Routine Care of the Newborn

This is for the most part a (redacted) summary of Chapter 1 from Elizabeth John’s very accessible Neonatal Handbook (2000).

 

Breathing becomes regular and continuous after the first breath in the majority of term infants. Although generally regular, differences in the rate and depth of breathing can occur in term infants especially during rapid eye movement sleep. The preterm infant on the other hand exhibits significant periodicity in its breathing pattern.

Uncomplicated transition from fetal to newborn state will be accompanied by absorption of fetal lung liquid by the pulmonary vasculature and lymphatics, secretion of surfactant into the alveoli, establishment of adequate functional residual capacity and the initiation of regular respiration. This transition may be altered by fetal, maternal, or intrapartum events.

Fetal	Maternal	Intrapartum
Post-term	DM	Emergency CS
Preterm	PIH	Abnormal presentation
SGA / LGA	HTN	Premature labour
Multiple gestation	Isoimmunisation	ROM > 24 hours
fetal activity	Infection	Smelly liquor
Fetal infection	Oligohydramnios	Precipitous labour
Malformation	Drugs	Prolonged labour
	Lithium	Abnormal FHR
	Magnesium	General anaesthesia
	Adrenergic blockers	Uterine tetany
	Drug abuse	Meconium stained liquor
		Prolapsed cord
		Abruptio placentae
		Placenta praevia

 

Newborn resuscitation

A series of steps—that may be halted at any time if it is found that the infant is normal and capable of independent life—are required in resuscitation of the newborn.

1. Clear airway +/- suction mouth and nose
2. Normal Respiration / Pink colour >> warm blankets
3. Normal / Blue >> oxygen via mask
4. Absent or Poor / Blue >> BVM + 100% O2
   1. +/- intubate / ventilate
   2. ICU
5. Absent or Poor / Blue / HR < 100 >> ventilate (continue) >> commence cardiac massage
6. No improvement >> continue cardiac massage and ventilation
   1. Initiate medications >> adrenalin 1:1,000 ETT

Drugs are very rarely required in newborn resuscitation:

• Epinephrine 1:1,000 (0.1-0.3 ml/kg) if no improvement in HR after 30 seconds of appropriate ventilation and cardiac massage
  • Delayed use in cardiac arrest / severe asphyxia will result in the cardiac recovery of an infant who has been neurologically damaged.
• IV NaHCO3 is very rarely needed if adequate cardiac output is established and infant ventilated – i.e. will self-correct acidosis
• Adequate amounts of glucose must be provided if progression of acidosis is to be prevented
• Rapid IVF not recommended (risk ICH) including asphyxiated
  • Risk CCF secondary asphyxia myocardial injury
• Naloxone is useful in infants delivered within 4-6 hours of the mother being given a narcotic
  • Not to babies born to substance abusing mothers
    • T_1/2 < morphine / pethidine and its effect may wear off before the narcotic >> it may have to be repeated
      • 1 mg / kg IV | IM | ETT

The fourth (4^th) day after birth is a good time to examine, as adaptation to extrauterine life has occurred, and then again in the next 2 weeks. A further complete examination in 4-6 weeks is then preferred, in the presence of the parent / mother, to:

• Identify any major problem / determine general well-being
• Detect any obvious congenital anomalies and birth trauma
• Establish gestational age and base line for serial conservations
• Determine type of care required

Prior to undressing / examining, enquire about postnatal (and subsequent) passage of meconium and urine (usually < 24 hours) and feeding, efficiency of sucking and swallowing:

• Weight
• Length
• Head circumference
• (temperature)

Infant undressed in a warm environment for inspection, before the actual handling of them:

General Inspection

• Colour
• Respiration
• Posture: pattern may direct attention to neurologic or musculoskeletal problems
  • Brachial plexus paralysis
  • Hemiplegia
• Spontaneous activity
• Skin: exanthemata, petechiae or bruising
• Congenital anomalies / syndromes

Skin

• Vermix caseosa: whitish fatty substance
• Lanugo: downy hair
• Pink–red colour: think skin with high blood flow
• Milia: face/nose
  • whitish papules of tiny epidermal cysts in relation to pilosebaceous follicles
• Erythema toxicum: scattered rash of small papules and surrounding erythema
• Mongolian spots: circumscribed bluish discolouration of skin in coloured races
• Mottling trunk and extremities +/- harlequin change
  • Especially preterms
• Absence subcutaneous tissues
  • Preterm / growth retarded
• Skin creases: soles feet >> help determine maturity

Wait for the baby to spontaneously open their eyes before examining them.

Eyes

• Retinal / subconjunctival haemorrhage not uncommon in NVD
• Pupil size and shape
• Cornea
  • Pupillary light reflex
  • Red reflex
  • Lenticular opacities and colobomata
• Lacrimal duct: may not be patent at birth >> excessive tearing >> no treatment unless persists >> ophthalmology
• Conjunctivitis
  • Viral or bacterial
  • Common and needs treatment

Face

• Appearance and specific syndromes
• Facial nerve palsy: look for forceps’ marks

Malformation of ears invokes many syndromic associations while, alternatively, the degree of cartilaginous development is indicative of gestational maturity (gestational age).

Ears

• Position: imaginary line joining inner and outer canthus of eye should cross ipsilateral pinna
• Shape
• Size

Colour

• Central cyanosis is always bad
• Acrocyanosis is not uncommon
• Jaundice is found in more than half (> 50%) of newborns at Day 2-3

The head may be asymmetric, with overriding sutures, due to excessive moulding, but generally settles within the first few days. Equally, scalp oedema (caput succedaneum) should also disappear within a few days after birth.

Head

• Cephalhaematoma: this subperiosteal haemorrhage may become more prominent after the disappearance of the caput
• Craniotabes: soft-feeling, flexible bones detectable in many newborns and considered normal (unless rickety or associated osteogenesis)
  • especially (up to 1/3) preterms
• anterior and posterior fontanelles open and of variable size
  • normally responsive and soft

Newborns are preferential (almost obligate) nose breathers. For them, therefore, their nasal patency is essential.

Nose

• Nostril patency: check individually by closing mouth and then occluding one nostril at a time while looking for a passage of (humidified) air
  • Patency can be determined by passing 5-FG catheter through each nostril (horizontally, avoiding trauma)
    • Bilateral choanal atresia requires prompt treatment

The entire soft and hard palate must be visualised in addition to the lips.

Mouth

• Cleft lip / palate varies in severity >> appropriate and prompt referral
• Sucking pad well developed in inner surface of each cheek in term infant
• firm, white inclusion cysts may be found along the gum margin
• frenulum linguae vary in length and width, usually without cause for concern
• unusual amounts of saliva in mouth (drooling) may suggest oesophageal atresia

The neck of the newborn is usually short squat.

Neck

• masses
  • enlarged thyroid
  • thyroglossal cyst
  • cystic hygroma
• the rarer branchial cysts and fistulae in line of branchial arches

Thorax

The newborn chest is barrel-shaped.

• supernumerary nipples are occasionally seen and usually of little consequence
• size of mammary glands indicative of gestational age

Newborn respiration is chiefly diaphragmatic and the rate varies between 30 and 40 breaths per minute.

Lungs

• suprasternal or intercostal recessions are a sign of respiratory distress
• percuss for pneumothorax or pleural effusion, because breath sounds heard on auscultation can be transmitted from opposite lung (although gross anomalies can be detected)

The position of the heart should be determined and dextrocardia or major shifts to mediastinal structures ruled out.

Heart

• rate
• rhythm
• quality of sounds
• Grade 1-2 systolic murmurs during first post-natal days is normal
  • Repeat examination in a few days to confirm resolution
    • Cardiology review if any doubt

Brachial and femoral pulses must be palpated in all instances.

Vasculature

• Weak or absent femoral pulses must trigger consideration of Coarctation of the Aorta
  • May still be palpable in persistent patent ductus arteriosus
• Umbilical cord stump vessels
  • Single umbilical artery has an association with renal anomalies

Abdominal hernia is a common finding, especially in the pre-term infant.

Abdomen

• Appears slightly full, especially after a feed
• Scaphoid abdomen: diaphragmatic hernia?
• Distended abdomen: intestinal obstruction?
• Diastasis recti normal
• Bimanual palpation of kidneys
  • Right lower pole usually palpable
• Anal orifice: patency as well as position

Determine the genital sex of the infant.

Genitalia

Male	Female
Undescended testis	Enlarged clitoris ·         prominent in extreme preterm infant nearing term ·         adrenal hyperplasia ·         intersex, etc.
Hernia
Hydrocoele (often resolve spontaneously)
Hypospadias	Hymenal tags and blood-stained vaginal discharge related to withdrawal from maternal hormones
Chordae

Gross anomalies of the limbs are easily detected.

Extremities

• polydactyly is not uncommon
• positional talipes: common, and easily correctable
• congenital dislocation of hip / fixed talipes >> immediate referral
  • hips are easily dislocatable during the first day or two in preterm infants and infants born by breech
  • examine hips again within the first weeks +/- refer

Flex hips to 90° with middle finger at greater trochanter and thumb at medial aspect of femur. Push outwards and downwards and abduct hips completely. Dislocatable hips produce an easily felt, reproducible click. Non-reproducible, inconsistent clicking relates to ligaments slipping and is inconsequential. Dislocated hips, on the other hand, produce a clunky feel making full abduction impossible (note: full hip abduction might be impossible if there is muscle spasm).

Gross anomalies of the central nervous system, such as hydrocephalus, microcephaly, meningomyelocoele, etc. should be obvious on inspection. Hydranencephaly can be detected by transillumination of the skull or ultrasound examination.

CNS & Musculoskeletal System

• Passive muscle tone: should be checked in all infants as any decrease or increase in tone is significant
• Active tone: can be determined by spontaneous activity

Test 2-3 reflexes

• Moro (Startle): lifting baby’s head and shoulders in one hand and dropping the head back on the hands that have been lowered by a few centimetres only (or by startling the infant with a noise)
  • Extension and abduction of arms
  • Extension of hands and fingers
  • Adduction of arms
  • Flexion of fingers
• Grasp: neonate flexes fingers when palm stroked
• Rooting: infant turns face toward side in which cheek stimulated
• Sucking: sucking response to stroking lips
• Pupillary: constriction of pupil in response to light
• Automatic walking: placement of one foot in front of the other when soles touch a solid surface
• Automatic stepping: lifts foot when its dorsum is stimulated
• Crossed-extensor: withdraws one leg, followed by extension, when contralateral leg firmly held in extension

Dubowitz chart assessment of gestation (see Downloads)

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References

John, Elizabeth. “1. Routine Care of the Newborn Infant.” In Neonatal Handbook. 2000.

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Downloads

Dubowitz et al, 2004

Dubowitz Ballard score CHeRP 2007