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NEWBORN NURSERY SURVIVAL GUIDE

The essentials every medical student should know before starting their newborn rotation.

Normal Vital Signs in a Newborn:

  • HR: 110-160 BPM

  • RR: 30-60

  • Temp: 36.5-37.5C

Red Flags: RR > 60 persistent, HR <100 when awake, Temperature instability.

Stooling and Voiding: A helpful rule in the nursery is “one diaper for each day of life.”

By day 4, infants should have 4–6 wet diapers per day.

  • Day 1-2: Meconium (black, sticky, stool)

  • Day 2-4: Transitional stool (green to brown)

  • Day 4 and beyond: Yellow, seedy stool

Understanding Newborn Jaundice:

1. Physiologic Jaundice: Appears 24 hours after life.

  • Breastfeeding Jaundice: Due to poor intake.

  • Breast Milk Jaundice: Later onset, benign.

2. Pathologic Jaundice:

  • Appears within 24 hours of life.

When to be concerned:

  • Jaundice appearing before 24 hours.

  • Rapid bilirubin rise (>0.3 mg/dL per hour).

  • Poor feeding or lethargy.

Breastfeeding: How to Tell if It’s Adequate

  • 8-12 feeds/day.

  • Weight loss <5% in first 24 hours OR <10% after first 24 hours OR NEWT score <75th percentile (if over this, then get lactation consult).

  • Appropriate diaper counts.

Signs of inadequate intake: These babies may require supplementation or lactation support.

  • Sleepy infant.

  • Fewer wet diapers.

  • Weight loss >5% in first 24 hours OR >10% after first 24 hours OR NEWT score >75th percentile.

  • Dry lips.

  • Sunken fontanelle.

Routine Newborn Screening

  • Hearing screen.

  • Pulse oximetry (for critical congenital heart disease).

  • Newborn metabolic screen.

Screening for Neonatal Hypoglycemia: Glucose screening is recommended for infants at risk (SLIMS)

  • Small for gestational age.

  • Large for gestational age.

  • Infants of diabetic mothers.

  • Premature infants (<37 weeks).

Signs of hypoglycemia: tremors, jitteriness, high-pitched cry, poor feeding, hypothermia.

Treatment Algorithm for Neonatal Hypoglycemia:

  • Asymptomatic: Management focuses on ensuring adequate nutrition like breast feeding, oral dextrose, formula.

  • Symptomatic:

    • First 4 hours of life: Severe symptoms + glucose <25 mg/dL → IV dextrose.

    • 4–24 hours of life: Severe symptoms + glucose <45 mg/dL → IV dextrose.

Circumcisions: Contraindications include:

  • Hypospadias.

  • Chordee.

  • Penile torsion.

  • Webbed or buried penis.

  • Epispadias.

  • Urethral hypoplasia.

  • Age <12–24 hours.

  • Active illness requiring monitoring.

  • Bleeding disorders (e.g., hemophilia).

  • Skin conditions that impair healing.

Frenotomy for Tongue Tie:

Ankyloglossia (tongue-tie) occurs when the lingual frenulum is too tight and a frenotomy may be performed when the condition interferes with breastfeeding.

Newborn Physical Exam:

1. Head: Examine the skull and fontanelles.

  • Fontanelles – should be soft and flat.

  • Caput succedaneum – diffuse scalp swelling crossing suture lines.

  • Cephalohematoma – bleeding under periosteum that does not cross sutures.

    • Both are common after delivery but cephalohematomas increase jaundice risk.

2. Eyes:

  • Red reflex (absence may suggest cataracts or retinoblastoma) .

  • Subconjunctival hemorrhage – very common and benign.

  • Symmetry and erythema or discharge.

3. Mouth, Nose and Ears:

  • Palate is intact.

  • Tongue moves freely.

  • No nasal flaring or signs of respiratory distress.

  • Normal ear placement and shape.

4. Neck and Clavicles

  • Assess range of motion, asymmetry, masses.

  • Crepitus over clavicles, which may indicate birth fracture.

5. Lungs

  • Normal respiratory rate is 30–60 breaths per minute.

  • Watch for signs of distress: Intercostal retractions, nasal flaring, grunting.

6. Heart

  • Heart rate: 120–160 bpm.

  • Presence of murmurs.

  • Femoral pulses: weak or absent femoral pulses can indicate coarctation of the aorta.

7. Abdomen

  • Active bowel sounds

  • Liver edge (normally palpable 1–2 cm below costal margin)

  • Umbilical cord cleanliness: A normal cord has 2 umbilical arteries and 1 vein.

8. Genitourinary Exam

  • Boys: testicles should be palpable bilaterally.

  • Girls: vaginal discharge or small amount of bleeding can be normal due to maternal hormones.

9. Spine and Trunk

  • Check for: Symmetry, skin lesions, masses, sacral dimples.

10. Extremities

  • Always: Count fingers and toes, assess limb symmetry.

  • Perform: Ortolani and Barlow maneuvers to screen for developmental dysplasia of the hip.

  • Also look for clubfoot deformities.

11. Neurologic Reflexes

  • Sucking reflex.

  • Grasp reflex.

  • Moro reflex.