The first four weeks of life of an infant are considered the neonatal period. During this period many complex physiologic changes occur, and the infant interacts with the different stimuli. Care during this period should be continuous and effective. Newborn care consists of evaluation for the need of resuscitation, a complete physical exam, administration of prophylactic medications and vaccines, adequate feedings, safe sleep, hygiene of the newborn, and other important areas for baby wellbeing.
Issues of Concern
Growth parameters and behavior are assessed at the moment of birth. In the setting of a normal spontaneous vaginal delivery or a Cesarean section with no complications, the examination is deferred until one hour of age after skin to skin contact with mother is established and breastfeeding is started if appropriate and desired. A pediatrician or nurse practitioner examines the newborn in the first twenty-four hours of life. A team with knowledge of the equipment, training, and resources is in charge of assessing and attending any resuscitation efforts needed by the newborn at the moment of birth. The Neonatal Resuscitation Guidelines are useful to guide resuscitation if necessary.
The Apgar score at 1 and 5 minutes of life is used to assess for the need for resuscitation. This scoring system takes into consideration five components with values from 0 to 2, and it includes respiratory effort, color, heart rate, and reflex irritability and muscle tone.
Growth parameters are considered at the moment of examination: weight, length, head circumference, and abdominal and chest circumference. The values vary depending on sex, socioeconomic status, and race. Boys are usually heavier than girls, but the average weight is around 3500 grams, length, and head circumference are an average of 50cm or 20 inches and 35cm or 14 inches +/- 2 inches, respectively. These measurements can be plotted on a growth curve, and patient results fall into 3 categories:
1) Small for gestational age (SGA) which is also <10 percentile,
2) Adequate for gestational age (AGA)
3) Large for gestational age (LGA) which is >90 percentile, based on weight and gestational age.
If the gestational age or due date is unknown, Dubowitz/Ballard maturational assessments can be used to take into consideration the infant's neuromuscular tone and reflexes as well as physical maturation.
A full physical exam is done to assess for any abnormalities. A head to toe approach is the preferred method. Starting with the head, look for the presence of hematomas, subcutaneous swelling, overriding of sutures, and patency of anterior and posterior fontanelles. For the eyes, symmetry and size should be assessed as well as any subconjunctival hemorrhage, and the red reflexes should be elicited before discharging the baby home. Examination of the nose looks for patency and symmetry of nares. In the mouth, the hard and soft palate are palpated and examined to rule out cleft palate or any other abnormalities, as well as an assessment of the sucking reflex. The ears are examined for size, patency of ear canals, malformations, skin tags or pits. Neck palpation checks for masses and range of motion. The clavicles should also undergo palpation to assure continuity and to rule out fractures. While examining the chest, evaluate for symmetry and location of nipples in relationship to the clavicular midline.
Auscultation of the heart identifies rhythm and the presence of murmurs if any. Lung fields are then auscultated for identification of adventitious sounds and air entry. While examining the abdomen evaluate for asymmetry or malformations, auscultate to assess peristalsis and palpate for the presence of masses or organomegaly (the liver edge is normally at 1cm below the costal margin). Examine the umbilical stump for normal vessels and hernias. The femoral pulses are palpated for intensity and symmetry and examination of the hips using the Ortolani and Barlow maneuvers to assess for the presence of clicks suggesting developmental dysplasia of the hip should follow. All extremities are examined for symmetry, pulses, the range of motion and any deformities. When it comes to inspecting the back, centralization of the spine is assessed to identify any abnormal deviations as well as the presence of sacral dimples or hair tuff.
Skin findings in the newborn are prevalent. Examination of the skin looks for color, macules, spots, birthmarks or trauma that might have occurred at birth or caused by medical equipment like scalp monitors, ensuring documentation of each finding. Neurologic development is evaluated by eliciting reflexes and assessing tone. The most common are primitive reflexes like the Moro, sucking, rooting, palmar and plantar grasp. It is essential to interact with the newborn and to observe the responses to light and touch.
Within 1 hour of birth, intramuscular vitamin K should be administered. Prophylaxis with erythromycin ointment to both eyes and injection of hepatitis B vaccine are recommendations, while the baby has skin-to-skin with the mother.
Breastfeeding: early skin-to-skin contact and breastfeeding initiation are key to successful breastfeeding. Skin-to-skin contact improves the transition of the newborn, increases the production of maternal milk and makes breastfeeding more effective. Effective sucking and latching should be established in the first 48 hours. If there is a weight loss of over 7% associated with a poor suckling reflex or feeding, supplementation with formula is an option. The volume of feedings can be increased each day during the first week starting at 3 to 17 cc/kg/day on day one to 140-170cc/kg/day on day 7.
Vitamin D supplementation should initiate within 2 months in breastfed only infants. Daily requirements are 400 IU/day. Infants fed with formula and breast milk that consume less than 32 ounces per day of formula should also be supplemented with vitamin D as well.
Skin Care: It is important to note that full-term newborn infant’s skin is covered by vernix caseosa which protects the epidermis in the uterus from water damage due to its high lipid content and hydrophobic properties. It is recommended to keep it in contact with the skin for at least 6 hours after birth.
Bathing: Until the umbilical stump falls, bathing should be done with a sponge to keep the cord dry and is not required frequently. Soaps usually contain surfactants to remove dirt, and this can damage subcutaneous lipid and cause irritation.
Diaper care: Diaper care is the ultimate goal to reduce excessive skin moisture. Skin cleansing should be with soft nonwoven wipes, water, and emollient cleansers; these wipes should be free of alcohol and fragrance.
Urine and stool: Newborns pass first meconium within 24 to 48 hours after birth. Meconium is a black and sticky substance and is the first stool passed by the infant. The stools progressively change to a characteristic seedy, mustard yellow or green stool with an increase in mother’s milk consumption. Infants have a gastro-colic reflex which makes them pass stools with almost every feeding. If meconium passage delays more than 48 hours, the infant should undergo evaluation for pathologies like imperforate anus or Hirschsprung disease. Urine usually is passed in the first 24 hours of life. It is important to remember that it is easy to miss urine when it is mixed with stools or is not witnessed or documented at the time of birth. If true anuria is suspected, the physical exam should be repeated to evaluate genitals and abdomen for any missed abnormalities. If there are valid concerns about voiding, catheterization and ultrasound along with a urology consultation should take place. The parents should receive counsel that vaginal discharge is normal at birth due to maternal hormones and that they might see the presence of urate crystals that look like brick dust, which can be confused with blood.. The discharge should happen after voiding and passing stools.
Hyperbilirubinemia is common in newborns, and most infants have some visible jaundice in the first week after birth. Jaundice during the first 24 hours of life is pathologic and requires investigation. Jaundice may be due to an immature uridine diphosphate glucuronyltransferase enzyme in the liver, elevated hemoglobin levels in newborns and increased destruction of RBCs. Bilirubin screening is done before hospital discharge either transcutaneous or measuring serum levels.
Umbilical cord: The umbilical cord is susceptible to bacterial colonization and can serve as a port of entry for bacteria into the systemic circulation. Dry cord care is the preferred method as per the World Health Organization. The umbilical cord should be kept exposed to the air, and if covered, it should be loosely covered with a clean garment. If contaminated at any point with stool or urine, it should be washed with soap and sterile water and dried. The umbilical stump usually falls off naturally in 10 to 14 days.
Safety: From the moment of birth, parents should be given education and guidance about sleep position, shaken baby syndrome, smoking around the baby, the effect on siblings and pets. Babies should be put to sleep on their back in a crib with the goal of decreasing sudden infant death syndrome (SIDS), with fitted sheets, no blankets or stuffed animals, and no co-bedding.
Enhancing Healthcare Team Outcomes
Routine newborn care is essential to aid babies in the transition period right after birth. While most babies are born with minimal difficulties requiring little or no support, a small number of them necessitate some intervention at the time of delivery. Having an interprofessional team that consists of a pediatrician, primary care provider, labor and delivery nurse, and an obstetrician can help identify infants in need of resuscitation.