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Hand washing is critical for all personnel to prevent transmission of infection. Active participation in the birth by both the mother and her partner facilitates adaptation of both 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 and 5 min after birth (see Table 2: Perinatal Problems: Apgar Score ). Apgar scores between 8 and 10 indicate 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 such as heart murmurs. The evaluation should ideally be performed under a radiant warmer with the family close by.
Preventive interventions include administration into both eyes of an antimicrobial agent (eg, 1% silver nitrate solution 2 drops, 0.5% erythromycin 1 cm ribbon, 1% tetracycline 1 cm ribbon) to prevent gonococcal and chlamydial ophthalmia, and administration of vitamin K 1 mg IM to prevent hemorrhagic disease of the newborn.
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 baby and can receive guidance from staff 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:
The neonate should undergo a thorough physical examination within 24 h. Performing the examination alongside the mother and family members allows the family to ask questions and the clinician to point out physical findings and provide anticipatory guidance.
Basic measurements include length, weight, and head circumference (see Physical Growth and Development: Length). 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 or small for age, the gestational age can be precisely determined using physical and neuromuscular findings (see Fig. 1: Approach to the Care of Normal Infants and Children: Assessment of gestational age—new Ballard score. ). These methods are typically accurate to ± 2 wk.
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Fig. 1
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Assessment of gestational age—new Ballard score.
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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. The Journal of Pediatrics 119(3);417–423, 1991; used with permission of the CV Mosby Company.)
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Many clinicians begin with examination of the heart and lungs when the infant is quiet. The examiner should identify the location where the heart sounds are loudest (to exclude dextrocardia). Normal heart rate is 100 to 160 beats/min. The rhythm should be regular, although an irregular rhythm from premature atrial or ventricular contractions is not uncommon. A murmur heard in the 1st 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 sought 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.
After cardiac and pulmonary evaluation, a systematic head to toe examination is performed. 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. Also common is a cephalohematoma, an accumulation of blood between the periosteum and the bone that produces 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 eyes may be easier to examine the day after birth because the birth process causes swelling around the eyelids. Eyes should be examined for presence of the red reflex; absence occurs with glaucoma, cataracts, and retinoblastoma. Subconjunctival hemorrhages are common and caused by forces exerted during delivery.
Low-set ears may indicate genetic anomalies, including trisomy 21. The external auditory canal should be examined. 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 detect a posterior palate defect. 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 infant's airway. These lesions can be removed without recurrence. Neonates can also be born with primary or natal teeth. Natal teeth do not have roots and may need to be removed because they may fall out and be aspirated. Inclusion cysts called Epstein's 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, goiters, or branchial arch remnants. Torticollis can be caused by a sternocleidomastoid hematoma from birth trauma.
The abdomen should be round and symmetric. A scaphoid abdomen may indicate a diaphragmatic hernia, through which intestines have migrated to the chest cavity in utero, sometimes causing pulmonary hypoplasia and postnatal respiratory distress. An asymmetric abdomen suggests an abdominal mass. Splenomegaly suggests congenital infection or hemolytic anemia. The kidneys may be palpable with deep palpation, the left more easily than the right. Large kidneys may be due to 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.
In boys, the penis should be examined for hypospadias or epispadias. In term boys, testes should be present in the scrotum. 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 be a consequence of several uncommon conditions (eg, congenital adrenal hyperplasia; 5α-reductase deficiency; Klinefelter's, Turner's, or Swyer syndrome); referral to an endocrinologist is indicated for evaluation and a discussion with the family about the benefits and risks of immediate vs delayed gender assignment.
Orthopedic examination focuses on detection of hip dysplasia. Risk factors for dysplasia include female sex, breech position in utero, twin gestation, and family history. The condition is assessed by using the Barlow or Ortolani maneuver. In the Ortolani maneuver, the neonate is placed on his back with his feet facing the examiner. With an index finger on the greater trochanter and a thumb on the lesser trochanter, the examiner first fully flexes the legs at the knees and hips, then fully abducts the legs while exerting pressure upward and inward until the knees touch the examining table. 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 maneuver may be falsely negative in infants > 3 mo because of tighter hip muscles and ligaments. If the examination is equivocal or the infant is 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 neurologic examination includes an evaluation of the neonate's tone, level of alertness, movement of extremities, and reflexes. Typically, neonatal reflexes, including the Moro, suck, and rooting reflexes, are elicited. The 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. The rooting reflex is elicited by stroking the neonate's cheek or lateral lip, which prompts the infant to turn the head toward the touch and open the mouth. The suck reflex can be elicited by using a pacifier or gloved finger. 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 1st 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 experiencing trauma during delivery, such as the face, in a delivery where 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:
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 of the risk of hemolytic disease of the newborn (see Abnormalities of Pregnancy: Erythroblastosis Fetalis).
All neonates are evaluated for jaundice throughout the hospital stay and before discharge. The risk of hyperbilirubinemia is assessed using risk criteria, a measurement of bilirubin, or both (see also Metabolic, Electrolyte, and Toxic Disorders in Neonates: Hyperbilirubinemia). Bilirubin can be measured using transcutaneous or serum measurements. Many hospitals screen all neonates and use a predictive nomogram to establish 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 (see Inherited Disorders of Metabolism), 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, and other organic acidemias.
HIV screening is required by some states and is otherwise indicated in children of mothers known to be HIV positive or those engaging in HIV high-risk behaviors.
Toxicology screening is indicated when there is a maternal history of drug use, unexplained placental abruption, or unexplained premature labor; the mother has had poor prenatal care; or the infant exhibits evidence of drug withdrawal.
Hearing screening varies by state; some screen only high-risk neonates (see Table 1: Approach to the Care of Normal Infants and Children: High-Risk Factors for Hearing Deficits in Neonates), whereas others screen all. 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 brainstem 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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Table 1
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High-Risk Factors for Hearing
Deficits
in Neonates
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Birth weight < 1500 g
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Apgar score ≤ 7 at 5 min
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Serum bilirubin > 22 mg/dL (> 376 μmol/L) in a neonate whose birth weight is > 2000 g, or > 17 mg/dL (> 290 μmol/L) in a neonate < 2000 g
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Perinatal anoxia or hypoxia
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Neonatal sepsis or meningitis
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Craniofacial abnormalities
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Seizures or apneic spells
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Congenital infections (rubella, syphilis, herpes simplex, cytomegalovirus, or toxoplasmosis)
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Maternal exposure to aminoglycoside drugs
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History of early hearing loss in a parent or close relative
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Routine care and
observation:
Neonates are bathed 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. The umbilical stump should be kept clean and dry to prevent infection. Some centers apply isopropyl alcohol several times a day or a single dose of triple dye, a bacteriostatic agent believed to decrease bacterial colonization of the cord. The cord should be observed daily for redness or drainage, because it is an entry portal for infection.
Circumcision can—if desired by the family—be safely performed using local anesthesia within the 1st few days of life. Circumcision should be delayed if there is 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 performed if the neonate has hemophilia or another bleeding disorder, there is a family history of bleeding disorders, or the mother has taken anticoagulants or aspirin .
Most neonates lose 5 to 7% of their birth weight in the 1st few days of life, due primarily to urinary and insensible fluid losses and secondarily to passage of meconium, loss of vernix caseosa, and drying of the umbilical cord. In the 1st 2 days, urine may stain the diaper orange or pink because of urate crystals, which are normal and a result of urine concentration. Most neonates void within 24 h after birth; the average time of 1st 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 in boys 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 the first void; failure to void within 12 h of the procedure may indicate a complication. If meconium has not been passed within 24 h, the clinician should consider evaluating the neonate for anatomic abnormalities, such as imperforate anus, Hirschsprung's disease, and cystic fibrosis, which can cause meconium ileus.
Hospital
discharge:
Neonates discharged within 48 h should be evaluated within 2 to 3 days to assess feeding success (breast or bottle), 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.
Last full review/revision November 2005
Content last modified November 2005
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