmed by cytogenetic analysis. Treatment... read more , 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 Limb deficiencies Congenital limb defects involve missing, incomplete, supernumerary, or abnormally developed limbs present at birth. (See also Introduction to Congenital Craniofacial and Musculoskeletal Disorders... read more ), contractures, and maldevelopment. Brachial nerve palsy Brachial Plexus Injuries The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more 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 Spina Bifida Spina bifida is defective closure of the vertebral column. Although the cause is not known, low folate levels during pregnancy increase risk. Some children are asymptomatic, and others have... read more , 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 Developmental Dysplasia of the Hip (DDH) Developmental dysplasia of the hip (formerly congenital dislocation of the hip) is abnormal development of the hip joint. (See also Introduction to Congenital Craniofacial and Musculoskeletal... read more . 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 months 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 weeks; some experts recommend screening ultrasonography at 4 to 6 weeks 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 weeks' 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 hours after birth, is scattered over the body and can last for up to 2 weeks.
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 Erythroblastosis Fetalis Erythroblastosis fetalis is hemolytic anemia in the fetus (or neonate, as erythroblastosis neonatorum) caused by transplacental transmission of maternal antibodies to fetal red blood cells.... read more ) is a risk.
All neonates are evaluated for jaundice throughout the hospital stay and before discharge. The risk of hyperbilirubinemia Neonatal Hyperbilirubinemia Jaundice is a yellow discoloration of the skin and eyes caused by hyperbilirubinemia (elevated serum bilirubin concentration). The serum bilirubin level required to cause jaundice varies with... read more 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/or rate of bilirubin rise from one determination to another, and risk of developing jaundice.
Most states test for specific inherited diseases Introduction to Inherited Disorders of Metabolism Most inherited disorders of metabolism (also called inborn errors of metabolism) are caused by mutations in genes that code for enzymes; enzyme deficiency or inactivity leads to Accumulation... read more , including phenylketonuria Phenylketonuria (PKU) Phenylketonuria is a disorder of amino acid metabolism that causes a clinical syndrome of intellectual disability with cognitive and behavioral abnormalities caused by elevated serum phenylalanine... read more , tyrosinemia Tyrosine Metabolism Disorders Tyrosine is an amino acid that is a precursor of several neurotransmitters (eg, dopamine, norepinephrine, epinephrine), hormones (eg, thyroxine), and melanin; deficiencies of enzymes involved... read more , biotinidase deficiency, homocystinuria Classic homocystinuria A number of defects in methionine metabolism lead to accumulation of homocysteine (and its dimer, homocystine) with adverse effects including thrombotic tendency, lens dislocation, and central... read more , maple syrup urine disease Maple syrup urine disease Valine, leucine, and isoleucine are branched-chain amino acids; deficiency of enzymes involved in their metabolism leads to accumulation of organic acids with severe metabolic acidosis. There... read more , galactosemia Galactosemia Galactosemia is a carbohydrate metabolism disorder caused by inherited deficiencies in enzymes that convert galactose to glucose. Symptoms and signs include hepatic and renal dysfunction, cognitive... read more , congenital adrenal hyperplasia Overview of Congenital Adrenal Hyperplasia Congenital adrenal hyperplasia is a group of genetic disorders, each characterized by inadequate synthesis of cortisol, aldosterone, or both. In the most common forms, accumulated hormone precursors... read more , sickle cell disease Sickle Cell Disease Sickle cell disease (a hemoglobinopathy) causes a chronic hemolytic anemia occurring almost exclusively in blacks. It is caused by homozygous inheritance of genes for hemoglobin (Hb) S. Sickle-shaped... read more , and hypothyroidism Hypothyroidism in Infants and Children Hypothyroidism is thyroid hormone deficiency. Symptoms in infants include poor feeding and growth failure; symptoms in older children and adolescents are similar to those of adults but also... read more . Some states also include testing for cystic fibrosis Cystic Fibrosis Cystic fibrosis is an inherited disease of the exocrine glands affecting primarily the gastrointestinal and respiratory systems. It leads to chronic lung disease, exocrine pancreatic insufficiency... read more , disorders of fatty acid oxidation Overview of Fatty Acid and Glycerol Metabolism Disorders Fatty acids are the preferred energy source for the heart and an important energy source for skeletal muscle during prolonged exertion. Also, during fasting, the bulk of the body’s energy needs... read more , other organic acidemias, and severe combined immunodeficiency Severe Combined Immunodeficiency (SCID) Severe combined immunodeficiency is characterized by low to absent T cells and a low, high, or normal number of B cells and natural killer cells. Most infants develop opportunistic infections... read more .
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 Drugs in Pregnancy Drugs are used in over half of all pregnancies, and prevalence of use is increasing. The most commonly used drugs include antiemetics, antacids, antihistamines, analgesics, antimicrobials, diuretics... read more , unexplained placental abruption Abruptio Placentae Abruptio placentae is premature separation of a normally implanted placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include vaginal... read more , unexplained premature labor Preterm Labor Labor (contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities, infection... read more , poor prenatal care, or evidence of drug withdrawal in the neonate Prenatal Drug Exposure Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus... read more .
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 hours 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 hour apart.
There is > 3% absolute difference between the oxygen saturation in the right hand (preductal) and foot (postductal) on 3 separate measurements taken 1 hour apart.
Any infant with a positive screen should have additional testing, including chest x-ray, electrocardiography, 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 Hearing Impairment in Children Common causes of hearing loss are genetic defects in neonates and ear infections and cerumen in children. Many cases are detected by screening, but hearing loss should be suspected if children... read more 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 an intensive care unit at birth. Currently, some states screen only high-risk neonates (see Table: High-Risk Factors for Hearing Deficits in Neonates High-Risk Factors for Hearing Deficits in Neonates 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... read more ); 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.
Neonates can be bathed (if the parents wish) once their temperature has stabilized at 37° C for 2 hours.
The umbilical cord clamp can be removed when the cord appears dry, usually at 24 hours. 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 Hypospadias Congenital anomalies of the urethra in boys usually involve anatomic abnormalities of the penis and vice versa. In girls, urethral anomalies may exist without other external genital abnormalities... read more , 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 hours after birth; the average time of first void is 7 to 9 hours after birth, and most void at least 2 times in the 2nd 24 hours 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 hours of the procedure may indicate a complication.
If meconium has not been passed within 24 hours, the clinician should consider evaluating the neonate for anatomic abnormalities, such as imperforate anus Anal Atresia Anal atresia is an imperforate anus. (Also see Overview of Congenital Gastrointestinal Anomalies.) In anal atresia, the tissue closing the anus may be several centimeters thick or just a thin... read more , Hirschsprung disease Hirschsprung Disease Hirschsprung disease is a congenital anomaly of innervation of the lower intestine, usually limited to the colon, resulting in partial or total functional obstruction. Symptoms are obstipation... read more , and cystic fibrosis Cystic Fibrosis Cystic fibrosis is an inherited disease of the exocrine glands affecting primarily the gastrointestinal and respiratory systems. It leads to chronic lung disease, exocrine pancreatic insufficiency... read more (which can cause meconium ileus Meconium Ileus Meconium ileus is obstruction of the terminal ileum by abnormally tenacious meconium; it most often occurs in neonates with cystic fibrosis. Meconium ileus accounts for up to 33% of neonatal... read more ).
Neonates discharged within 48 hours should be evaluated within 2 to 3 days to assess feeding success (breast or formula), hydration, and jaundice Neonatal Hyperbilirubinemia Jaundice is a yellow discoloration of the skin and eyes caused by hyperbilirubinemia (elevated serum bilirubin concentration). The serum bilirubin level required to cause jaundice varies with... read more (for those at increased risk). Follow-up for neonates discharged after 48 hours should be based on risk factors, including those for jaundice and for breastfeeding difficulties, and any identified problems.