Immediate care of the well newborn: Clinical sciences

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 preventive medications; routine screenings; anticipatory guidance; and optional care such as circumcision.

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 1 and 5 minutes after birth. This score consists of 5 categories: Appearance of the skin, which should be pink rather than pale or cyanotic; Pulse rate, which should be over 100 beats per minute; 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 2 points. A combined score of 7 to 10 is considered normal, whereas infants with scores lower than 7 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 newborn’s 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’s 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 conjunctivae.

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 first 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 sclerae 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; and their cry should be vigorous, and not raspy or high-pitched.

Normally, the cardiac examination demonstrates a regular heart rate between 100 and 160 beats per minute, 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 I or II of VI. 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 epispadias.

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 a 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.