Chapter 2: The Newborn

Economics of newborn care · Normal fetal–neonatal transition · Routine care of full‑term infant · Examination of the neonate · Labor ward routines · Postnatal ward routines · Forfar & Arneil's Pediatrics
📌 Core principles: Newborn care begins with understanding physiologic transition (clamping cord → first breath → circulatory changes). Cost‑effective neonatal interventions reduce mortality. Routine care includes thermoregulation, early breastfeeding, vitamin K, eye prophylaxis, and systematic examination to detect anomalies.

📖 Core summary: newborn care, transition & economics

💰 Economics of newborn care
Cost‑effective interventions: antenatal steroids, KMC (kangaroo care), breastfeeding promotion, infection prevention, resuscitation training. Reduces neonatal mortality (2.4 million deaths annually).
🔄 Fetal–neonatal transition
Clamping umbilical cord → first breath → ↑PaO₂ → ↓PVR, closure of ductus arteriosus/foramen ovale. Surfactant production. Transitional circulation may take hours.
🧹 Labor ward routines
Warm, dry, stimulate. Delayed cord clamping (30–60 sec). Apgar at 1 & 5 min. Vitamin K IM (1 mg). Erythromycin eye ointment. Mother–infant skin‑to‑skin.
🏥 Postnatal ward routines
Regular monitoring (temperature, feeding, jaundice, voiding/stool). Newborn screening (heel prick 24–48h). Hearing screen. Hepatitis B vaccine. Safe sleep counseling.
👩‍⚕️ Neonatal examination
Head (fontanelles, sutures), eyes, palate, heart (murmurs), lungs, abdomen (umbilical cord, liver), hips (Barlow/Ortolani), spine, genitalia, anus, primitive reflexes.
📋 Routine care essentials
Thermoregulation (axillary temp 36.5–37.5°C). Breastfeeding initiation within 1h. Prevent hypoglycemia (early feeding). Vitamin K, eye prophylaxis, immunization (HepB).
📊 Key economic measures: NICU costs vs long‑term disability. Preventive care (maternal immunization, clean delivery) reduces high‑cost intensive care. KMC reduces mortality in LBW infants.

🔍 Approach to newborn physical examination & transition

1
Immediate assessment (delivery room) – Tone, cry, color, heart rate, respiratory effort. Resuscitation if needed (NRP algorithm). Delayed cord clamping, skin‑to‑skin for stable term infants.
2
Systematic head‑to‑toe examination – Head: sutures, fontanelles (anterior 2‑4 cm, posterior <1 cm). Eyes: red reflex, conjunctiva. Mouth: palate intact. Heart: murmurs, femoral pulses (rule out coarctation). Lungs: symmetric breath sounds.
3
Abdominal & umbilical exam – Umbilical cord: 2 arteries, 1 vein (single artery associated with renal anomalies). Palpate liver (2 cm below costal margin normal), spleen, kidneys.
4
Musculoskeletal & hips – Ortolani (reduce dislocation) and Barlow (subluxate) maneuvers. Palpate clavicles (fracture), count digits. Spine midline, no tufts/sinuses.
5
Neurologic & primitive reflexes – Moro, grasp, stepping, rooting. Tone (pulled to sit, scarf sign). Assess for asymmetry.
6
Signs of abnormal transition – Cyanosis (persistent acrocyanosis normal, central cyanosis abnormal), respiratory distress (grunting, retractions), poor perfusion, delayed passage of meconium (>48h).

📋 Stepwise newborn care protocols (labor ward & postnatal)

1
Labor ward immediate care – Dry infant, remove wet linen, place on mother's abdomen (skin‑to‑skin). Assess breathing and tone. Clamp cord after 30‑60 seconds. Initiate breastfeeding within first hour.
2
Prophylaxis (first hour) – Vitamin K 1 mg IM (vastus lateralis). Erythromycin 0.5% ophthalmic ointment (gonorrhea prophylaxis). Hepatitis B vaccine within 24h.
3
Postnatal ward monitoring – Vital signs q4h for first 24h. Monitor feeding (≥8 feeds/24h), urine output (≥1 void by 24h, ≥6 voids by 48h), stool passage (meconium by 48h). Daily weight.
4
Newborn screening (24‑48h) – Heel prick blood spot: PKU, hypothyroidism, MCAD, galactosemia, cystic fibrosis, sickle cell. Pulse oximetry for CCHD (after 24h). Hearing screen (OAE/AABR).
5
Discharge criteria (term well newborn) – Stable vital signs, established feeding, passed meconium/urine, no jaundice requiring treatment, hepatitis B vaccine given, follow‑up arranged, safe home environment.
6
Economic considerations – Promote breastfeeding (reduces infection costs). Avoid unnecessary NICU admissions. Early discharge (<48h) requires early follow‑up. Kangaroo mother care reduces costs for LBW/preterm.
⚡ Key reminder: Delayed cord clamping (≥30 sec) increases iron stores and reduces need for transfusion. All jaundice in first 24h is pathological.

🧠 Reflex prompts – high‑yield newborn topics

🤰 Term newborn, delayed cord clamping – benefit?
Increases neonatal iron stores, improves hematocrit, reduces risk of iron deficiency anemia.
🩺 Ortolani and Barlow maneuvers detect:
Developmental dysplasia of the hip (DDH). Ortolani = reduction; Barlow = subluxation/dislocation.
💛 Newborn jaundice before 24h – next step?
Pathological. Obtain total/direct bilirubin, blood type, Coombs test, CBC, G6PD. Start phototherapy if indicated. Evaluate for hemolysis.
💉 Vitamin K IM prevents:
Hemorrhagic disease of the newborn (Vitamin K deficiency bleeding – VKDB). Classic onset 1‑7 days, late 2‑12 weeks.
🧪 Newborn heel prick – what metabolic disorders are screened?
PKU, congenital hypothyroidism, MCAD, galactosemia, CF, sickle cell, CAH (21‑hydroxylase).
🌡️ First hour after birth: thermoregulation priority
Dry baby, skin‑to‑skin with mother, cover head, warm room (25‑28°C). Prevents cold stress, hypoglycemia, acidosis.