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Normal Newborn Care

Michael A. Davis, MD

Prenatal Pediatric Visit

The prenatal pediatric visit usually takes place during the third trimester of the pregnancy.

Maternal nutrition, the hazards of alcohol, cigarette smoking and other drugs to the unborn baby; and the dangers of passive smoking once the infant is home should be discussed. Maternal illnesses and medications should be reviewed.

Information about the benefits of breast feeding or information about infant formula is provided.

The use of car seats, safety of cribs, and issues regarding circumcision of boys should be discussed.

Delivery

Neonatal Resuscitation

A pediatrician should be present for high-risk deliveries, and all equipment must be set up and checked before delivery.

The infant who fails to breath spontaneously at birth should be placed under a radiant warmer, dried, positioned to open the airway, mouth and nares suctioned, and gentle stimulation provided.

The mouth should be suctioned first to prevent aspiration in case the infant takes a deep gasp when the nose is suctioned. Prolonged or overly vigorous suctioning may lead to bradycardia and should be avoided unless moderate-to-thick meconium is present in the airway.

The infant born with primary apnea is most likely to respond to the gentle stimulation of drying, rubbing of the back, and gentle tapping of the soles of the feet. The infant who fails to respond rapidly to these measures is experiencing secondary apnea and requires positive pressure bag ventilation with oxygen.

Adequate ventilation is assessed by looking for chest wall excursions and listening for air exchange. The heart rate should be assessed while positive pressure ventilation is being applied. If the heart rate does not increase rapidly after ventilation, chest compressions must be started by an assistant. If the infant fails to respond to these measures, intubation and medications are necessary. Epinephrine can be administered via the endotracheal tube.

Apgar scores are used to assess the status of the infant at 1 and 5 min following delivery.

Early Routine Care of the Newborn

Parent-Newborn Interaction. Early interaction between the infant and parents in the delivery room should be established. Holding, eye-to-eye contact, and early breast feeding should be encouraged.

Vitamin K is given to the infant by intramuscular injection to prevent hemorrhagic disease of the newborn.

Ocular prophylaxis against gonorrheal and chlamydial infection is administered after birth with erythromycin ophthalmic ointment.

Umbilical cord blood syphilis serology is completed if there is no documented record of a negative third-trimester maternal test.

Umbilical cord care consists of local application of triple dye or bacitracin ointment.

Hepatitis B Prophylaxis. If the mother is hepatitis B surface antigen-positive, or if she has active hepatitis B, the infant should be given an IM injection of hepatitis B immune globulin and a course of three injections of hepatitis B vaccine before hospital discharge, and at 1 and 6 months of age.

Physical Examination of the Newborn

General Gestalt

The examiner should assess whether the infant appears to be sick or well.

An unusual cry may indicate sepsis, hypothyroidism, a congenital anomaly of the larynx, or a chromosomal abnormality.

Vital Signs. The normal temperature of the newborn is 36.5 to 37.0 degrees C. The normal respiratory rate ranges from 40 to 60 breaths per minute, and the normal heart rate can range from 94 to 175 beats per minute.

Assessment of the Adequacy of Fetal Growth

Gestational Age Assessment. The gestational age of the newborn infant is assessed with the Ballard score of neuromuscular and physical maturity.

Premature Infants

A preterm infant is defined as an infant of less than 37 weeks' gestation, and a postterm infant is defined as being of greater than 42 weeks' gestation.

Preterm infants may develop respiratory distress syndrome, apnea, bradycardia, and retinopathy of prematurity. Respiratory distress syndrome is recognized by tachypnea, grunting, retractions, an elevated oxygen requirement, and a characteristic roentgenographic picture of poor inflation and a fine homogeneous ground-glass appearance of the lung fields with air bronchograms.

Premature infants of less than 34-1/2 to 35 weeks' gestation are at increased risk for apnea and bradycardia. Apnea is defined as a respiratory pause of 20 sec or longer and frequently is accompanied by a drop in heart rate. Periodic breathing is defined as cycles of pauses of 5 to 10 sec followed by hyperpnea, and it is a benign condition.

Measurements and Growth Charts

Height, weight, and head circumference should be measured. A low-birthweight infant is defined as any neonate with a birthweight <2,500 g. Height, weight, and head circumference should be plotted as a function of gestational age on an intrauterine growth chart. This will permit identification of infants who are small for gestational age and those who are large for gestational age.

Factors that may result in an infant who is small for gestational age include chromosomal and other dysmorphic syndromes, congenital infections, maternal hypertension, smoking, uterine anomalies, and multiple gestations.

The small-for-gestational age infant is at greater risk for cold stress, hypoglycemia, hypocalcemia, and polycythemia.

The differential diagnosis for the large-for-gestational age infant includes maternal diabetes and maternal obesity. The large-for-gestational age infant is at risk for shoulder dystocia, birth trauma, and hypoglycemia.

Examination of Organ Systems and Regions

Head, Face, and Neck

The head circumference is measured and plotted, and the scalp, fontanelles, and sutures are examined. Bruising and hematomas of the scalp should be noted. Cephalohematomas are subperiosteal and do not cross suture lines, whereas caputs are subcutaneous and do cross suture lines. An enlarged posterior fontanelle may be a sign of congenital hypothyroidism.

Facial features that suggest a chromosomal anomaly include midfacial hypoplasia, small eyes, or low-set ears. Fetal alcohol syndrome is suggested by a small upper lip and a smooth philtrum.

The eyes should be examined with an ophthalmoscope to document a red reflex. The absence of a clear red reflex is indicative of a retinoblastoma, cataract, or glaucoma.

The lips, mouth, and palate are inspected and palpated for clefts. Nares patency can be documented by closing the mouth and occluding one nostril at a time while observing air flow through the opposite nostril.

Thorax and Cardiovascular Systems

Chest wall excursions should be observed and the respiratory rate determined. The normal neonatal respiratory rate is 40 to 60 breaths per minute.

Auscultation of Breath and Heart Sounds. The normal heart rate during the first week of life may range from 94 to 175 beats per minute. Heart murmurs in the newborn may be caused by serious congenital heart defects. The brachial and femoral pulses should be examined simultaneously to diagnose aortic coarctation.

Abdomen and Gastrointestinal System

Visual inspection of the abdomen should assess symmetry and distension. Palpation of the abdomen may be done with one hand while the other hand holds the hips and knees in flexion to relax the abdominal musculature.

Abdominal palpation for masses, hepatosplenomegaly, or renal masses is completed, and the anus should be visually inspected; digital examination is not recommended unless obstruction is a possibility.

Genitourinary System. The genitalia are examined for the presence of ambiguous genitalia, which requires immediate endocrinologic and urologic consultation. An assignment of gender should not be made until the therapeutic plan has been determined.

Musculoskeletal System

Hip examination may detect developmental dysplasia. Risk factors for hip dysplasia include a family history, foot deformities, congenital torticollis, Down syndrome, and breech presentation. The female to male ratio is 7:1. Ultrasonography is used to evaluate suspected hip dysplasia.

Fracture of the clavicle occurs in 0.2-3.5% of vaginal deliveries. The majority of these infants are asymptomatic. Physical findings include local swelling and crepitations and an asymmetric Moro reflex. Treatment consists of making a sling by pinning the shirt sleeve of the involved side to the opposite side of the shirt.

Neurologic System

The degree of alertness, activity, and muscle tone should be noted. The head circumference is plotted on the growth chart.

The posterior midline area should be examined for evidence of neural tube defects. Pilonidal dimples with tufts of hair or no visible floor are evaluated with ultrasonography.

Common Neonatal Problems

Hypoglycemia

Hypoglycemia is common in premature infants, infants who are small for gestational age, infants of diabetic mothers, and infants who have experienced perinatal asphyxia.

Hypoglycemia is defined as a blood glucose of <40-45 mg/dL (<2.2-2.5 mMol/L). Hypoglycemic infants require early feedings or IV glucose.

Anemia during the newborn period may be caused by hemolytic and congenital anemias, fetal-to-maternal hemorrhage, placental abruption, and occult hemorrhage (intraventricular, intrahepatic, adrenal, or gastrointestinal).

Bilirubin Metabolism

Hyperbilirubinemia occurs frequently in the normal newborn because of increased production and decreased elimination of this breakdown product of heme.

Initial workup for neonatal hyperbilirubinemia includes measurements of total and direct bilirubin levels, hematocrit, Coombs test, and testing of urine for reducing substances to exclude galactosemia.

High levels of bilirubin can cause an acute encephalopathy (ie, kernicterus).

Phototherapy in healthy full-term newborns with nonhemolytic jaundice is not indicated when the total bilirubin is <20 mg/dL.

Sepsis must be considered in any newborn who develops respiratory distress, temperature instability, hypoglycemia, lethargy, poor feeding, or jaundice. When sepsis is suspected, cultures of blood, urine, and spinal fluid are obtained. Antibiotic therapy must be initiated promptly.

Gastrointestinal Problems

Ninety-six percent of full-term newborns pass a meconium stool before 24 hours of age. A delayed or absent passage of meconium may be caused by meconium plug syndrome, Hirschsprung disease, meconium ileus (cystic fibrosis), imperforate anus, or the small left colon syndrome (in infants of diabetic mothers).

Bilious vomiting in the newborn is always abnormal and usually is caused by an intestinal obstruction. Vomiting in the newborn also may be caused by inborn errors of metabolism and congenital adrenal hyperplasia.

Urinary Problems. Ninety nine percent of normal full-term infants will urinate by 24 hours. If urination has not occurred within 24 hours, renal ultrasonography should be done and an intravenous fluid challenge may be given.

Preparation for Discharge

An infant's feeding pattern, weight, and degree of jaundice must be evaluated before discharge.

Some serious ductal-dependent congenital cardiac defects, such as hypoplastic left heart and coarctation of the aorta, may not present until after 48 h of age; therefore, the first visit to the pediatrician's office should be within 3 days.

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