Thermoregulation

• Heat loss: Evaporation, radiation, conduction, convection.
  
• Heat production: Mainly through nonshivering thermogenesis (lipolysis of brown adipose tissue).

Gas Exchange

• From placenta to lungs.
  
• Fetal Hb allows fetus to maintain lower arterial oxygen tension (greater affinity for oxygen binding than adult Hb).

Effective Breathing and Pulmonary Inflation

• From sporadic breathing to continuous breaths.
  
• Replacement of fetal lung fluid with air (decreased production and increased absorption).

Circulation

• In fetus: ↑ PVR, ↓ SVR.
  
• At birth: SVR increases with removal of placenta; PVR decreases with replacement of fetal lung fluid with oxygen and endogenous nitric oxide production, causing vasodilation.
  
• Mixed circulation persists during this “transition” secondary to ductus arteriosus (closes within 2 wk, but flow decreases within a few hours of birth) and foramen ovale (right-to-left flow reverses soon after birth).

Vital Signs

• Temperature (36.5°C–37.4°C)
  
• Respirations (<60 breaths/min with no signs of respiratory distress)
  
• HR (100–160 beats/min)

Head Circumference, Length, Weight, and Assessment of Gestational Age

General Appearance

• Activity, color, abnormalities

Skin

• Color, normal rashes (erythema toxicum, pustular melanosis), mongolian spots, abnormalities (nevi, hemangiomas)

• Swelling (caput, cephalohematoma, subgaleal hemorrhage), trauma (forceps marks, scalp electrode marks), scleral hemorrhage, symmetric pupillary response, presence of red reflex, choanal atresia, cleft lip/palate, ear pits/tags, facial symmetry

Neck

• Clavicles, cysts, webbing, masses

Chest

• Equal breath sounds, respiratory distress (grunting, retracting)
  
• Nipples (supernumerary), sternal abnormalities (ie, pectus excavatum or carinatum)

Heart

• S1/S2 , rate, murmur, PMI, brachial and femoral pulses

Abdomen

• Bowel sounds, defects, organomegaly, masses, appearance, cord vessels (two arteries, one vein)

Genitals/Anus

• Patent anus, ambiguous genitalia, abnormal anatomy (hypospadias, epispadias)
  
• Boys: Descended testicles, penile length
  
• Girls: Perforate hymen, clitoral length

Extremities

• Tone, equal movement, perfusion, digits, Barlow and Ortolani maneuvers for hip dysplasia

Reflex

• Rooting, grasp, asymmetric tonic neck reflex, Moro reflex

Hearing Screen

• Mandated ABER or OAE testing prior to 3 months.

Bathing

• Sponge bath until cord stump falls off.

• Encourage breastfeeding within 1 hr of birth and formula within 3 hr if baby is alert, has no abdominal distension or respiratory distress, and has a good cry.
  
• Term babies take 0.5–1 oz q2–4hr initially.
  
• Breastfeeding should occur q1-3hr (see Chapter 4).

Eyes

• 0.5% erythromycin ointment to both eyes within 2 hr after birth for prophylaxis against ophthalmia neonatorum.

Vitamin K

• 0.5–1 mg IM within 6 hr of life to prevent hemorrhagic disease of the newborn.

Stool

• Meconium within 48 hr of life.

Urine

• Void within 30 hr of life.

Umbilical Cord

• Triple dye, then keep cord clean and dry until stump falls off (average 6–14 DOL).

Nails

• Keep short with emery board or baby nail clippers.

Sleep

• Back to sleep to reduce the risk of SIDS.

(Pediatrics 2006;118(3):1304)

• The process of testing newborn babies for genetic, endocrinologic, metabolic, and hematologic diseases.
  
• Tests are performed by heelstick after feeds have been established, usually between 24 and 48 hr of age.
  
• Each state determines what screens will be performed. For a state-by-state list, see the U.S. National Newborn Screening & Genetics Resource Center (NNSGRC) website (http://genes-r-us.uthscsa.edu).
  
• Most states now utilize tandem mass spectrometry, which allows for detection of a greater number of inborn errors of metabolism.
  
• If an abnormality is noted, the agency performing the test is responsible for contacting the parents, physician, hospital, and/or nursery. Appropriate response varies by disease screened for, but a guide can be found with ACTion sheets at the NNSGRC website (http://genes-r-us.uthscsa.edu).

• 37-41 completed weeks’ gestation
  
• No findings that require continued hospitalization.
  
• Vital signs documented as normal (see “Newborn Exam” above).
  
• Infant has urinated regularly and passed at least one stool spontaneously.
  
• Infant has completed at least 2 successful, consecutive feeds
  
• No significant bleeding at circumcision site
  
• Risk of development of hyperbilirubinemia has been assessed and appropriate follow up arranged.
  
• Infant has been appropriately screened for sepsis on the basis of maternal risk factors (including GBS status and adequacy of antepartum prophylaxis).
  
• Maternal labs have been reviewed and found to be normal/negative (RPR, Hepatitis B surface antigen, HIV and GBS).
  
• Infant blood work, such as blood type, Coombs, have been reviewed (as clinically indicated)
  
• Initial hepatitis B vaccine administered
  
• Newborn metabolic and hearing screens have been completed per state regulations.
  
• Mother is able to provide adequate newborn care upon discharge (including feeding, normal urination/stooling patterns, cord, skin, and genital care, able to identify signs of illness, identify jaundice, and understands basic infant safety (eg, car seat safety, supine positioning for sleep)
  
• Maternal social and environmental risk factors are assessed (substance abuse, homelessness, abuse or neglect, domestic violence, etc.)
  
• A medical home for the infant is established (infants discharged <48 hours of age will follow up within 48-72 hours of discharge).
  
• Any potential barriers to follow up have been identified and addressed (lack of transportation, no access to telephone services, language barriers, etc.)