The majority of full-term newborns have an uneventful postnatal course. Once the newborn transitions from the intrauterine to extrauterine environment, management centers on routine care and parental anticipatory guidance. However, certain clinical conditions may not manifest in the immediate newborn period, and their early detection may prevent long-term morbidity or even death. Therefore, proper parental education not only makes the mother’s and father’s transition into parenthood easier but also prevents potential adverse outcomes for the infant.

Assessment of the newborn begins with review of the maternal history, the pregnancy, and the delivery (Table 124-1). A physician must perform a thorough head-to-toe examination of the newborn infant within 24 hours of birth and daily while the infant is in the hospital. Every examination should start with a review of the vital signs; the range of normal values for newborns is provided in Table 124-2. The initial examination should also include measurements of birth weight, length, and head circumference. These are plotted on standard growth curves to determine whether they are proportional and appropriate for the gestational age.

The infant should be completely undressed and observed for any signs of distress, dysmorphology, asymmetry, or abnormal color. Pertinent findings of the newborn examination are summarized in Table 124-3. Abnormalities, including vital signs outside the normal range, often require further investigation or follow-up.

BREASTFEEDING

In a 2012 policy statement, the American Academy of Pediatrics (AAP) reaffirmed its recommendation of exclusive breastfeeding for the first 6 months of life, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.¹ Hospital procedures to encourage and support the initiation of exclusive breastfeeding should be based on the AAP-endorsed “Ten Steps to Successful Breastfeeding” and have been demonstrated to increase breastfeeding success and duration. For healthy infants, it is important for breastfeeding to begin within the first hour after birth (even for cesarean deliveries) and for mothers to have continuous infant access through rooming-in arrangements that facilitate around-the-clock, on-demand feeding. Providers should place emphasis on the numerous health benefits of exclusive breastfeeding. Artificial nipples or pacifiers should be avoided when possible, and mothers should be provided contact information for breastfeeding support after discharge from hospital.

Medical contraindications to breastfeeding in the United States are rare, and include infant galactosemia, maternal human immunodeficiency virus (HIV) infection, active tuberculosis infection, human T-lymphotropic virus type I and II infection, and certain drugs, including drugs of abuse, cytotoxic drugs, and radioactive compounds. Medications taken by the breastfeeding mother should be reviewed to ensure that their transfer via breast milk will not adversely affect the infant. A complete list of drugs compatible with breastfeeding is available from the American Academy of Pediatrics.²

FORMULA FEEDING

Formula-fed infants usually take between ¼ and 1 ounce (approximately 7.5 to 30 mL) per feeding in the first 24 hours of life. This amount increases in subsequent days. At discharge, most infants take 2 to 3 ounces (60 to 90 mL) of formula every 3 to 4 hours. Full-term formula-fed infants can be started on any of the standard 20 kcal/oz formulas. Although there are differences among the various brand-name formulas, they all meet nutritional standards and provide adequate calories and nutrients to full-term infants. Premature infants have unique nutritional needs and may require special formulas. All infants should be fed iron-fortified formula. Although low-iron formulas are available, they provide inadequate amounts of this essential element and there is no medical indication for their routine use.

The use of soy formula should be limited to infants with galactosemia or congenital lactase deficiency.³ Soy formulas may also be fed to infants whose parents want a formula that is free of animal products. However, soy formulas should not be fed to premature infants because of the poor bone mineralization associated with their use. Soy formulas are often used in infants with suspected cow’s milk protein intolerance; however, and hydrolysate formulas should be considered for these infants given a 10% to 30% cross-reactivity between cow milk and soy proteins.³ As signs and symptoms of allergy usually do not become evident until after the newborn is discharged home, standard cow milk-based formula should be routinely offered unless there is a strong family history of milk-protein intolerance.

ELIMINATION

Many infants urinate in the delivery room, and most void within hours of birth. A normal infant should urinate within 24 hours of birth; if no urine output is recorded within that time frame, the cause should be investigated. An infant with decreased urine output may be dehydrated; this is more common in infants who are having difficulty breastfeeding with inadequate oral intake. Other considerations are anatomic or functional abnormalities that prevent normal urination.

Most full-term infants pass meconium (thick, sticky, dark green or black with a “tarry” appearance) in the first 24 hours of life, then transition to yellow, seedy stools in the first 48 hours of life. A delay in the passage of meconium may be a variant of normal or may signal a problem, such as meconium plugging, Hirschsprung disease, or dehydration. When addressing a lack of stool production, it should be noted whether there was meconium staining of the amniotic fluid. An infant who has not produced a stool in 48 hours should undergo investigation for an underlying pathology (e.g. cystic fibrosis, Hirschsprung disease, imperforate anus, anorectal malformations, small left colon syndrome).

WEIGHT

Normal infants typically lose weight in the first few days of life as they diurese the excess fluid not needed for extrauterine life. Weight should be monitored daily in the nursery because a weight loss of more than 7% may indicate a potential problem, usually inadequate intake. Loss of more than 10% of birth weight for an appropriate for gestational age infant should be considered a significant problem that requires exploration and rectification before discharge and close follow-up afterward. Parents should be reassured that infants usually regain their birth weight in the first 10 to 14 days of life.

VITAMIN SUPPLEMENTATION

After delivery, all infants should receive prophylaxis against hemorrhagic disease of the newborn with the intramuscular administration of 1 mg of vitamin K₁ (phytonadione). Breastfed infants should routinely receive an oral supplement of vitamin D, 400 IU per day, beginning at hospital discharge to prevent vitamin D deficiency and rickets.¹