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The newborn infant

Last updated: February 15, 2021

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Infants are usually born at term between 37 and 42 weeks of gestation. This time period can be further divided into early term (37 to 38 weeks), full term (39 to 40 weeks), and late term (41 weeks) deliveries. After 42 weeks of gestation, birth is considered postterm. Approximately 10% of births are preterm, occurring prior to 37 completed weeks of pregnancy. Most infants born at term require very little medical attention in order to successfully adapt to extrauterine life. Routine management of a newborn infant immediately after birth consists of removing airway secretions, drying the newborn, and providing him or her with warmth. Health care providers also clamp and cut the umbilical cord. The Apgar score is typically used to gauge the clinical status of newborn infants at one and five minutes after birth using the following parameters: heart rate, respiratory effort, muscle tone, reflex irritability to tactile stimulation, and skin color. Infants who are born at term or late preterm and are breathing and moving satisfactorily should immediately be given to their mother for skin-to-skin contact and initiation of breastfeeding. Infants who are born prematurely, lack muscle tone, or are not breathing or crying may require supplemental oxygen or neonatal resuscitation.

Preventive medicine measures in the delivery room include the administration of ophthalmic antibiotics and vitamin K. Within 24 hours of birth, a detailed assessment of the newborn should take place. This typically includes a history of the pregnancy and a physical exam from head to toe, as well as measurements of length and weight.

Immediate care of the newborn

  • Wipe the newborn's mouth and nose to clear airway secretions, use suction only if necessary.
  • Dry and stimulate the newborn.
  • Provide warmth.
  • Skin-to-skin contact with mother and initiation of breastfeeding
  • Clamp and cut the umbilical cord.
  • Apgar score assessment at 1 and 5 minutes after birth
  • Begin resuscitation if onset of respirations has not yet occurred within 30–60 seconds

Apgar score [9]

  • Used for standardized clinical assessment of newborns at 1 and 5 minutes after birth
    • Five components: skin color, heart rate, reflex irritability to tactile stimulation, muscle tone, respiratory effort
    • Each component is given 0–2 points, depending on the status of the newborn.
    • The total Apgar score is the sum of all five components.
  • Assessing the need for and beginning neonatal resuscitation should be done independently of and before the Apgar score is determined
  • Assessment of the Apgar score at 5 minutes: infants with scores < 7 may require further intervention
    • Reassuring: 7–10
    • Moderately abnormal: 4–6
    • Low: 0–3
  • In infants with a score below 7, the Apgar assessment is performed at 5–minute intervals for an additional 20 minutes.
  • Persistently low Apgar scores are associated with long-term neurologic sequelae.
Calculation of the Apgar score
0 Points 1 Point 2 Points
Appearance (skin color) Blue (cyanotic) or pale Pink trunk, blue extremities (acrocyanosis) Pink body and extremities
Pulse (heart rate) None < 100 beats/min ≥ 100 beats/min
Grimace (reflex irritability upon tactile stimulation) None Grimace Cry or active withdrawal
Activity (muscle tone, movement) No movement, limp body Some flexion Active motion, flexion
Respirations None Weak cry, irregular/slow/weak breathing or gasping Regular breathing, strong cry

APGAR: Appearance, Pulse, Grimace, Activity, Respirations

The Apgar score is useful for evaluating the status of a newborn infant, but it should not be used to draw conclusions about individual neonatal morbidity or mortality and it should not be used as a long-term prognostic tool.

Neonatal resuscitation [10][11]

Preventive measures directly after birth

Measurement and a detailed examination of the newborn should take place within the first 24 hours of life. See “Clinical relevance” for examples of pathological findings of a newborn examination.

  • Measurements [12]
    • Normal range (10th to 90th percentile at 40 weeks gestation)
    • Length: ∼ 50 cm (48– 53 cm)
    • Weight: ∼ 7½ lb (6 lb, 6 oz to 8 lb, 9 oz (2.9–3.9 kg))
      • Boys: 6 lb, 6 oz to 8 lb, 9 oz (2.9–3.9 kg)
      • Girls: 6 lb, 2 oz to 8 lb, 6 oz (2.8–3.8 kg)
    • Head circumference: ∼ 35 cm (33–37 cm)
  • Vital signs [13]
  • Bilirubin: see ”Neonatal jaundice
  • pH: ≥ 7.2 (slightly more acidic than adults) [14]
  • Urine and meconium [15]
    • First passage of urine within 24 hours of birth
    • First passage of meconium; (a black-green, tarry substance that forms the newborn's feces) within 48 hours after birth
  • Feeding: encourage and provide counseling regarding breastfeeding
  • Losing weight after birth [16]
  • Consequences of intrauterine estrogen exposure

The physiological respiratory rate and heart rate of newborns are substantially higher than in adults and older pediatric patients.

Healthy newborns normally lose uo to 7% if their original birth weight in the first 5 days of life. This weight is then gained back through drinking breast milk and/formula by age 10–14 days. No treatment is necessary.

External signs of maturity

Erythema toxicum neonatorum

  • Definition: : a benign, self-limiting rash; that appears within the first week of life
  • Etiology: unknown (probable contributing factors: immature sebaceous glands and/or hair follicles)
  • Clinical features
  • Diagnostics
    • Based on clinical appearance of rash
    • Biopsy or smear of pustula (rarely necessary): eosinophils
  • Treatment: observation only
  • Prognosis: typically resolves without complications within 7–14 days

Congenital dermal melanocytosis (Mongolian spot)

  • Definition: benign blue-gray pigmented skin lesion of newborns
  • Neonatal prevalence [20]
    • Asian and Native American: 85–100%
    • African American: > 60%
    • Hispanic: 46–70%
    • White: < 10%
  • Pathophysiology: melanocytes migrating from the neural crest to the epidermis during development become entrapped in the dermis
  • Clinical features
    • Blue-gray pigmented macule (may also be green or brown)
    • Diameter: typically < 5 cm, may be > 10 cm
    • Location: most common on the back; , also seen on the buttocks; , flanks, and shoulders
  • Diagnostics
    • Based on clinical appearance
    • It is important to document the diagnosis of Mongolian spots, as they may resemble bruises and lead to false suspicions of child abuse.
  • Prognosis: : usually resolves spontaneously during childhood (typically by the age of 10 years) [21]

Congenital melanocytic nevus

  • Epidemiology: 1/20,000 births [22]
  • Clinical features [22]
    • Vary in size: < 1.5 cm to > 20 cm
    • A nevus larger than 20 cm in size is referred to as a giant congenital melanocytic nevus
    • Light to darkly pigmented lesion
    • Often with increased hair growth
  • Treatment: surgical excision or laser ablation (depending on type and size of lesion)
  • Prognosis: large nevi are at risk of degeneration → frequent follow-up

Infantile hemangioma (strawberry hemangioma)

  • Definition: benign capillary vascular tumor of infancy
  • Epidemiology
    • Occurs in 3–10% of infants [23]
    • Mostly affects girls
  • Pathophysiology
  • Clinical features
    • Manifests during the first few days to months of life
    • Progressive presentation; : blanching of skin fine telangiectasias red painless papule or macule (strawberry appearance)
    • Most commonly on head and neck
    • Usually solitary lesions
  • Diagnostics
    • Based on clinical findings
    • The differential diagnosis of cherry angioma is found mostly in adults.
  • Treatment
  • Complications
    • Ulceration
    • Disfigurement
  • Prognosis
    • Usually good prognosis
    • Spontaneous resolution is common
    • Visual impairment if periorbital hemangioma is left untreated

Others

Some congenital infections may manifest with rashes or other skin conditions and should be differentiated from benign skin lesions in the newborn.

  • In the US, each state has its own newborn screening program, and the conditions screened for vary from state to state.
  • The U.S. Department of Health and Human Services has made some recommendations, for a comprehensive list of recommended uniform screening panels, see the “Tips & links” section.
  • Most of the tests are performed on filter paper using a few drops of blood from a newborn's heel.
  • Optimal time for screening: 36–72 hours after birth

Examples of commonly screened conditions

  1. Pappas A, Delaney-Black V. Differential diagnosis and management of polycythemia.. Pediatr Clin North Am. 2004; 51 (4): p.1063-86, x-xi. doi: 10.1016/j.pcl.2004.03.012 . | Open in Read by QxMD
  2. Bashir B, Othman S. Neonatal polycythaemia. Sudan J Paediatr. 2019 : p.81-83. doi: 10.24911/sjp.106-1566075225 . | Open in Read by QxMD
  3. Özek E, Soll R, Schimmel MS. Partial exchange transfusion to prevent neurodevelopmental disability in infants with polycythemia. Cochrane Database of Systematic Reviews. 2010 . doi: 10.1002/14651858.cd005089.pub2 . | Open in Read by QxMD
  4. Gupta D. Mongolian spots: How important are they?. World Journal of Clinical Cases. 2013; 1 (8): p.230. doi: 10.12998/wjcc.v1.i8.230 . | Open in Read by QxMD
  5. Chua RF, Pico J. Dermal Melanocytosis. StatPearls. 2020 .
  6. Viana ACL, Gontijo B, Bittencourt FV. Giant congenital melanocytic nevus. An Bras Dermatol. 2013; 88 (6): p.863-878. doi: 10.1590/abd1806-4841.20132233 . | Open in Read by QxMD
  7. Meni C. Infantile hemangioma: Epidemiology update. J Am Acad Dermatol. 2013; 68 (4): p.AB95. doi: 10.1016/j.jaad.2012.12.395 . | Open in Read by QxMD
  8. Al-Salem AH. Hemangiomas and Vascular Malformations. Atlas of Pediatric Surgery.. Springer ; 2020
  9. O'Connor NR, McLaughlin MR, Ham P. Newborn skin: Part I. Common rashes.. Am Fam Physician. 2008; 77 (1): p.47-52.
  10. Child growth standards. https://www.who.int/tools/child-growth-standards/standards. Updated: January 1, 2021. Accessed: January 26, 2021.
  11. Assessments for Newborn Babies. https://www.stanfordchildrens.org/en/topic/default?id=assessments-for-newborn-babies-90-P02336. Updated: January 1, 2021. Accessed: January 25, 2021.
  12. Yeh P, Emary K, Impey L. The relationship between umbilical cord arterial pH and serious adverse neonatal outcome: analysis of 51,519 consecutive validated samples.. BJOG. 2012; 119 (7): p.824-31. doi: 10.1111/j.1471-0528.2012.03335.x . | Open in Read by QxMD
  13. American Academy of Pediatrics. Newborn: First Stool and Urine. Pediatrics in Review. 1994; 15 (8): p.319-320. doi: 10.1542/pir.15-8-319 . | Open in Read by QxMD
  14. McInerny TK, Foy JM, Adam HM. American Academy of Pediatrics Textbook of Pediatric Care. American Academy of Pediatrics ; 2016
  15. Watterberg KL, Aucott S, Ecker JL et al. The Apgar Score. Pediatrics. 2015; 136 (4). doi: 10.1542/peds.2015-2651 . | Open in Read by QxMD
  16. Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142 (16_suppl_2). doi: 10.1161/cir.0000000000000902 . | Open in Read by QxMD
  17. Neonatal reuscitation. https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-13-neonatal-resuscitation/. Updated: January 1, 2015. Accessed: May 10, 2017.
  18. Infant Timeline. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/HALF-Implementation-Guide/Age-Specific-Content/Pages/Infant-Timeline.aspx. Updated: January 1, 2021. Accessed: January 25, 2021.
  19. Newborns: improving survival and well-being. https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality. Updated: September 19, 2020. Accessed: January 25, 2021.
  20. Maternal and Perinatal Health. http://www.who.int/maternal_child_adolescent/topics/maternal/maternal_perinatal/en/. Updated: January 1, 2018. Accessed: January 15, 2018.
  21. State Definitions of Live Births, Fetal Deaths, and Gestation Periods at which Fetal Deaths are Registered. https://books.google.de/books?id=I_BLt5IwZw8C&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false. Updated: January 1, 1966. Accessed: January 22, 2021.
  22. American College of Obstetricians and Gynecologists. ACOG Committee Opinion: Definition of term pregnancy. Obstet Gynecol. 2013; 122 (5): p.1139-1140. doi: 10.1097/01.AOG.0000437385.88715.4a . | Open in Read by QxMD
  23. Quinn JA, Munoz FM, Gonik B, et al. Preterm birth: Case definition & guidelines for data collection, analysis, and presentation of immunisation safety data.. Vaccine. 2016; 34 (49): p.6047-6056. doi: 10.1016/j.vaccine.2016.03.045 . | Open in Read by QxMD
  24. Schlaudecker EP, Munoz FM, Bardají A, et al. Small for gestational age: Case definition & guidelines for data collection, analysis, and presentation of maternal immunisation safety data.. Vaccine. 2017; 35 (48 Pt A): p.6518-6528. doi: 10.1016/j.vaccine.2017.01.040 . | Open in Read by QxMD
  25. Newborns with low birthweight. https://www.who.int/whosis/whostat2006NewbornsLowBirthWeight.pdf. Updated: January 1, 2006. Accessed: January 25, 2021.
  26. Gestational Assessment. http://www.chop.edu/conditions-diseases/gestational-assessment. Updated: January 1, 2017. Accessed: May 10, 2017.
  27. Preterm Birth Fact Sheet. http://www.who.int/mediacentre/factsheets/fs363/en/. Updated: November 1, 2016. Accessed: May 10, 2017.
  28. Intraventricular Hemorrhage (IVH) . https://www.ucsfbenioffchildrens.org/pdf/manuals/49_IntraventricularHem.pdf. Updated: January 1, 2004. Accessed: May 10, 2017.
  29. Premature Birth. http://www.mayoclinic.org/diseases-conditions/premature-birth/basics/definition/con-20020050. Updated: November 27, 2014. Accessed: May 10, 2017.
  30. Reproductive Health - Preterm Birth. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm. Updated: November 10, 2016. Accessed: May 10, 2017.