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Evaluation and Care of the Normal Neonate

By

Deborah M. Consolini

, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Last full review/revision Sep 2019| Content last modified Sep 2019
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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.

The First Few Hours

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 Score ). 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.

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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.

The First Few Days

Physical Examination of the Newborn

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 Assessment of gestational age—new Ballard score ). 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

Scores from neuromuscular and physical domains are added to obtain total score. (Adapted from Ballard JL, Khoury JC, Wedig K, et al: New Ballard score, expanded to include extremely premature infants. 119(3):417–423, 1991; used with permission of the CV Mosby Company.)

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 Birth Injuries and congenital abnormalities.

Cardiorespiratory system

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 Patent Ductus Arteriosus (PDA) . Daily heart examination confirms the disappearance of this murmur, usually within 3 days.

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 .

Head and neck

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 Cephalhematoma 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.

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 Cleft Lip and Cleft Palate 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.

Abdomen and pelvis

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 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 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 Classification of Abdominal Hernias , 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 Hypospadias 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 Epispadias . 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 Cryptorchidism ). 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 Congenital hydrocele , 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.

Musculoskeletal system

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.

Neurologic system

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.

Skin

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 Tests for Newborns

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 Sickle Cell Disease , 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 Cystic Fibrosis , 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.

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 Hearing Impairment in Children 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 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.

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Routine Infant Care and Observation

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 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 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.

Hospital Discharge

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.

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