INTRODUCTION — After birth, most full-term infants (gestational age [GA] >39 weeks) and early term infants (GA 37 0/7 to 38 6/7 weeks) require normal neonatal routine care to make a successful transition to extrauterine life. Depending on hospital policy, late preterm infants (GA 34 0/7 to 36 6/7 weeks) who are >35 weeks and well appearing may also only require routine care and may be admitted and cared for in the newborn nursery (neonatal level of care 1).
Routine management of the healthy newborn (GA ≥35 weeks) will be reviewed here. The assessment of the newborn is discussed in greater detail elsewhere. (See "Assessment of the newborn infant".)
OVERVIEW — The major components of routine care of the neonate are:
●Delivery room and transitional care, including early bonding
●Newborn assessment including a comprehensive review of the maternal history and a complete physical examination
Prophylaxis care to prevent serious disorders
●Universal newborn screening (see "Newborn screening")
●Family education
●Discharge evaluation
DELIVERY ROOM CARE
Initial management — After delivery, immediate care includes drying the newborn, clearing the airway of secretions, and providing warmth. (See "Neonatal resuscitation in the delivery room", section on 'Initial steps'.)
For newborns who are more likely to require resuscitation, a clinician skilled in neonatal resuscitation should be present in the delivery room to care for the high-risk infant. The identification of high-risk infants and their care is discussed separately. (See "Neonatal resuscitation in the delivery room", section on 'High-risk delivery'.)
Assessment and disposition — A delivery room assessment of the neonate's clinical status is quickly performed by addressing the following questions [1]. The answers are used to determine whether the newborn is admitted to the normal nursery (neonatal level of care 1) or requires a higher level of care (neonatal level of care 2, 3, or 4) [2].
●Is the newborn's GA ≥35 weeks?
●Does the newborn have good muscle tone?
●Is the newborn breathing or crying?
If yes is the answer to all of these questions, the newborn does not require further intervention and should be given to the mother. Well appearing newborns should remain with the mother and be placed skin-to-skin (STS) to promote infant-maternal bonding and early initiation of breastfeeding [3]. Medical staff should instruct and assist the mother on safe positioning of the newborn during STS and breastfeeding, and directly observe the first breastfeeding session. These infants can be admitted to the newborn nursery (neonatal level of care 1). (See "Initiation of breastfeeding", section on 'Skin-to-skin contact'.)
If the answer to any of the questions is no, then the newborn requires further evaluation and intervention [1]. The following interventions may be required and are discussed in greater detail separately (see "Neonatal resuscitation in the delivery room"):
●Oxygen administration
●Positive pressure ventilation
●Chest compressions
●Use of resuscitative medications (eg, epinephrine)
●Transfer to higher level of care (neonatal level of care 2, 3, or 4)
Apgar score — The Apgar scores at one and five minutes of age provide an accepted, universally used method to assess the status of the newborn infant immediately after birth. Although data from a population-based study reported that lower Apgar scores of 7, 8, and 9 versus 10 were associated with higher neonatal mortality and morbidity [4], the Apgar score should not be used to predict individual neonatal outcome as it is not an accurate prognostic tool [5].
The following signs are given values of 0, 1, or 2, and added to compute the Apgar score. Scores may be determined using the Apgar score calculator (calculator 1).
●Heart rate
●Respiratory effort
●Muscle tone
●Reflex irritability
●Color
Approximately 90 percent of neonates have Apgar scores of 7 to 10, and generally require no further intervention. These neonates usually have all of the following characteristics and can be admitted to the level 1 newborn nursery for routine care:
●Gestational age (GA) ≥35 weeks
●Spontaneous breathing or crying
●Good muscle tone
●Pink color
Infants with lower scores require further evaluation and possible intervention, including 1 percent of all neonates who require extensive resuscitative measures at birth. The care of these newborns is discussed in greater detail separately. (See "Neonatal resuscitation in the delivery room".)
Transitional period — The transitional period between intrauterine and extrauterine life is during the first four to six hours after birth. Physiological changes that can occur during the transitional period include decreasing pulmonary vascular resistance (PVR) with increased blood flow to the lungs, lung expansion with clearance of alveolar fluid and improved oxygenation, and closure of the ductus arteriosus. (See "Physiologic transition from intrauterine to extrauterine life".)
During this period of time, the clinical status of the newborn should be assessed every 30 to 60 minutes to ensure further interventions and/or evaluations beyond routine care are no longer required for successful transition to extrauterine life. The following clinical parameters are monitored beginning in the delivery room and continuing in the mother/infant's room (rooming in) or nursery:
●Temperature − The normal axillary temperature should be between 36.5 to 37.5ºC (97.7 to 99.5ºF) for an infant in an open crib [1,6]. Initial hyperthermia may be reflective of maternal fever or the intrauterine environment. Persistent hyperthermia or hypothermia may be a sign of sepsis. Hypothermia may contribute to metabolic disorders such as hypoglycemia or acidosis. (See "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm neonates".)
●Respiratory rate − The normal respiratory rate is 40 to 60 breaths per minute, and should be counted over a full minute. Tachypnea may be a sign of respiratory or cardiac disease. Apnea may be secondary to exposure to maternal medications (eg, maternal anesthesia or sedation), a sign of neurologic impairment, or sepsis.
●Heart rate − The normal heart rate is 120 to 160 beats per minute, but may decrease to 85 to 90 per minute in some term newborns during sleep. Heart rates that are too high or low may be a sign of underlying pathology, such as cardiac disease, sepsis, and metabolic derangements.
●Color − Central cyanosis (lips, tongue, and central trunk) may be indicative of respiratory or cardiac disease. (See "Overview of cyanosis in the newborn".)
●Tone − Hypotonia may be secondary to exposure to maternal medications or maternal fever during labor [7], or be indicative of an underlying syndrome (Down syndrome), sepsis, neurologic impairment, or metabolic derangement (eg, hypoglycemia). (See "Clinical features, diagnosis, and treatment of neonatal encephalopathy" and "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia", section on 'Clinical presentation'.)
Respiratory disease and suspected cardiac disease in the newborn are discussed in greater detail separately. (See "Overview of neonatal respiratory distress and disorders of transition" and "Identifying newborns with critical congenital heart disease".)
NEWBORN NURSERY CARE
Overview of care — A newborn admitted to the newborn nursery should have a thorough evaluation performed within 24 hours of birth to identify any abnormality that would alter the normal newborn course or identify a medical condition that should be addressed (eg, anomalies, birth injuries, jaundice, cardiopulmonary disorders, or increased risk of sepsis). The assessment of the newborn infant including review of the maternal, family, and prenatal history, and a complete examination is discussed in detail separately. The assessment and management for neonatal sepsis are also presented separately. (See "Assessment of the newborn infant" and "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm neonates" and "Management and outcome of sepsis in term and late preterm neonates".)
In addition to the assessment of the newborn, the following routine procedures and ongoing evaluations are performed after birth to prevent serious disorders:
●Prophylactic eye care to prevent neonatal gonococcal ophthalmia
●Intramuscular (IM) administration of vitamin K1 to prevent vitamin K deficient bleeding (VKDB)
●Hepatitis B vaccination
●Umbilical cord care to prevent infection
●Monitoring for hyperbilirubinemia and hypoglycemia
●Newborn screening
Eye care — In the neonate, the risk of contracting gonococcal conjunctivitis is reduced by prophylactic administration of ophthalmic antibiotic agents shortly after birth [8]. Ocular prophylaxis is safe, easy to administer, and an inexpensive method to prevent sight-threatening gonococcal ophthalmia. In the United States, prophylaxis against gonococcal ophthalmia neonatorum is recommended by the US Preventive Services Task Force and is mandatory for all newborns [9,10]. (See "Gonococcal infection in the newborn", section on 'Ophthalmia neonatorum'.)
Erythromycin ophthalmic ointment (0.5 percent) is recommended by the American Academy of Pediatrics (AAP) [8] and the Centers for Disease Control and Prevention (CDC) [11] for prophylaxis against ophthalmia neonatorum. Erythromycin ophthalmic ointment is the only approved agent available in the United States for prevention of ophthalmia neonatorum. It should be applied as a 1 cm ribbon in each eye within two hours of birth.
Erythromycin ophthalmic ointment causes less chemical conjunctivitis than does silver nitrate solution. However, silver nitrate is more effective as a prophylaxis for penicillinase-producing Neisseria gonorrhoeae than erythromycin and should be used in areas where that organism is prevalent [12,13]. One percent silver nitrate solution and 1 percent tetracycline are not commercially available in the United States.
Povidone-iodine solution (2.5 percent) also may prevent ocular gonococcal infection with less toxicity and at lower cost than other agents, although further confirmatory studies are needed. This preparation is not commercially available in the United States.
Ocular infections in newborns caused by Chlamydia trachomatis are common in the United States [8]. The agents used for gonococcal prophylaxis are not effective in preventing neonatal chlamydial conjunctivitis. The most effective measure to prevent neonatal chlamydial conjunctivitis is the diagnosis and treatment of chlamydial infections in pregnant women. (See "Chlamydia trachomatis infections in the newborn", section on 'Prophylaxis against conjunctivitis'.)
Technique — After wiping each eyelid with sterile cotton gauze, the prophylactic agent is placed in each of the lower conjunctival sacs [14]. The agent should be spread by gentle massage of the eyelids, and excess solution or ointment can be wiped away after one minute. The eyes should not be irrigated after the application because doing so may reduce efficacy.
Timing and side effects — Eye prophylaxis should be performed within two hours of birth in all newborns, regardless of mode of delivery. If prophylaxis is delayed, a monitoring system should be established to ensure that all newborns receive prophylaxis. The efficacy of longer delays is not known.
The principal side effect is chemical (noninfectious) conjunctivitis. This condition typically appears within the first 24 hours of age and resolves by 48 hours. It is most often seen after application of silver nitrate.
Vitamin K
Term infants — All newborn infants weighing greater than 1500 grams should receive an intramuscular dose of 1 mg vitamin K1 (phytonadione) within six hours of birth to prevent VKDB, previously referred to as hemorrhagic disease of the newborn [15-17]. (See "Overview of vitamin K", section on 'Prevention'.)
Data show that the administration of vitamin K1 compared with placebo improves the biochemical indices of coagulation status during the first week after birth and is more effective in preventing VKDB. A single IM dose of vitamin K has been shown to be more effective in preventing late-onset VKDB (defined as VKDB between 2 and 12 weeks of age), when compared with oral vitamin K regimens [18-22]. Because the effects of late VKDB can be devastating, we recommend the IM route for administration of vitamin K prophylaxis. An oral vitamin K preparation for newborn prophylaxis is not available in the United States [16].
In some countries outside the United States, oral administration of vitamin K has been advocated because it is easier to administer and is less costly. However, despite increasing the oral dose of vitamin K, the risk of bleeding, including intracranial bleeding, remains [23]. The use of IM administration was supported by a study that reported a decrease in significant bleeding in Australia after national guidelines recommended changing from oral to IM administration of vitamin K [24].
In countries where oral vitamin K is the standard, IM rather than oral prophylaxis should be administered to infants who are preterm, receiving antibiotics, or who have liver disease or diarrhea, because they may have decreased absorption of the oral preparation. VKDB may still develop despite IM administration of vitamin K in neonates with liver disease [25].
The rate of parental refusal of newborn vitamin K administration is approximately 0.5 percent, and parental refusal is associated with half of the severe cases of VKDB [24-26]. In the previously mentioned Australian studies, the six reported deaths were due to intracranial hemorrhage, of which three were in infants who were not given vitamin K due to parental refusal [24]. It is imperative that parents are counseled about the potential dire consequences of VKDB (eg, intestinal hemorrhage, intracranial hemorrhage with subsequent neurodevelopmental impairment and possible death) if their newborn does not receive vitamin K.
Other causes of VKDB include failure to administer vitamin K despite parental consent, liver or biliary disease, and rarely, no underlying cause can be identified [24,25].
Preterm infants — Although the optimal dosing in preterm infants is unknown, the AAP suggests preterm infants weighing less than or equal to 1500 grams receive a single IM dose of 0.3 mg/kg to 0.5 mg/kg vitamin K after birth [15,27]. A single intravenous dose of vitamin K for preterm infants is not recommended for prophylaxis.
Umbilical cord — The postpartum care of the umbilical cord for reducing the risk of infection (omphalitis) is dependent upon the quality of the care at delivery and postnatally. If there is an increased risk for omphalitis, especially in a clinical setting of low resources, the use of antiseptic agents (eg, triple dye, alcohol, silver sulfadiazine, and chlorhexidine) for cord care is an excellent and inexpensive option that reduces neonatal morbidity and mortality. However, in developed countries where aseptic care is routine in the clamping and cutting of the umbilical cord, additional topical care beyond dry cord care is not needed to prevent omphalitis. (See "Care of the umbilicus and management of umbilical disorders", section on 'Cord care'.)
Hepatitis B vaccination — Universal vaccination of newborns regardless of maternal hepatitis B virus surface antigen (HBsAg) status is recommended. The first dose of the hepatitis B vaccine is given within 24 hours of delivery (table 1) [28]. Newborns of HBsAg-positive mothers should receive hepatitis B vaccine (HBV) in addition to hepatitis B immunoglobulin (HBIG) shortly after birth, preferably within 12 hours of age (table 2). If the mother's HBsAg status is unknown at the time of delivery, the neonate should receive HBV within 12 hours of birth while awaiting the results of mother's HBsAg; if mother is subsequently found to be HBsAg positive, HBIG should be given to the newborn within the first week of life. (See "Hepatitis B virus immunization in adults" and "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Routine infant immunization'.)
Newborn screening — In the United States, screening for congenital hearing loss, metabolic and genetic disorders, critical congenital heart disease (CCHD), and congenitally acquired infections are routinely performed for all neonates.
Hearing loss — Universal newborn hearing screening is recommended to detect infants with hearing loss.
In the United States, all 50 states and the District of Columbia have early hearing detection and intervention laws or voluntary compliance programs that screen hearing in the newborn. (See "Screening the newborn for hearing loss".)
Metabolic and genetic disorders and congenital infections — All states require newborn screening for disorders that are threatening to life or long-term health, and for which early intervention has been shown to improve outcomes. Also known as "blood spot" testing, the screen is obtained by analyzing drops of blood placed on special paper. The specific disorders screened for vary from state to state; however, most states test for the conditions specified by the Health Resources and Services Administration (HRSA) in their Recommended Uniform Screening Panel (RUSP) [29]. Blood is collected for an initial screen between 24 and 48 hours of life; some states also require a second screen which is usually collected between 7 and 14 days of age. (See "Newborn screening".)
Critical congenital heart disease — In the United States, all fifty states and the District of Columbia perform pulse oximetry screening to detect critical congenital heart disease. (See "Newborn screening for critical congenital heart disease using pulse oximetry".)
Feeding — Newborns should be fed early and frequently to avoid hypoglycemia. The frequency, duration, and volume of feeds will be dependent upon whether the newborn is breastfed or receives formula. Each feeding should be recorded, and if the newborn is fed formula, the volume of feeding should also be recorded.
Breastfeeding is recommended because of its increased benefits for both the infant and mother compared with formula feeding, except when medically contraindicated, such as in infants with mothers with human immunodeficiency virus (HIV) infection in the United States, or in some cases of maternal drug abuse. (See "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding" and "Infants with prenatal substance use exposure", section on 'Breastfeeding' and "Prenatal evaluation of women with HIV in resource-rich settings".)
●Breastfed infants should be fed as soon as possible after delivery, preferably in the delivery room. They should receive at least 8 to 12 feeds per day during the newborn hospitalization. Rooming-in, skin-to-skin contact, frequent demand feedings in the early postpartum period, and lactation support increase the rate of successful breastfeeding. (See "Breastfeeding: Parental education and support" and "Initiation of breastfeeding".)
●Healthy newborns who are fed formula should be offered standard 19 to 20 kcal/oz (19 to 20 kcal per 30 mL) iron containing infant formula. They are fed on demand, but the duration between feedings should not exceed four hours. The volume of feedings should be at least 0.5 to 1 oz (15 to 30 mL) per feed during the first few days of life.
●Pasteurized, human donor milk may be available in some nurseries for the healthy, breastfed newborn who may require supplementation.
Weight loss — Term newborns may lose up to 10 percent of their BW in the first few days of life and typically regain their BW by 10 to 14 days [30,31]. Exclusively breastfed infants delivered by cesarean section tend to have greater weight loss in the first week of life, as demonstrated by data from a large health maintenance organization, where 25 percent of exclusively breastfed infants delivered by cesarean section had >10 percent weight loss at 72 hours of age [31]. In this study, infants born vaginally returned to BW more quickly than those delivered by cesarean section. For infants born vaginally, 86 percent achieved BW by 14 days and 95 percent by 21 days. For infants born by cesarean delivery, 76 percent achieved BW by 14 days and 92 percent by 21 days.
Excessive weight loss should be evaluated with a complete feeding assessment, ongoing lactation support for breastfeeding mothers, and interventions as deemed necessary. Weight loss nomograms based on mode of delivery and for exclusively breastfed infants have been developed [30,31]. (See "Initiation of breastfeeding", section on 'Assessment of intake'.)
Glucose screening — Healthy, asymptomatic term newborns born after an uncomplicated pregnancy and delivery are at low risk for significant hypoglycemia. As a result, blood glucose measurement is not routinely performed in these neonates.
Per AAP guidelines, glucose monitoring should be performed for newborns with the following with risk factors [32]:
●Infants of GA <37 weeks.
●Large for gestational age (LGA).
●Small for gestational age (SGA).
●Infants of diabetic mothers (IDM).
●Infants with a family history of a genetic form of hypoglycemia or have physical findings suggestive of a syndrome (eg, Beckwith-Wiedemann) associated with hypoglycemia.
In our institutions, we also perform glucose screening for infants born to mothers who have received no prenatal care. Other populations at risk for hypoglycemia include infants with fetal growth restriction or perinatal stress, those born postterm (gestational age >42 weeks), and those whose mothers were treated with beta adrenergic or oral hypoglycemic agents. The clinical manifestations, evaluation, and management of neonatal hypoglycemia are presented separately. (See "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia".)
Newborn circumcision — The risks, benefits, and procedures for newborn circumcision are discussed separately. (See "Neonatal circumcision: Risks and benefits" and "Neonatal circumcision: Techniques".)
Hyperbilirubinemia — Hyperbilirubinemia with a total serum bilirubin level greater than 25 mg/dL (428 micromol/L) is associated with an increased risk for bilirubin-induced neurologic dysfunction (BIND). As a result, during the birth hospitalization, newborns should be routinely assessed every 8 to 12 hours and at discharge for the presence of jaundice. Because visual assessment is not accurate for estimating the degree of hyperbilirubinemia, most institutions include routine bilirubin testing either by transcutaneous bilirubin or total serum bilirubin measurement prior to discharge. However, a transcutaneous or total serum bilirubin measurement should be performed on any infant who appears jaundiced during the first 24 hours of age. The most reliable predictor for subsequent development of significant hyperbilirubinemia combines a predischarge bilirubin screen with an assessment of risk factors. (See "Screening for hyperbilirubinemia in term and late preterm newborn infants".)
Bilirubin screening with both a total serum bilirubin level and a conjugated, or direct, bilirubin level may be helpful in identifying babies with biliary atresia. (See "Biliary atresia".)
The clinical manifestations, evaluation, and management of neonatal hyperbilirubinemia are discussed separately. (See "Risk factors, clinical manifestations, and neurologic complications of neonatal unconjugated hyperbilirubinemia" and "Screening for hyperbilirubinemia in term and late preterm newborn infants" and "Initial management of unconjugated hyperbilirubinemia in term and late preterm newborns".)
Postnatal parental education — The parents or primary caregiver should receive training and demonstrate competence or understanding of the following infant care tasks [33]:
●The importance and benefits of breastfeeding. (See "Breastfeeding: Parental education and support" and "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding" and "Patient education: Breastfeeding (The Basics)" and "Patient education: Deciding to breastfeed (The Basics)".)
●If breastfeeding, positioning the infant and determining adequate latch and swallowing. (See "Initiation of breastfeeding".)
●Appropriate frequency of urination and stooling, and normal and abnormal appearance of urine and stool. In particular, acholic stools that appear either white or pale can be an early finding of biliary atresia. (See "Biliary atresia", section on 'Signs and symptoms'.)
●Umbilical cord, skin, and genital care. (See "Care of the umbilicus and management of umbilical disorders", section on 'Umbilical cord at birth' and "Neonatal circumcision: Techniques", section on 'Post-circumcision care'.)
●Recognition of the signs of common neonatal illnesses, particularly hyperbilirubinemia and sepsis. (See "Patient education: Jaundice in babies (The Basics)" and "Patient education: Jaundice in newborn infants (Beyond the Basics)" and "Patient education: Sepsis in newborn babies (The Basics)".)
●Proper infant safety, including supine sleeping position and sleeping on a firm mattress, installation and use of car safety seat, and hand hygiene. (See "Sudden infant death syndrome: Risk factors and risk reduction strategies", section on 'Sleep position' and "Sudden infant death syndrome: Risk factors and risk reduction strategies", section on 'Sleep environment' and "Patient education: Sudden infant death syndrome (SIDS) (The Basics)".)
●Strategies that parents can use to reduce pain during their infant’s routine immunizations, which are discussed separately. (See "Standard immunizations for children and adolescents: Overview", section on 'Reducing injection pain'.)
LENGTH OF HOSPITAL STAY — The optimal length of hospital stay (LOHS) varies for each mother-infant pair and should be long enough to permit detection of early neonatal problems and to ensure that the family is able and prepared to care for the infant at home [33]. Factors involved in this decision include the health of the mother, the health and stability of the infant, the ability and confidence of the mother to care for the infant, the adequacy of support systems at home, and access to appropriate follow-up care [33-35].
Discharge criteria — Decision for discharge is made jointly with the family and the obstetric and neonatal care providers, and is based upon the perception that the infant-mother dyad are ready for discharge. Factors associated with a perceived need for longer hospital stay include first-time mother, chronic maternal illness, in-hospital neonatal illness, breastfeeding, mothers with inadequate prenatal care and poor social support [33].
The American Academy of Pediatrics (AAP) Committee on Fetus and Newborn issued the following recommended minimum criteria and conditions that should be met before discharge of the newborn [33]:
●No neonatal abnormality requiring continued hospitalization was detected during the hospital course, or on physical examination at discharge. (See "Assessment of the newborn infant".)
●The infant's vital signs are within normal ranges and are stable for at least 12 hours before discharge (respiratory rate <60 per min; heart rate between 120 and 160 beats per minute [resting heart rate as low as 85 is acceptable for term infants]); axillary temperature 36.5 to 37.5ºC [97.7 to 99.5ºF]).
●The infant has urinated and passed at least one stool spontaneously. Almost all term infants will have urinated and passed at least one stool during the first 24 hours of life [36].
●The infant has completed at least two successful feedings. If the infant is breastfeeding, a knowledgeable care provider should observe a feeding and document successful performance of latching, swallowing, and infant satiety. If the infant is bottle-fed, observation and documentation of successful feeding based on the ability to coordinate sucking, swallowing, and breathing while feeding. (See "Initiation of breastfeeding" and "Neonatal oral feeding difficulties due to sucking and swallowing disorders".)
●If the infant was circumcised, there is no evidence of excessive bleeding at the circumcision site for at least two hours prior to discharging home.
●If the infant is jaundiced, the clinical significance has been determined and appropriate plans for management and follow-up have been instituted. (See "Screening for hyperbilirubinemia in term and late preterm newborn infants".)
●The infant has been screened and monitored for sepsis based upon maternal risk factors and guidelines for the management of neonates with suspected or proven early-onset sepsis. (See "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm neonates" and "Management and outcome of sepsis in term and late preterm neonates".)
●Review of maternal test results including maternal syphilis screening, hepatitis B surface antigen status, and human immunodeficiency virus (HIV) infection screening. When clinically indicated, results for cord or infant blood-type, and neonatal direct Coombs test, should be obtained and reviewed. (See "Assessment of the newborn infant".)
●Initial hepatitis B vaccine is administered and, for infants of hepatitis B surface antigen positive mothers, hepatitis B immunoglobulin has been administered. (See "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Routine infant immunization'.)
●For unvaccinated mothers, tetanus toxoid, reduced diphtheria toxoid, and acellular absorbed (Tdap) vaccine should be administered to the mother after the infant is born. In addition, Tdap vaccination should be given to other adults and adolescents who have not previously received the Tdap vaccine and will be in close contact with the infant.
●Completion of hearing screening, blood spot newborn screening, and pulse oximetry screening for critical congenital heart disease (CCHD) [37]. (See "Screening the newborn for hearing loss" and "Newborn screening" and "Newborn screening for critical congenital heart disease using pulse oximetry".)
●The mother has received training and demonstrated competency in the care of her newborn as described above. (See 'Postnatal parental education' above.)
●Confirmation that an appropriate car seat has been obtained and the parents have demonstrated to hospital personnel the ability to place the infant in the proper position and use the car seat properly. (See "Discharge planning for high-risk newborns", section on 'Car seat/bed use'.)
●Family members or other support persons, including health care professionals with knowledge about newborn care, are available to the mother and her infant after discharge.
●A medical home for continuing infant care has been identified and timely communication of pertinent birth hospitalization information has been sent to the care providers of the medical home. If the newborn is discharged before 48 hours after delivery, a follow-up appointment should occur at the medical home by a licensed health care professional within 48 hours. If an appropriately timed follow-up appointment cannot be ensured then discharge should be deferred until an appointment can be made. (See 'Follow-up visit' below.)
●Family, environmental, and social risk factors have been assessed and addressed (eg, substance abuse, child abuse or neglect, domestic violence, mental illness, lack of social support, lack of reliable income). Barriers to follow-up care are assessed and addressed (eg, transportation, access to telephone communication).
These criteria are generally not achieved before the infant is 48 hours of age. In meta-analyses, newborns with a shortened hospital stay were more likely to be readmitted to the hospital within 28 days than those with a longer hospital stay of greater than 48 hours [38,39]. In addition, a population-based study reported that early discharge(<48 hours) versus later discharge was associated with an increase in health care cost for term infants for the first 28 days after birth and higher neonatal readmission rates [40]. For late preterm infants, early birth discharge was also associated with a higher hospital readmission rate and a trend to a higher health care cost, which was not significant. If early discharge is being considered, it should be limited to term newborns (37 0/7 to 41 6/7 weeks of gestation) with an uncomplicated pregnancy, labor, and delivery and who meet the above criteria.
Discharge legislation — In the United States, because of concerns that early discharge could adversely affect maternal and infant health outcomes, both state and federal governments passed postpartum discharge laws in the late 1990s (Newborns' and Mothers' Health Protection Act [NMHPA]) to prevent extremely short LOHS. In general, these laws require insurance plans to cover postpartum stays of up to 48 hours for infants born by vaginal deliveries and up to 96 hours for cesarean deliveries [41]. The impact of legislation ensuring insurance coverage for a minimum of 48 hours has increased the LOHS of newborn infants and their mothers and appears to have decreased neonatal readmission rates and emergency department visits [38,42,43].
FOLLOW-UP VISIT — The early newborn follow-up visit is conducted at an identified medical home by a health care provider competent in the assessment of newborns. This visit can take place in the home or a clinic, based on the needs of the family and availability of the provider, and includes the following [33]:
●Assess the general health of the neonate − Review birth hospitalization information (pregnancy, delivery, complications during the hospital course), and pertinent events after discharge. Perform a physical examination of the infant including measurement of the weight, and assessment for signs of dehydration and extent of jaundice. In addition, the clinician should identify new problems, review feeding pattern, including stool and urine output.
●Assess the quality of mother-infant interaction.
●Assess infant behavior.
●Reinforce maternal and family education in infant care for feeding, supine sleeping position, and child safety seats, and encourage and support breastfeeding (if appropriate).
●Review results of outstanding laboratory tests including the newborn blood spot screen.
●Perform any necessary tests such as bilirubin check in an infant with clinically significant jaundice.
●Establish a relationship with the medical home. Verify the plan for health care maintenance and the medical home.
●Assess parental well-being, including symptoms of postpartum depression (PPD) in the mother. The US Preventive Services Task Force, in addition to several professional organizations including the American Academy of Pediatrics, recommends routine universal screening for postpartum depression in women to facilitate early evidence-based treatment and referrals [44]. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)
The timing of the first well-child visit is dependent on the length of the birth hospitalization. For infants with a birth hospitalization less than 48 hours, an early follow-up visit is necessary within 48 hours of discharge [33,45], whereas for infants with a birth hospitalization greater than 48 hours, an initial well-child visit within three to five days after discharge is reasonable. This approach, which is consistent with guidelines from the American Academy of Pediatrics (AAP), was supported by a study using data from a large health care system, which showed that early follow-up visits reduced the rate of rehospitalization for infants with a birth hospitalization of less than 48 hours [45]. Earlier follow-up visits within 24 to 48 hours after hospital discharge, regardless of length of hospital stay, are particularly important for the following: late preterm and early term infants, newborns with weight loss >8 percent, newborns with risk factors for hyperbilirubinemia, and newborns who were treated with phototherapy.
HOME BIRTH — We concur with the policy statement from the American Academy of Pediatrics that home birth is not recommended in developed countries due to the twofold to threefold increase in infant mortality when compared with delivery outcomes in medical care facilities [46]. Pediatric health care providers should offer information about the increased risk of neonatal mortality and complications associated with planned home births to mothers considering a home birth. In addition, mothers with a pregnancy complicated by intrauterine growth restriction or diabetes should deliver in a medical care facility due to the increased risk of hypoglycemia in the newborn and other potential complications associated with these types of high-risk pregnancies.
Nevertheless, recognizing that home births do and will continue to occur, care for the newborn delivered at home should be consistent with the care provided to newborns born in a medical care facility [46]. Planned home births are safest when they are part of an integrated regulated, system with multiple well-qualified providers for both the care of the mother and infant, appropriate risk assessment, and ability for seamless transfer, if necessary. (See "Planned home birth", section on 'Program organization'.)
●Delivery – Presence of two care providers at delivery, one of whom has primary responsibility for the newborn infant.
●Transitional care – During the first four to eight hours, the newborn should be kept warm, and a detailed physical examination is performed that includes assessment of gestational age. During this period, ongoing monitoring is conducted every 30 minutes and includes assessment of respiratory and heart rate, color, and tone until the newborn's status is determined normal and stable for at least two hours. If the gestational age is <37 weeks or the infant is ill appearing (eg, sepsis), the infant should be transferred to a medical facility for continued observation and management. (See 'Transitional period' above and "Late preterm infants" and "Management and outcome of sepsis in term and late preterm neonates".)
●Routine newborn care – Infants born at home should receive all the procedures and ongoing evaluations that are routinely administered at birthing centers, including (see 'Newborn nursery care' above):
•Eye care prophylaxis to prevent gonococcal conjunctivitis
•Parenteral vitamin K prophylaxis
•Hepatitis B vaccination
•Newborn screening: Hyperbilirubinemia, universal "blood spot" screening for metabolic and genetic disorders, hearing screening, and pulse oximetry screening for critical congenital heart disease
•Feeding assessment and counseling
●Follow-up care – Identify a medical home for continuing care and communicate pertinent birth hospitalization information. (See 'Follow-up visit' above.)
READMISSIONS — Despite enactment of the Newborns' and Mothers' Health Protection Act (NMHPA), potentially preventable readmissions of newborns continue to occur. Newborn readmission is associated with early discharge, inexperienced parenting, difficulty establishing infant feeding, and being of Asian or Pacific Islander descent as these infants have an increased risk of hyperbilirubinemia [47].
These factors were identified in an analysis of 2540 newborns readmitted in the first 10 days of life based on clinical discharge records collected by the Pennsylvania Health Care Cost Containment Council (PHC4) [47]. In this cohort, the mean time to readmission was 111 hours since birth and 62 hours since nursery discharge. Jaundice was the most common diagnosis occurring in 92 percent of the infants. The remaining infants were readmitted for dehydration, feeding problems, and/or associated electrolyte abnormalities.
These findings may be useful in providing additional support for at-risk families and anticipatory care, thereby decreasing the need for readmission.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Newborn appearance (The Basics)")
SUMMARY AND RECOMMENDATIONS — Most newborn infants make a successful transition to extrauterine life and require only routine care immediately after birth.
●Initial management – Immediately after an uncomplicated delivery, routine care includes drying the newborn, clearing the airway of secretions, and providing warmth. Approximately 90 percent of newborns will not require further intervention in the delivery room, and these newborns should be given to their mothers for skin-to-skin contact and initiation of breastfeeding. (See 'Delivery room care' above.)
●Transitional period – During the transitional period (first four to six hours of life), optimal routine care, which begins in the delivery room, includes promoting early bonding with skin-to-skin contact and early initiation of breastfeeding. The clinical status of the newborn is monitored every 30 to 60 minutes to determine whether further intervention is required. (See 'Transitional period' above.)
●Overview of care – Routine care includes a thorough evaluation performed within 24 hours of birth to identify any abnormality that would alter the newborn course or identify a medical condition that should be addressed during the first days of life. The assessment includes a review of the maternal, family, and prenatal history and a complete physical examination. (See "Assessment of the newborn infant".)
●Eye care – We recommend that all neonates are treated with an ophthalmic antibiotic agent shortly after birth to prevent gonococcal conjunctivitis (ophthalmia neonatorum) (Grade 1A). In our practice we use 0.5 percent erythromycin ointment (1 cm ribbon in each eye). Alternative medications, which are not available in the United States, include 1 percent silver nitrate solution, 1 percent tetracycline ointment, or 2.5 percent povidone-iodine solution. (See 'Eye care' above and "Gonococcal infection in the newborn", section on 'Ophthalmia neonatorum'.)
●Vitamin K – We recommend that all neonates receive prophylactic administration of vitamin K1 oxide (phytonadione) to prevent vitamin K deficient bleeding (VKDB) (Grade 1A). We recommend intramuscular (IM) versus oral preparations of vitamin K because of the superiority of the IM route for prevention of both early and late VKDB (Grade 1B). (See 'Vitamin K' above.)
●Hepatitis B vaccination – We recommend hepatitis B vaccination (HBV) of all newborns regardless of maternal hepatitis B virus surface antigen (HBsAg) status to prevent HB infection (Grade 1A). We recommend that infants of HBsAg-positive mothers receive both hepatitis B immunoglobulin (HBIG) and HBV shortly after birth (table 2) (Grade 1A). (See "Hepatitis B virus immunization in adults" and "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Routine infant immunization'.)
●Newborn screening – In the United States, universal newborn screening for hearing loss and disorders that are threatening to life or long-term health is implemented in all fifty states. (See "Screening the newborn for hearing loss" and "Newborn screening".)
●Hyperbilirubinemia and hypoglycemia – Routine care includes assessing newborns for hyperbilirubinemia and hypoglycemia, which may result in significant morbidity. (See 'Glucose screening' above and 'Hyperbilirubinemia' above.)
●Discharge criteria – Minimum criteria and conditions established by the American Academy of Pediatrics (AAP) should be met prior to discharge. These include normal and stable vital signs for at least 12 hours before discharge, evidence of urination and stooling, completion of two successful feedings, no physical abnormalities requiring continued care, no evidence of excessive bleeding (especially in infants who are circumcised), and successful training of the family to provide ongoing care at home. (See 'Discharge criteria' above.)
●Length of hospital stay – In the United States, legislation requires insurance plans to cover postpartum stays up to 48 hours for newborns delivered vaginally, and up to 96 hours for newborns delivered by cesarean section. (See 'Discharge legislation' above.)
●Follow-up visit – At discharge, a medical home should be identified and an appropriately timed follow-up visit should be made. For all newborns who are discharged before 48 hours of age, follow-up assessment is performed within 48 hours, and no later than 72 hours after discharge. The follow-up visit should include assessment of the general health and behavior of the newborn infant, the infant-mother interaction, parent's well-being, verification of ongoing health care, and parental education. (See 'Follow-up visit' above.)
