Overview of the routine management of the healthy newborn

infant
Author
Tiffany M McKee-Garrett, MD
Section Editor
Leonard E Weisman, MD
Deputy Editor
Melanie S Kim, MD
Disclosures
All topics are updated as new evidence becomes available and
our peer review process is complete.
Literature review current through: Mar 2013. | This topic last
updated: Nov 27, 2012.

INTRODUCTION — After birth, most newborn infants require only

routine care to make a successful transition to extrauterine life.

The major components of routine care for the term (gestational age
≥37 weeks) and late preterm (gestational age between 34 to
36 6/7 weeks) neonate are:

 Deliveryroom 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
 Family education
 Discharge evaluation

The routine management of the healthy newborn will be reviewed

here. The assessment of the newborn is discussed in greater detail
elsewhere. (See"Assessment of the newborn infant" .)

In addition, issues specific to the late preterm infant are presented

separately. (See "Late preterm infants" .)

DELIVERY ROOM CARE — After delivery, immediate neonatal care

includes drying the infant, clearing the airway of secretions, and
providing warmth. (See "Neonatal resuscitation in the delivery room",
section on 'Initial steps' .)
During this initial care, a delivery room assessment of the neonate's
clinical status is quickly performed by addressing these questions
[ 1,2 ]:

 Is the infant full-term?

 Is the infant breathing or crying?
 Does the infant have good muscle tone?

If yes is the answer to all the questions, the infant does not require
further intervention and should be given to the mother. Healthy term
or late preterm infants should remain with the mother to promote
infant-maternal bonding by skin-to-skin contact and early initiation of
breastfeeding.

If the answer to any of the questions is no, then the infant requires
further evaluation and intervention [ 1,3,4 ]. 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)

Apgar score — Evaluation is generally based upon the assignment

of an Apgar score at one and five minutes of age [ 1 ]. 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

About 90 percent of all neonates have Apgar scores of 7 to 10, and

generally require no further intervention. They usually have all of the
following characteristics and can be admitted to the level 1 newborn
nursery for routine care:
  Term or late preterm gestation
 Spontaneous breathing or crying
 Good muscle tone
 Pink color

Infants with lower scores may require further evaluation and

intervention including one percent of all neonates who require
extensive resuscitative measures at birth [ 3 ]. The care of these
infants 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 of life after
delivery. Physiological changes that occur during the transitional
period include decreased pulmonary vascular resistance 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 infant 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 either the nursery or mother's room:

 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 ]. Initial hyperthermia may be reflective of
maternal fever or the intrauterine environment. Persistent
hyperthermia or hypothermia may be indicative of sepsis.
Hypothermia may contribute to metabolic disorders such as
hypoglycemia or acidosis.
 Respiratory rate — The normal respiratory rate is 40 to 60
breaths per minute, which 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, magnesium sulfate and anesthesia), 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 infants during sleep. Heart rates that are too high or low
may be indicative of underlying cardiac disease.
 Color — Central cyanosis (lips, tongue, and central trunk) may
be indicative of respiratory or cardiac disease.
 Tone — Hypotonia may be secondary to exposure to maternal
medications or fever [ 5 ], be indicative of an underlying
syndrome (Down syndrome), sepsis, or neurologic
impairment.

ROUTINE CARE — A newborn 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) [ 3 ]. 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. (See "Assessment of the newborn
infant" .)

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
 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

In the United States, universal newborn screening for hearing loss,

metabolic and genetic disorders, and congenitally acquired infectious
disorders are routinely performed in all neonates.

Eye care — In the neonate, the risk of contracting gonococcal

conjunctivitis is markedly reduced by prophylactic administration of
ophthalmic antibiotic agents shortly after birth [ 6 ]. Ocular
prophylaxis is safe, easy to administer, and an inexpensive method to
prevent sight-threatening gonococcal ophthalmia. In the United
States, the majority of states require prophylaxis against gonococcal
ophthalmia neonatorum.

The following are regimens recommended by the American Academy

of Pediatrics [ 6 ] and the Centers for Disease Control and Prevention
(CDC) [ 7 ]:

 0.5 percent erythromycin ointment (1 cm ribbon in each eye)

 1 percent tetracycline ointment (1 cm ribbon in each eye)

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. 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 also is not commercially available in the United States.

In 2009, there was a shortage of 0.5

percent erythromycin ophthalmic ointment in the United States. As of
December 2009, according to the Food and Drug Administration,
erythromycin ophthalmic ointment is available in sufficient quantities
to meet the historical demand for this product [ 8 ]. However, it
remains important for institutions to limit their orders to meet their
immediate clinical needs until increased production rates produce
sufficient amounts to restore inventory supplies.

If erythromycin ophthalmic ointment is not available, the Centers of

Disease Control (CDC) recommends the following [ 9 ]:
  If 0.5 percent erythromycin ophthalmic ointment is not
available, an acceptable alternative is 1
percent azithromycin ophthalmic solution (AzaSite). The
recommended dose is 1 to 2 drops placed in the conjunctival
sac of each eye, taking care to not touch the applicator tip to
the infant. Because this is a solution, it is important to assure
that the drops are placed properly, and a two person
administration approach should be considered.
 If neither 0.5 percent erythromycin ophthalmic ointment or 1
percent azithromycin ophthalmic solution is available, other
alternatives include:

 0.3 percent gentamicin ophthalmic ointment (Gentak)

 0.3 percent tobramycin ophthalmic ointment (Tobrex)
 If none of these are available, a fluoroquinolone ophthalmic
ointment (0.3 percent Ciprofloxacin ophthalmic ointment) can
be used, but this is a less suitable alternative given data on
possible gonococcal antimicrobial resistance.

Of note, there have been adverse reports associated with 0.3

percent gentamicin ophthalmic ointment of lid swelling and
dermatitis, appearing a few days after ointment application [ 10 ].
Most cases have been mild and have not required additional
treatment. Some cases were much more severe with eyelid
discharge, blistering, erythema, and swelling, which have prompted
some clinicians to suggest that gentamicin ophthalmic ointment not
be used as an alternative for neonatal ocular prophylaxis [ 11 ]. If
gentamicin ointment is used, excess ointment from the eyelids should
be removed by delivery room staff to prevent and reduce the severity
of this complication.

Since there are no efficacy data for any of the above suggested
alternatives, providers should be alert to the possibility of failure of
prophylaxis. At the first postnatal visit within 48 to 72 hours after
discharge, the infant should be examined closely for ophthalmia
neonatorum. Infants with ophthalmia neonatorum should be tested
for Neisseria gonorrhoeae infection and should be reported to the
local health department and CDC as a prophylaxis failure.

The CDC has also recommended that hospitals:

  Routinely review their supply of 0.5
percent erythromycin ophthalmic ointment.
 Reserve 0.5 percent erythromycin ophthalmic ointment for only
neonatal prophylaxis.
 If there are severely low supplies (ie, depletion within the
week), contact their wholesale distributor or call Bausch and
Lomb customer service, 1-800-323-0000.
 If supplies are not available, contact the FDA drug shortage
email account ( drugshortages@fda.hhs.gov ).

Ocular infections in newborns caused by Chlamydia trachomatis are

common in the United States [ 6 ]. The agents used for gonococcal
prophylaxis are not effective in preventing neonatal chlamydial
conjunctivitis. Povidone-iodine appears to be significantly more
effective against C. trachomatis thansilver nitrate or erythromycin .

Technique — After wiping each eyelid with sterile cotton gauze, the
prophylactic agent is placed in each of the lower conjunctival sacs
[ 6 ]. 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.

Eye prophylaxis should be performed shortly after birth within the

first hour of life in all infants, regardless of whether they are
delivered vaginally or by cesarean section. If prophylaxis is delayed,
a monitoring system should be established to ensure that all infants
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 — Prophylactic vitamin K1 is given to newborns shortly

after birth to prevent vitamin K deficient bleeding (VKDB), previously
referred to as hemorrhagic disease of the newborn. In a systematic
review of trials that compared either oral or intramuscular
administration of vitamin K to placebo, vitamin K1 oxide improved
biochemical indices of coagulation status during the first week after
birth [ 12 ]. In the single trial of intramuscular vitamin K, vitamin K
compared to placebo was more effective in preventing VKDB.
(See "Overview of vitamin K", section on 'Prevention of vitamin K
deficient bleeding in newborns' .)

Vitamin K1 can be given either orally or intramuscularly. However,

currently used oral regimens are less effective than a single
intramuscular dose of vitamin K in preventing late-onset VKDB
(defined as bleeding disorder due to vitamin K deficiency in infants
between two weeks and two months of age) [13-16 ]. This was
illustrated in a review of surveillance data from four countries that
used oral vitamin K prophylaxis in a variety of different regimens
[16 ]. The rate of late-onset VKDB was 1.2 to 1.8 per 100,000 births
for oral prophylaxis versus no reported cases of late VKDB in infants
who received vitamin K intramuscularly.

Several small studies suggested that intramuscular preparations of

vitamin K may increase the risk of childhood cancer [ 17,18 ],
however, subsequent studies have failed to show an association
between vitamin K and childhood cancer [ 19-22 ]

The American Academy of Pediatrics (AAP) concluded that

intramuscular prophylaxis of vitamin K is superior to oral
administration because it prevents both early (within the first week of
life) and late VKDB, and the risk of cancer from intramuscular vitamin
K is unproven [ 23 ]. Based upon these conclusions, the AAP
recommends vitamin K1 be given to all newborns as a single
intramuscular dose of 0.5 to 1 mg. An oral suspension of vitamin K is
not available in the United States.

Oral prophylaxis with vitamin K1 (2 mg per dose) is generally given

at the first feeding and then at one, four, and eight weeks. Small
daily oral doses of vitamin K may approach the efficacy level of
parenteral administration, but further studies are needed for
confirmation. In some countries, oral administration of vitamin K has
been advocated because it is easier to administer and is less costly.
Efforts continue to develop an oral regimen that is equally effective
as the single intramuscular dose of vitamin K.
Infants who are premature, receiving antibiotics, or have liver
disease or diarrhea, should receive intramuscular prophylaxis
because they may have decreased absorption of the oral preparation.

Preterm infants — The above AAP recommendation to administer

intramuscular vitamin K to newborns is based upon evidence
obtained in full term infants. The optimal dosing in preterm infants is
unknown. In one small controlled trial of infants less than 32 weeks
gestation, intramuscular prophylaxis of 0.2 mg provided adequate
vitamin K supplementation as demonstrated by normal
undercarboxylated prothrombin concentrations and no evidence of
clinical bleeding [ 24 ]. A larger intramuscular dose of 0.5 mg
resulted in higher vitamin K1 and vitamin K1 2,3-epoxide
concentrations, suggesting that an excess of vitamin K1 was
administered. Further studies with a larger number of patients are
required to determine whether the lower intramuscular vitamin K
dose of 0.2 mg is sufficient in preterm infants.

Umbilical cord — The postpartum care of the umbilical cord in

reducing the risk of infection (omphalitis) is dependent on 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 ( table 1 ). Infants of HBsAg-positive mothers
should receive hepatitis B immunoglobulin (HBIG) in addition
to hepatitis B vaccine (HBV) shortly after birth, preferably within 12
hours of age ( table 2 ). (See "Standard immunizations for children
and adolescents", section on 'Hepatitis B vaccine' and"Hepatitis B
virus vaccination" .)
Newborn screening

Hearing loss — Universal screening for hearing loss is

recommended to detect infants with hearing loss. It is legally
mandated in most of the United States. (See "Screening the newborn
for hearing loss" .)

Metabolic and genetic disorders — In addition, screening for

disorders that are threatening to life or long-term health in
asymptomatic newborns is recommended so that interventions can
be initiated to prevent or reduce morbidity and mortality. Universal
screening of newborns for congenitally acquired infections, metabolic
disorders, and genetic disorders, including phenylketonuria,
congenital hypothyroidism, galactosemia, toxoplasmosis, and
hemoglobinopathies occurs throughout the entire United States.
(See "Newborn screening" .)

Critical congenital heart disease — In 2011, a report from the

United States Health and Human Services Secretary’s Advisory
Committee on Heritable Disorders in Newborns and Children
recommended routine pulse oximetry newborn screening to detect
infants with critical congenital heart disease (CHD), defined as CHD
requiring surgery or catheter based intervention in the first year of
life. This report has been endorsed by the American Heart
Association, American Academy of Pediatrics, and the American
College of Cardiology Foundation. The implementation of a universal
screening program has been challenging because of the costs to train
personnel needed to perform testing and establish diagnostic services
to perform and interpret high-quality echocardiography in a timely
manner for infants with positive test results. However, several states
currently require mandatory pulse oximetry screening [ 25 ].
(See "Congenital heart disease (CHD) in the newborn: Presentation
and screening for critical CHD", section on 'Pulse oximetry
screening' .)

Feeding — Infants should be fed early and frequently to avoid

hypoglycemia. The frequency, duration, and volume of feeds will be
dependent upon whether the infant is breastfed or receives formula.
Each feeding should be recorded, and if the infant 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 to formula feeding, except
when medically contraindicated, such as in infants with mothers with
human immunodeficiency viral (HIV) infection or in some cases of
maternal drug abuse. (See"Infant benefits of
breastfeeding" and "Maternal and economic benefits of
breastfeeding" and "Infants of mothers with substance abuse",
section on 'Breastfeeding' and "Prenatal evaluation and intrapartum
management of the HIV-infected patient in resource-rich settings" .)

 Breastfed infants should be fed as soon as possible after

delivery, preferably in the delivery room. They should receive
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 infants who are fed formula should be offered standard
20 cal/oz iron containing 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
per feed during the first few days of life.

Weight loss — Weight loss is normal after delivery particularly in

the breastfed infant. However, weight loss beyond 7 percent requires
medical attention and should be evaluated with a complete feeding
assessment. Normal infants stop losing weight by five days of age
and typically regain their birth weight by 10 to 14 days. The expected
weight loss is up to 7 percent. Greater weight loss in the breastfed
infant should prompt ongoing lactation assessments and
interventions. (See "Initiation of breastfeeding", section on 'Weight
loss' .)

Glucose screening — Although neonatal hypoglycemia may

contribute to brain injury, healthy asymptomatic term infants born
after an uncomplicated pregnancy and delivery are at a low risk for
significant hypoglycemia. As a result, blood glucose measurement is
not routinely performed in these neonates.

Monitoring of serum glucose in the normal nursery is performed in

the following infants who are at risk for significant hypoglycemia.

 Premature infants
 Infants who are large or small for gestational age
 Infants of diabetic mothers
 Infants whose mothers were treated with beta adrenergic or
oral hypoglycemic agents
 Infants who require intensive care
 Infants with polycythemia
 Infants with symptoms consistent with hypoglycemia such as
jitteriness, tremors, hypotonia, irritability, lethargy, stupor,
apnea, poor feeding, hypothermia or seizures

The clinical manifestations, evaluation, and management of neonatal

hypoglycemia are presented separately. (See "Neonatal
hypoglycemia" .)

Newborn circumcision — The risks, benefits, and procedures for

newborn circumcision are discussed separately. (See "Neonatal
circumcision: Risks and benefits" and "Techniques for neonatal
circumcision" .)

Hyperbilirubinemia — Hyperbilirubinemia with a total serum

bilirubin level greater than 25 mg/L (428 micromol/L) is associated
with an increased risk for bilirubin-induced neurologic dysfunction
(BIND). As a result, during the birth hospitalization, infants should be
routinely assessed every 8 to 12 hours and at discharge for the
presence of jaundice. In patients who present with jaundice within
the first 24 hours of life, or who have jaundice in excess for their age,
bilirubin measurement should be performed either by transcutaneous
bilirubin or total serum bilirubin measurement. Because visual
assessment is not as reliable as measurement of total serum
bilirubin, most birthing centers include routine bilirubin testing either
by transcutaneous bilirubin or total serum bilirubin measurement.
The most reliable predictor for subsequent development of significant
hyperbilirubinemia combines a predischarge bilirubin screen with an
assessment of risk factors. (See "Evaluation of unconjugated
hyperbilirubinemia in term and late preterm infants", section on
'Which infants require evaluation' .)

The clinical manifestations, evaluation, and management of neonatal

hyperbilirubinemia are discussed separately. (See "Clinical
manifestations of unconjugated hyperbilirubinemia in term and late
preterm infants" and "Evaluation of unconjugated hyperbilirubinemia
in term and late preterm infants"and "Treatment of unconjugated
hyperbilirubinemia in term and late preterm infants" .)

Education — The parents or primary care giver should receive

training and demonstrate competence or understanding of the
following infant care tasks [ 26 ].

 The importance and benefits of breastfeeding.

(See "Breastfeeding: Parental education and
support" and "Infant benefits of breastfeeding" and"Maternal
and economic benefits of breastfeeding" .)
 Positioning the infant and determining adequate latch-on and
swallowing, if breastfeeding. (See "Initiation of
breastfeeding" .)
 Appropriate frequency of urination, and defecation and
appearance of urine and stool.
 Cord, skin, and genital care.
 Recognition of the signs of common neonatal illnesses,
particularly hyperbilirubinemia and sepsis.
 Proper infant safety, including supine sleeping position, and
installation and use of car safety seat.

LENGTH OF HOSPITAL STAY — The optimal length of stay 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 [ 26 ]. 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 [ 26-28 ].
All efforts should be made to keep the infant-mother dyad together
to promote maternal-infant bonding.

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 need for increased hospital stay
include first time mother, chronic maternal illness, in-hospital
neonatal illness, breastfeeding, mothers with inadequate prenatal
care and poor social support, and black non-Hispanic maternal
ethnicity [ 26 ].

The American Academy of Pediatrics Committee on Fetus and

Newborn issued the following recommended minimum criteria and
conditions that should be met before discharge of the newborn
[ 26 ]:

 No neonatal abnormality requiring continued hospitalization was

detected during the hospital course and 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 100 and 160 beats per minute;
axillary temperature 36.5 to 37.4ºC [97.7 to 99.3ºF]).
 The infant has urinated and passed at least one stool
spontaneously. Almost all term infants will have urinated and
passed at least one stool by the first 24 hours of life [ 29 ].
 The infant has completed at least two successful feedings and is
able to coordinate sucking, swallowing, and breathing while
feeding. (See "Sucking and swallowing disorders in the
newborn" .)
 If the infant was circumcised, there is no evidence of excessive
bleeding at the circumcision site for at least two hours.
 If the infant was jaundiced, the clinical significance has been
determined and appropriate plans for management and
follow-up have been instituted. (See "Evaluation of
unconjugated hyperbilirubinemia in term and late preterm
infants" .)
 The infant has been screened and monitored for sepsis based
upon maternal risk factors and guidelines for the prevention
of perinatal group B streptococcal disease.
 (See "Chemoprophylaxis for the prevention of neonatal group
B streptococcal disease" and "Management of the infant
whose mother has received group B streptococcal
chemoprophylaxis", section on 'Management approach' .)
 The mother has received training and demonstrated
competency in the care of her infant as described above.
(See 'Education' above.)
 Family members or other support persons, including health care
professionals, are available to the mother and her infant after
discharge.
 Maternal test results were reviewed including maternal syphilis,
hepatitis B surface antigen status, and, in some states, HIV
screening. When clinically indicated, test results for cord or
infant blood-type, and neonatal direct Coombs test results
were obtained and reviewed. (See"Assessment of the
newborn infant" .)
 Initial hepatitis B vaccine is administered. Hepatitis B
immunoglobulin also is given to infants with mothers who are
hepatitis B virus surface antigen positive. (See "Standard
immunizations for children and adolescents", section on
'Hepatitis B vaccine' .)
 Hearing and metabolic screening has been completed [ 30 ].
(See "Screening the newborn for hearing loss" and "Newborn
screening" .)
 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, telephone communication).
 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 infant is discharged before 48 hours
after delivery, a follow-up appointment should occur at the
medical home by a licensed health care professional no later
than 72 hours after discharge and within 48 hours if there are
identified risk factors. If an appropriately timed follow-up
appointment cannot be ensured than discharge should be
deferred until an appointment can be made.
These criteria are generally not achieved before the infant is 48 hours
of age [ 26 ]. Consideration of discharge before 48 hours of age
should be limited to singleton infants who are born between 38 and
42 weeks of gestation, are appropriate weight for gestational age,
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 (Newborns' and
Mothers' Health Protection Act [NMHPA]) passed postpartum
discharge laws in the late 1990s to prevent extremely short length of
hospital stay (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 [ 31 ].
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 room visits [ 32,33 ].

FOLLOW-UP VISIT — A follow-up visit can take place in the home

or clinical setting as long as the health care professional is competent
in assessing newborns and communicates the results of the
evaluation to the infant's physician.

The follow-up visit includes [ 26 ]:

 Assess the general health of the neonate — Weigh the infant,

assess for signs of dehydration and extent of jaundice,
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, child safety seats, and the
benefits of breastfeeding (if appropriate)
 Review results of outstanding laboratory tests including the
newborn screen
 Perform any necessary tests such as bilirubin check in an infant
with clinically significant jaundice
  Verifythe plan for health care maintenance and the medical
home
 Assess parental well-being including any indications of post-
partum depression in the mother (see "Postpartum blues and
depression" )

READMISSIONS — Despite enactment of the Newborns' and

Mothers' Health Protection Act, potentially preventable readmissions
of newborns continue to occur. This was illustrated in an analysis of
2540 newborns readmitted in the first 10 days of life who were
identified from clinical discharge records collected by the
Pennsylvania Health Care Cost Containment Council (PHC4) [ 34 ].
The following findings were noted:

 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.
 Multivariate analysis demonstrated that infants were more likely
to be readmitted with first-time compared to experienced
mothers, mothers of Asian or Pacific Islander ancestry
compared to other races, older mothers greater than 30 years
of age compared to younger mothers, or mothers with
diabetes or pregnancy-induced hypertension. In addition,
nursery length of stay less than <72 hours and prematurity
also increased the risk of readmission.

These results identified several predictors of newborn readmission

that appear to be associated with early discharge, inexperienced
parenting, difficulty establishing infant feeding, and in Asian and
Pacific Islander infants, who have an increased risk of
hyperbilirubinemia. These findings may be useful in providing
additional support for at-risk families and anticipatory care, thereby
decreasing the need for readmission.

SUMMARY AND RECOMMENDATIONS — Most newborn infants

make a successful transition to extrauterine life and require only
routine care immediately after birth.
 Immediately after an uncomplicated delivery, routine delivery
care includes drying the infant, clearing the airway of
secretions, and providing warmth. About 90 percent of infants
will not require further intervention in the delivery room, and
these infants should be given to their mothers for skin-to-skin
contact. (See 'Delivery room care' above.)
 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, and monitoring the
clinical status of the infant every 30 to 60 minutes to
determine whether further intervention is required.
(See 'Transitional period' above.)
 Routine care includes 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 during the first days of life. The
assessment includes a review of the maternal, family, and
prenatal history and a complete examination.
(See "Assessment of the newborn infant" .)
 We recommend that all neonates are treated with an
ophthalmic antibiotic agent shortly after birth to prevent
gonococcal conjunctivitis ( 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, and 2.5 percent povidone-
iodine solution. (See 'Eye care'above and "Gonococcal
infection in the newborn", section on 'Ophthalmia
neonatorum' .)
 We recommend that all neonates receive prophylactic
administration of vitamin K1 oxide to prevent Vitamin K
deficient bleeding (VKDB) ( Grade 1A). We recommend
intramuscular versus oral preparations of vitamin K because
of the superiority of the intramuscular route for prevention of
both early and late VKDB ( Grade 1C ). (See 'Vitamin
K' above.)
 We recommend hepatitis B vaccination (HBV) of all newborns
regardless of maternal hepatitis B virus surface antigen
(HBsAg) status to prevent HB infection ( Grade 1B ). We
recommend that infants of HBsAg-positive mothers receive
both hepatitis B immunoglobulin (HBIB) and HBV shortly after
 birth ( table 2 ) ( Grade 1A ). (See "Standard immunizations
for children and adolescents", section on 'Hepatitis B
vaccine' and "Hepatitis B virus vaccination" .)
 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" .)
 Routine care includes assessing infants for hyperbilirubinemia
and hypoglycemia, which may result in significant morbidity.
(See 'Glucose screening' above
and 'Hyperbilirubinemia' above.)
 Minimum criteria and conditions established by the American
Academy of Pediatrics should be met prior to discharge.
These include normal and stable vital signs for at least 12
hours before discharge, evidence of urination and defecation,
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.)
 In the United States, legislation requires insurance plans to
cover postpartum stays up to 48 hours for infants born by
vaginal deliveries and up to 96 hours for cesarean deliveries
with complications. (See 'Discharge legislation' above.)
 At discharge, a medical home should be identified and an
appropriately timed follow-up visit should be made. Infants
who are discharged before 48 hours after delivery should be
assessed within 48 hours, and no later than 72 hours after
discharge. The follow-up visit should be include assessment of
the general health of the infant, the infant-mother interaction,
parent's well-being, and infant behavior, verification of
ongoing health care, and parental education. (See 'Follow-up
visit' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate, Inc. would

like to acknowledge Dr. Lori Sielski, who contributed to an earlier
version of this topic review.

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