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.
- Infant: a child under 1 year of age 
- Newborn: a child under 28 days of age 
- Perinatal period: the period from the 22nd week of gestation to the 7th day after birth 
- 6–8 weeks after birth: first
- Live birth: postnatal presence of vital signs (e.g., respiration, pulse, umbilical cord pulse) 
Timing of birth 
- Term birth: umbrella term for live births between 37 and 42 weeks of gestation
- live birth between 20 0/7 weeks and 36 6/7 weeks of gestation  :
- live birth after the 42nd week: of gestation
Evaluation of birth weight
- Appropriate-for-gestational-age infant (AGA): birth weight 10th–90th percentile for gestational age
- Small-for-gestational-age infant (SGA): birth weight < 10th percentile for gestational age 
- Large-for-gestational-age infant (LGA): birth weight > 90th percentile for gestational age
Low birth weight 
- Birth weight < 2,500 g regardless of the gestational age
- Occurs in early term infants and infants with intrauterine growth restriction
- Associated with increased mortality, particularly due to sudden infant death syndrome
- Very low birth weight: birthweight between 1,000–1,499 g regardless of the gestational age
- Extremely low birth weight: birthweight < 1,000 g regardless of the gestational age
Immediate care and Apgar score
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.
- 1 and 5 minutes after birth assessment at
- Begin resuscitation if onset of respirations has not yet occurred within 30–60 seconds
Apgar score 
- Used for standardized clinical assessment of newborns at 1 and 5 minutes after birth
- 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 
High-risk deliveries: should have a team of health care providers experienced in neonatal resuscitation on hand
- Maternal factors: very advanced maternal age or very young maternal age, diabetes or hypertension, substance abuse, previous fetal loss
- Fetal factors: prematurity, postmaturity, congenital anomalies, multiple gestations
- Complications of pregnancy and delivery: placental anomalies, oligohydramnios/polyhydramnios, transverse/breech delivery, chorioamnionitis, meconium-stained amniotic fluid, abnormal fetal heart rate, delivery with forceps/vacuum/cesarean
- Preductal pulse oximetry
Positive pressure ventilation (bag-mask ventilation) at a rate of 40–60/minute.
- Indicated if there is inadequate respiratory effort (e.g., gasping, apnea) or a heart rate < 100 bpm
- Intubation if pressure ventilation is ineffective or compressions are required
- Restrictive use of supplementary oxygen guided by pulse oximetry 
- Chest compressions
- IV epinephrine if heart rate < 60 bpm despite adequate ventilation and chest compressions for at least 30–60 seconds
- If there is no evidence of ROSC within 20 minutes, consider termination of resuscitation. 
Preventive measures directly after birth
- Measurements 
- Vital signs 
- Bilirubin: see ” ”
- pH: ≥ 7.2 (slightly more acidic than adults) 
- Urine and meconium 
- Feeding: encourage and provide counseling regarding breastfeeding
- Losing weight after birth 
- Consequences of intrauterine estrogen exposure
Healthy newborns normally lose up to 7% of 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
- Skin color and texture: rosy
- Body hair: lanugo may be present, thinning, or mostly absent
- Eyes: open
- Ears: well-formed pinna (auricular cartilage) that instantly recoils
- Breast: clearly discernible areola
- Testicles: descended
- Labia: labia minora covered by labia majora
- Plantar creases: cover the entire soles of the feet
Examination for abnormalities
For an overview of potential examination findings, see “.”
Face and head 
- Look for dysmorphic facial features.
- Check head shape (including cranial sutures and fontanelles).
- Perform an eye examination including the for . 
- Visualize and palpate the oral palate for cleft palate.
- Check the tongue for ankyloglossia.
- Check for ear abnormalities; low-set ears are often associated with genetic disorders.
- Assess hearing function (see “Newborn hearing screening”).
Intermittent strabismus is a normal finding in children < 4 months of age. 
Spine and nervous system 
- Assess the neck.
- Examine the spine.
- Perform a full neurological examination including assessment of tone.
- Palpate clavicles to exclude .
- Look for skeletal deformities (e.g., ) and check for .
- Look for symmetric movement, and auscultate the chest to detect neonatal pneumothorax.
- Assess for congenital cardiac defects (see also “Newborn screening”).
- Check that the abdomen is not distended or scaphoid.
- Palpate the abdomen for masses and organomegaly.
- Auscultate for bowel sounds.
- Check the umbilical cord.
Genitourinary examination 
- Assess for an imperforate anus.
- Check the inguinal region for hernias.
- In males infants: Rule out cryptorchidism, congenital hydrocele, and hypospadias.
- In female infants: Assess for and abnormalities of the hymen.
- Check the fingers and toes for supernumerary, absent, or deformed digits.
- Assess the range of motion of all extremities.
- Examine the hips using the and to rule out .
- Look for signs of .
- Look for signs of .
- Carefully inspect all of the skin for (including birthmarks).
- Before leaving the hospital, newborns should be screened for serious and life-threatening conditions.
- The optimal time for screening is 24–48 hours after birth. 
- Screening usually involves assessment for:
- Critical congenital cardiac defects
- Congenital deafness
- Various genetic disorders, e.g., endocrine, metabolic, and hematological disorders
Which genetic disorders to screen for varies according to national and state law; check local guidelines.
Overview of screening for newborns 
|Newborn recommended screening |
|Conditions to screen||Recommended ages||Method of screening||Actions for abnormal findings|
|Congenital metabolic or hematological disorders|| || |
|Hyperbilirubinemia|| || || |
| || || |
|Congenital deafness || || |
Examples of commonly screened genetic conditions
- Metabolic conditions
- Hemoglobinopathies (e.g., , )
- Other conditions
- Bulging fontanelles as a sign of
- Newborn conjunctivitis
- (may indicate )
Ear, nose, and mouth
Neck and clavicles
- Cyanotic and
Trunk, spine, and extremities
- Neonatal hypocalcemia
- Congenital hypothyroidism
- Congenital hyperinsulinism
- Neonatal diabetes
- Congenital hypopituitarism
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
- 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 
- 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
- Blue-gray pigmented macule (may also be green or brown)
- Location: most common on the back, also seen on the buttocks, flanks, and shoulders
- Diameter: typically < 5 cm, may be > 10 cm
- Prognosis: : usually resolves spontaneously during childhood (typically by the age of 10 years) 
Congenital melanocytic nevus
- Definition: a congenital skin lesion caused by the proliferation of melanocytes
- Epidemiology: 1/20,000 births 
- Clinical features ; 
- 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
- Occurs in 3–10% of infants 
- More commonly affects girls
- Clinical features
- Based on clinical findings
- The differential diagnosis of is found mostly in adults.
- Active nonintervention (monitoring, parental education)
- Systemic therapy with propranolol in complicated cases
If unresponsive to medication
- Laser therapy
- Resection if necessary
- Usually good prognosis
- Spontaneous resolution is common
- Visual impairment if periorbital hemangioma is left untreated
- Milia neonatorum
Capillary malformations (naevus flammeus, port-wine stain, firemark)
- Definition: congenital, benign vascular malformations of the small vessels in the dermis
- Epidemiology: may occur in association with a neurocutaneous disorder such as
- Clinical features: typically unilateral, blanchable, pink-red patches that grow and become thicker and darker with age
- Treatment: cosmetic laser treatment if desired (not necessary)
- Prognosis: benign skin lesion
Transient neonatal pustular melanosis (TNPM)
- Definition: a benign, transient, idiopathic neonatal skin condition
- Epidemiology 
- Clinical features
- Treatment: reassurance
- Prognosis: benign, self-limiting skin lesion
- Nevus anemicus
- LEOPARD Syndrome ( with multiple lentigines)
Blueberry muffin syndrome
- A descriptive term for neonates born with multiple bluish, purple marks in the skin, which can be due to extramedullary erythropoiesis, purpura, or metastases.
- The differential includes various cancers (e.g., rhabdomyoscarcoma), blood disorders (e.g., hemolytic disease of the new born), and congenital viral infections (e.g., rubella)
- Definition: a physiologic decrease in RBC production that typically appears at 8–12 weeks of age in term infants and 4–8 weeks of age in preterm infants
- Pathophysiology 
- Clinical features
- Diagnostics: screening for anemia should be performed at 12 months of age via measurement of Hb levels. 
- Differential diagnoses
- Treatment 
- Definition: venous hematocrit (HCT) greatly exceeding normal values for gestational and postnatal age
- Epidemiology: 1–5% of newborns 
- Risk factors
- Maternal hyperglycemia → chronic fetal hyperglycemia → ↑ metabolic effects and oxygen demand → fetal hypoxemia → ↑ erythropoietin concentrations
- Delayed umbilical cord clamping → erythrocyte transfusion → ↑ circulating red blood mass (HCT)
- Placental insufficiency or chronic intrauterine hypoxia → increased intrauterine erythropoiesis → ↑ circulating red blood mass (HCT)
- Clinical features
- Venous HCT > 65%
- Hemoglobin > 22 g/dL
- Treatment (if symptomatic)
- Definition: low blood glucose in a newborn
- Transitional neonatal hypoglycemia: a normal physiological drop in a newborn's plasma glucose levels within the first 2 hours of life that typically resolves within 72 hours of birth
Persistent neonatal hypoglycemia: low plasma glucose levels (< 50 mg/dL) in a newborn that persist beyond the first 48 hours of life
Risk factors 
- Persistent hyperinsulinemic hypoglycemia (e.g., due to gestational diabetes)
- Intrauterine growth restriction
- Small for gestational age
- Large for gestational age
- Persistent hypoglycemia
- Inadequate glycogen stores and/or impaired glucose production
- Increased glucose utilization
- Maternal hyperglycemia → fetal hyperglycemia → beta cells hypertrophy and hyperfunctioning → fetal and neonatal hyperinsulinemia → delivery → ↓ maternal glucose supply → transient hypoglycemia
- Insufficient glycogen stores and hyperinsulinemia → impaired hepatic glycogen mobilization → transient hypoglycemia
- Clinical features
- Diagnostics: Glucose levels should be obtained for symptomatic infants and/or those with known risk factors. 
- Close glucose level monitoring for the first 24–48 hours
- Oral or IV glucose supplementation, if necessary.
- Prognosis 
- Definition: a fetus that is > 4000 g (8 lbs 13 oz), regardless of gestational age
- Etiology 
- Maternal hyperglycemia → fetal hyperglycemia → stimulation of fetal pancreas → fetal hyperinsulinemia → ↑ insulin, insulin-like growth factors, growth hormone, and other growth factors → ↑ fetal growth, fat deposition, hepatic glucose uptake, and glycogen synthesis → ↑ delivery to insulin-sensitive tissues (e.g., heart, liver, skeletal muscle)
- ↑ Maternal lipid levels → ↑ supply of fatty acids to the fetus and fetal hyperinsulinemia → incorporation of fatty acids into fetal adipocytes → ↑ fetal adiposity
- Diagnostics: > 4000 g (8 lbs 13 oz), as estimated by ultrasound measurements (e.g., fetal abdominal circumference)
- Individuals with diabetes mellitus in pregnancy should achieve adequate glycemic control.
- All pregnant individuals should avoid excessive weight gain.