Immediate care of the well newborn: Clinical sciences

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Introduction0:00–0:28

Immediate care of the well, newborn begins at birth and continues through hospital discharge. Routine, newborn care includes identification of any abnormalities requiring further investigation, as well as support for newborn feeding, administration of immunizations and preventative medications, routine screenings, anticipatory guidance and optional care such as circumcision.

H&P0:28–9:12

When a well newborn presents for immediate care. Your first step is to obtain a comprehensive history and physical examination.
Also be sure to review the prenatal and maternal history in addition to the birth history, along with the newborn's gestational age and apgar scores.
Now, here's a clinical pearl. The apgar score provides a standardized assessment of a newborn's general condition at one and five minutes after birth.
This score consists of five categories, appearance of the skin which should be pink rather than pale or cyanotic pulse rate, which should be over 100 BPM, grimace or the newborn's response to stimulation.
Also called reflex irritability, activity or muscle tone and spontaneous movement and respiration or breathing effort. For each category, a newborn receives up to two points.
A combined score of 7 to 10 is considered normal. Whereas infants with scores lower than seven require further monitoring remember to ask caregivers about any concerns as well as social determinants of health like tobacco exposure, intimate partner, violence and food insecurity.
Next. Perform a physical exam starting with vital signs and general appearance.
Also observe the caregiver, newborn interaction, including how they respond to their newborns cues by attempting to comfort or feed them when they cry.
Then proceed with a head to toe exam starting with a skin assessment. A healthy newborn skin is pink without cyanosis or jaundice.
Keep in mind that a visual assessment of skin color isn't always reliable in newborns with deeply pigmented skin. So check areas where the skin is thinnest or has the least amount of pigment like the oral mucosa or conjunctivi.
Central cyanosis indicates poor circulation or inadequate blood oxygenation. Whereas bluish purple discoloration isolated to the hands and feet called acrocyanosis is a transient and benign finding caused by immature vascular tone jaundice or yellow skin discoloration suggests hyperbilirubinemia which is always an abnormal finding during the 1st 24 hours of life.
Now, jaundice usually appears on the face first and progresses in a cephalocaudal direction. So to look for jaundice, examine the SCLE eye and mucous membranes and gently blanch the facial skin.
If jaundice is present, the skin may appear yellow when your finger is lifted. Here's another clinical pearl.
Well, newborns often have benign skin findings that fade over time. Some common examples include erythema, toxicum, neonatorum, milia, congenital dermal melanocytosis and nevus simplex which are also called stork bites or angel kisses.
Next, examine the skull and the anterior and posterior fontanelles which should be open and not sunken or bulging. If labor was precipitous or prolonged or if vacuum assistance was required during delivery, your patient might have significant facial bruising or molding.
You might also notice a cephalohematoma which is a well circumscribed subperiosteal collection of blood that doesn't cross suture lines or a caput succedaneum, which is a fluctuant area of edema above the periosteum that may cross suture lines, then examine the face, ensure the nares are patent and look for cleft lip or palate, shine an ophthalmoscope into the newborn's eyes to check the red reflex in each pupil if it's absent or if it's white, which is called leukocoria.
Your patient may have a congenital cataract or retinoblastoma. Finally look for preauricular skin tags or pits.
The presence of either is often associated with hearing deficits. Now, let's move on to the cardiopulmonary examination.
A healthy newborn should demonstrate no signs of respiratory distress, like nasal flaring, retractions or grunting. Their cry should be vigorous and not raspy or high pitched.
Normally, the cardiac examination demonstrates a regular heart rate between 101 160 BPM and femoral pulses will be strong and symmetrical.
You might hear a soft, low intensity and vibratory systolic murmur with a grade of no more than one or two out of six. A murmur with these characteristics is typically benign.
As long as you identify no abnormal cardiac signs and symptoms. Next, examine the newborn's abdomen, external genitalia and anus.
The abdomen should be soft without masses or hepatosplenomegaly. And the umbilical stump should have three vessels with two arteries and one vein.
For biological males palpate the scrotum to locate both testicles. A unilaterally undescended testicle is a common finding.
And in this case, you might locate the testis within the inguinal canal. The urethral meatus should be visible at the tip of the penis without evidence of hypospadias or epispadia.
In biological females, check the vaginal opening for patency and remind caregivers that they may notice a mucoid or bloody discharge during the weeks following birth due to estrogen withdrawal.
Finally examine the anus to ensure patency and check for a sacral dimple, which suggests spinal dysraphism time for a clinical pearl.
If the testicle hasn't descended by one year of age, consult surgery for consideration of orchiopexy to reduce the risk of infertility and malignancy.
Keep in mind that newborns with bilaterally undescended testicles or atypical genitalia should be evaluated for differences in sexual development during the immediate newborn period.
Next check your patient's reflexes. For example, you can elicit the rooting reflex by stroking the side of the newborn's mouth or cheek.
In response. They should turn their head toward your hand and open their mouth to check the suck reflex, place a gloved finger in the infant's mouth and touch the roof of their mouth to see if they begin sucking, finally assess the Moro or startle reflex by making a sudden movement or a loud sound or by holding the infant horizontally and carefully allowing the head to fall backward on your hand.
In response, you should observe abduction and extension of the upper extremities followed by flexion of the upper extremities and a cry.
Also look for orthopedic abnormalities such as club foot and screen for developmental hip dysplasia. Using the Ortolani and Barlow maneuvers.
Both maneuvers begin with the infant on their back with their hips flexed to perform the Ortolani maneuver, slowly abduct the hip and then gently apply anterior pressure to the lateral thigh.
A palpable clunk during this maneuver represents the reduction of a dislocated femoral head back into the acetabulum to perform the Barlow maneuver, slowly adduct the hips and then gently apply posterior pressure to the knee.
The Barlow is positive if you feel the femoral head dislocating from its socket during the maneuver. Keep in mind that you might hear a benign click during either of these maneuvers, which represents soft tissue manipulation rather than true hip dislocation.
It's important to identify and treat hip dysplasia early to avoid permanent limb length, discrepancy. Finally review growth parameters including length, weight, weight for length and head circumference.
In addition, if your patient's obstetrical gestational age is unknown or uncertain, perform a gestational age assessment of physical maturity and neuromuscular development using the new Ballard score.
If you identify no abnormal findings, your patient is a well newborn and you can begin postdelivery care. Breastfeeding infants should attempt to feed immediately after delivery during skin to skin time, provide lactation support.

Feeding9:12–10:04

If your patient has difficulty latching and begin daily Vitamin D supplementation for all exclusively or partially breastfed infants, those who are not fed breast milk should receive an iron fortified infant formula.
Now, healthy newborns normally void within the 1st 24 hours of life and stool within the 1st 48 hours. The first stool called meconium is dark greenish and sticky, but stools eventually become brown or yellow.
After a newborn begins feeding all newborns who fail to pass meconium within 48 hours of birth should be evaluated for conditions associated with intestinal obstruction such as meconium ileus or hirschsprung disease.
Remember to administer intramuscular Vitamin K to prevent hemorrhagic disease of the newborn and Erythromycin eye ointment to prevent chlamydial and gonococcal ophthalmia neonatorum which can cause blindness if left untreated.

Medications/immunization10:04–10:28

Additionally, administer the Hepatitis B vaccine within 24 hours of birth to reduce the risk of hepatitis B infection. Next, perform routine screenings.

Screenings10:28–12:25

First newborn metabolic screening consists of a panel of tests that can detect serious but treatable conditions. This panel varies by state and usually includes screening for inborn errors of metabolism like phenylketonuria as well as congenital hypothyroidism, cystic fibrosis, hemoglobinopathies and immunodeficiencies.
Perform metabolic screening after the infant has been feeding for at least 24 hours to reduce the chance of a false negative result.
Also perform hearing screening using the automated auditory brainstem response or otoacoustic emissions testing, then measure pulse oximetry after 24 hours of age to screen for critical congenital heart disease.
Measurements from the right hand indicate preductal oxygen saturations and measurements from either foot indicate postductal saturations.
Now, because a visual assessment of jaundice cannot reliably predict serum bilirubin levels. You should also measure a transcutaneous bilirubin level which provides an estimate of total serum bilirubin, then plot the result against the patient's age and our on a nomogram.
If it falls within the high or high intermediate risk zone, your patient requires further evaluation and possibly treatment of hyperbilirubinemia.
Finally perform blood glucose screening for all neonates at risk of hypoglycemia, including infants of diabetics, late preterm infants and those who are small or large for gestational age.
Additionally, if the group B streptococcus status was unknown or positive during pregnancy or if intrapartum antibiotic, prophylaxis was inadequate, you should observe your patient for at least 48 hours.
Now that you've completed screening, it's time to provide anticipatory guidance. Talk to caregivers about illness prevention measures such as frequent hand washing as well as safe sleep practices which include supine sleep positioning and avoidance of loose or soft bedding before discharge.

Anticipatory guidance12:25–12:50

Make sure caregivers understand the importance of appropriate car seat use, fall prevention and umbilical cord care. Finally discuss circumcision with parents of biologically male infants because this is an elective procedure.

Circumcision12:50–13:32

Some parents choose to circumcise their infant on the basis of personal or cultural preferences. After weighing potential benefits and risks benefits include a decreased risk of sexually transmitted infections, urinary tract infections and penile cancer.
While potential risks include bleeding, infection and pain, contraindications to circumcision include hypospadias, penile curvature, retractile penis, bleeding disorders and lack of Vitamin K administration.
All right, as a quick recap, immediate care of the newborn begins with a comprehensive history and physical examination, followed by initiation of feedings and administration of hepatitis B, immunization, intramuscular Vitamin K and Erythromycin eye ointment then perform metabolic hearing pulse oximetry and bilirubin screening and when indicated, perform blood glucose monitoring and observe infants exposed to group B.

Review13:32–14:11

Streptococcus. Finally provide anticipatory guidance regarding safety and umbilical cord care and discuss the pros and cons of circumcision.