This is a 3640 gram newborn male infant born at 39 weeks gestation via normal spontaneous vaginal delivery (NSVD) to a 17 year old G3P0 mother who is O+, VDRL NR, Hepatitis B surface antigen (HBsAg) positive, rubella immune, group B streptococcus (GBS) negative, and HIV negative . Artificial rupture of membranes (AROM) occurred 18 hours prior to delivery with clear fluid. Apgar scores were 8 and 9 at 1 and 5 minutes respectively.
Maternal history is remarkable for 1 prenatal visit 1 month ago. An ultrasound performed at that time was consistent with 34 weeks gestation. Toxicology screening at that visit and on admission were negative. Mother is reportedly healthy, with no chronic medical problems and no significant family history. She reports no difficulty during the pregnancy. She denies alcohol, cigarette, medication or drug use. Social history reveals that the mother's support system includes the father of the baby (FOB) and both maternal and paternal grandparents.
Exam: VS T 37.0 rectal, P 145, R48, BP 49/35. Weight 3640 grams (8 pounds) (75th%), 51 cm (20 inches) (75th%), head circumference 34 cm (13.5 inches) (50th%). This infant is term in appearance, pink and active. Anterior fontanelle is soft and flat. Caput succedaneum is present. Corneas are clear. Ears are normally placed. Nares are patent. Oral mucosa is pink and the palate is intact. Neck is supple without masses. Clavicles are intact. His chest is symmetric and mature breast buds are present. Lungs are clear with equal aeration. Heart is regular with no murmurs heard. Abdomen is flat and soft with no masses. Three vessels are visible within the umbilical cord. Femoral and brachial pulses are symmetric and 2+. Hips demonstrate full range of motion, no tightness, no clicks. Ortolani and Barlow signs are negative. Perineal creases are symmetric. Anus is patent. Male genitalia are normal, with both testes descended. His skin is pink with a few facial petechiae. He moves all extremities well. His Moro reflex is intact. His grasp response is symmetrical. His suck reflex is strong.
By 7 hours of age, he has passed meconium once, has had no urine output, and has nippled 15 cc of infant formula from a bottle. His mother does not want to breastfeed because she says she has no milk and will be returning to school soon. Besides, she read that formula makes your baby grow just as well as breast milk. During a discussion between one of the pediatric residents and the mother following the initial newborn exam, she begins to cry and says that she has no idea how to care for a baby. She doesn't know how often to feed him or how to position him for sleep. She has received paperwork describing tests and procedures to be performed before they are discharged (i.e., circumcision, hepatitis immunization, hearing screening), but doesn't understand why they are all necessary. She also wonders why there was medicine put in his eyes and why he received a shot shortly after birth. Additionally, she is quite shocked to discover that she needs a pediatrician as she thought her obstetrician would take care of the baby.
Routine newborn care encompasses not only the evaluation and health maintenance of the infant, but also the counseling and education of parents or other caregivers.
The maternal history provides pertinent information such as the presence of certain risk factors, which could affect the newborn. A comprehensive may not be readily available, especially if the mother has had limited or no prenatal care. Reviewing the maternal chart may identify maternal risk factors that could impact the health of the newborn, as well as complications of labor and delivery that could impact fetal/newborn well being and transition.
The initial physical examination should be performed within 24 hours of birth. It may demonstrate subtle differences related to the age of the infant. An infant who is 30 minutes old has not yet completed the normal transition (from intrauterine to extrauterine life) and thus, variability may exist in vital signs and examination of the respiratory, neurological, gastrointestinal, skin, and cardiovascular systems. It is therefore ideal that a comprehensive examination be performed after the infant has completed transition. In a quiet infant, the examination should proceed from the least invasive and noxious elements of the exam (auscultation of heart and lungs) to those most likely to irritate the infant (examination of the hips and eliciting the Moro reflex).
An enormous amount of information regarding the well being of an infant can be obtained by a general visual assessment. Initial observation gives an impression of healthy (stable) versus ill and term versus preterm. Gestational age is determined by assessing various physical signs and neurological characteristics that vary according to fetal age and maturity. The new Ballard scoring system provides an objective estimate of gestational age (accuracy plus or minus 2 weeks). Gestational age assessment is pertinent as it allows the clinician to plot growth parameters, and to anticipate potential problems related to prematurity/postmaturity and also to growth abnormalities such as SGA/LGA (small and large for gestational age). After assuring that the infant is stable and thus able to tolerate a full and in depth examination, the examiner should proceed in a step-wise manner, taking into account the state and tolerance of the infant.
The specific components of the typical newborn exam are listed as follows:
General: overall behavioral state, color, respiratory status; any congenital anomalies, gender
Head: occipitofrontal circumference and shape, molding (deformation of the skull caused by labor), caput succedaneum (normal scalp edema at the apex of the head secondary to the compression sustained during labor and delivery) versus cephalohematoma (subperiosteal bleeding), sutures, fontanels, scalp trauma, defects, craniotabes (soft portions of the skull which are benign).
Eyes: presence, retinal red reflex, symmetry and completeness of iris, pupil reactivity.
Ears: shape and position, skin tags.
Nose: patency of nares.
Mouth: mucosa color, palpation of palate, presence of teeth.
Neck: range of motion, length, cysts, sinuses or masses.
Chest: symmetry, pectus deformity, clavicles, breast tissue.
Respiratory: color, respiratory rate and effort, presence, quality and equality of breath sounds, and work of breathing.
Heart: rate and rhythm, presence of murmurs; situs and precordial activity.
Pulses: strength and equality in four extremities.
Abdomen: placement of the umbilicus, 3 vessels within the umbilical cord (2 arteries, 1 vein), palpation of the liver edge (not always palpable), palpation of the spleen and kidneys (not easily palpable), any masses, bowel sounds, contour (scaphoid, flat, distended).
Male genitalia: foreskin and position of urethra, palpable descended testes, scrotum with rugae, no other masses in scrotum/groin.
Female genitalia: labia majora and minora, position of urethra, discharge.
Anus: patency and position.
Extremities: number of digits, hip exam for dysplasia/dislocation (Ortolani/Barlow), perineal creases, range of motion at all joints (especially the hips).
Spine: presence of dimples, cysts, tracts, cutaneous defects, swellings or tufts of hair.
Skin: color, rashes, ecchymoses/petechiae, perfusion, nevi, pigmentation.
Neurological system: symmetry of movement, muscle tone, posture, strength, grasp reflex, suck reflex, Moro reflex, response to being handled.
In addition to a comprehensive physical examination, several preventive measures are undertaken to ensure good newborn health. Within 1 hour of birth, infants should receive erythromycin ophthalmic ointment to both eyes to prevent ophthalmia neonatorum (from gonococcal infection). Eye prophylaxis does not prevent chlamydia conjunctivitis. Intramuscular vitamin K should also be given within 1 hour to prevent hemorrhagic disease of the newborn. Finally, bathing of skin and hair should be completed once thermal and cardiorespiratory stability have been achieved in order to reduce skin bacterial colonization.
Screening for hearing, metabolic, endocrine, and hematologic disease should also be done prior to discharge. The State of Hawaii has recently expanded the newborn screening program to test for over 30 disorders. The previous newborn screen tested for 7 disorders: hypothyroidism, phenylketonuria (PKU), congenital adrenal hyperplasia (CAH), galactosemia, sickle cell anemia, biotinidase deficiency, and maple syrup urine disease (MSUD).
Hepatitis B immunization is offered to all infants prior to discharge. If a mother is hepatitis B surface antigen (HBsAg) positive, the immunization should be administered along with hepatitis B immune globulin.
Anticipatory guidance is a major part of providing care to the healthy newborn. Educating parents about the care of their baby, especially new mothers, is of utmost importance. Nutrition is a primary educational objective. All babies must have an appropriate feeding routine established prior to discharge. Breast-feeding and breastmilk are the most beneficial for the infant as well as the mother. The mother should be counseled on the nutritional and immunological benefits of breastmilk (e.g., provides protection against illnesses such as gastroenteritis and otitis media). In cases where breastfeeding is not feasible (medically contraindicated or lack of maternal interest), then it is imperative that the infant successfully establishes bottle feeding prior to discharge. A newborn feeds every 1 to 4 hours, with longer intervals expected in formula fed infants as breastmilk tends to empty from the stomach faster than formula. A typical feeding session should last approximately 20-30 minutes.
Prior to discharge the infant should have voided and passed meconium. The first void may not occur until 16 hours of life, but in general 90% of babies will have voided by this time. In addition, 98% of infants have had their first stool by 24 hours of age. The mother should be counseled on the change in appearance of stool from meconium (dark green sticky sludge) to transitional to normal milk feeding stools and the variability between formula fed stools (tends to be brown) and breast fed stools (tends to be yellow, loose and seedy). The mother should also be aware of the appropriate number of wet diapers per day. By the end of the first week, the infant should be voiding 5 to 7 times per day.
It is essential to discuss sleep position, since prone sleeping is a known risk factor for sudden infant death syndrome. Parents should be instructed to put their infant to sleep in a supine position. Pillows, blankets and thick comforters may pose a suffocation risk and should not be present in a crib or bassinet.
General safety issues should also be addressed. The law requires rear facing car seats for infants less than 1 year of age and less than 20 pounds. Parents should be warned to never leave an infant unattended on a raised surface, in a bathtub or near water (beach, pool, bucket, etc.). Parents should also be instructed about thermal regulation. Because infants lose much of their heat from their heads, caps should be used in the hospital and in cold environments. Otherwise, newborns should be dressed as is appropriate for their immediate environment.
Caregivers should know their physician's name, office number and location, and an after hours contact number. Additionally, they should be aware that in a true emergency, 911 should be called.
Parents should anticipate that their baby may lose up to 10% of their birthweight within the first 3 to 5 days of life. The baby should regain or exceed their birthweight by 2 weeks of age.
Peeling skin is normal and does not, in general, benefit from lotions. Sponge baths should be done until the umbilical cord falls off. The drying of the cord can be aided by wiping the base with rubbing alcohol when the diaper is changed.
Circumcision is the elective surgical removal of the penile foreskin. There are no true medical indications for circumcision in the newborn. All newborns have some degree of phimosis (inability to fully retract the foreskin). It has been demonstrated that there is a decreased incidence of urinary tract infections in the first year of life in circumcised male infants. Contraindications to circumcision include hypospadias, bleeding disorders, and small penile size. Local anesthesia should be used.
Pseudomenses occurs in many female neonates. Small amounts of blood tinged mucus or frank blood may be passed vaginally within the first two weeks of life. This is due to withdrawal from the high hormone levels that the infant was exposed to in utero. Anticipatory counseling prevents unnecessary anxiety when this occurs.
Physiologic jaundice is common in the first few days of life. Risk factors for pathologic jaundice include O+ maternal blood type, bruising/cephalohematoma, prematurity, infants of diabetic mothers, polycythemia, and ethnic groups (males) at risk for G6PD deficiency.
A baby's first follow up appointment may be scheduled 2 weeks after discharge for infants who remain in the hospital for more than 48 hours after delivery. However, many physicians choose to see the baby 1 to 2 days after discharge. This is especially the case for infants discharged from the hospital at less than 48 hours of age, in accordance with American Academy of Pediatrics recommendations.
1. List three disease prevention measures routinely administered to all newborns.
2. List three early disease detection measures routinely administered to all newborns.
3. True/False: Abnormal vital signs within the first 30-60 minutes of life are always pathologic and indicate a unhealthy newborn.
4. True/False: Breast milk is associated with a decrease in the incidence of several common infections.
5. True/False: Circumcision should be routinely recommended based on medical advantages.
6. True/False: Normal stools from breast fed infants appear to be loose, yellow and seedy.
1. Fletcher MA. Chapters 1,2,3. In: Physical Diagnosis in Neonatology. 1998, Philadelphia: Lippincott-Raven Publishers, pp. 18-66.
2. Taeusch HW. Chapter 23 - Initial Evaluation: History and Physical Examination of the Newborn. In: Taeusch HW, Ballard RA (eds). Avery Diseases of the Newborn, sixth edition. 1984, Philadelphia: W.B. Saunders Co., pp. 207-224.
3. Kliegman RM. Chapter 6 - Fetal and Neonatal Medicine. In: Behrman RE, Kliegman RM (eds). Nelson Essentials of Pediatrics fourth edition. 2002, W.B. Saunders Co., pp 179-249.
Answers to questions
1. Vitamin K prophylaxis, antibiotic eye prophylaxis, bathing, and hepatitis B immunization. Breast feeding should also be considered to be an infection prevention/modifying measure.
2. Newborn blood and metabolic disease screening, hearing screening, physical examination.