Pediatrics

Newborn

The first 28 days have their own rules: the history starts before birth, jaundice is a bilirubin-and-time question with a treatment threshold, and fever means the full evaluation however well the baby looks.

The history before birth

Which details matter for this presentation?

A 10-day-old, sleepy, feeding less for a day, temperature 36.1.

Choose the history domains that matter most for this presentation (the expert chose 6), then commit.

The examination, shown

Newborn Exam by N. Gold

OPENPediatrics (Boston Children's Hospital) · embedded with attribution; their teaching, not ours

The complete newborn examination, head to toe, with what is normal and what is not.

Watch for

The order of the examination and why it starts with observation
Fontanelles, sutures and the shape of the head
The hips, the femoral pulses and the red reflex

Watch on YouTube

Assessing Newborn Primitive Reflexes by N. Gold

OPENPediatrics (Boston Children's Hospital) · embedded with attribution; their teaching, not ours

Moro, grasp, rooting, sucking and stepping: how each is elicited and what an absent or asymmetric reflex means.

Watch for

How the Moro is elicited safely
Asymmetry as the finding that matters
When each reflex should disappear

Watch on YouTube

How to Test for Newborn Hip Dysplasia by N. Gold

OPENPediatrics (Boston Children's Hospital) · embedded with attribution; their teaching, not ours

The Ortolani and Barlow manoeuvres, one hip at a time, with the hand position that makes them reliable.

Watch for

The hand position on the thigh
The difference between a click and a clunk
Who needs an ultrasound regardless of the examination

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Jaundice

Timing, fraction, threshold

Under 24 hours

Never physiological: hemolysis (ABO or Rh incompatibility, G6PD deficiency, spherocytosis) or sepsis until proven otherwise. Bilirubin now, blood group and direct antiglobulin test, full count and reticulocytes.

Days 2 to 5

Physiological jaundice peaks here in term infants: immature conjugation, a high red cell mass, and enterohepatic recirculation. Still measured, still plotted; breastfeeding jaundice from insufficient intake sits in the same window and is treated with feeding.

Beyond 14 days (21 in the preterm)

Prolonged jaundice needs a split bilirubin. Unconjugated and thriving is usually breast milk jaundice, a diagnosis of exclusion after hypothyroidism, infection and hemolysis are considered. Any raised conjugated fraction is a liver question, and pale stools with dark urine is biliary atresia until an ultrasound and hepatology say otherwise.

Unconjugated

Unconjugated (indirect) bilirubin crosses the blood-brain barrier and, at high levels, causes acute bilirubin encephalopathy and kernicterus. Its causes are production (hemolysis, bruising, polycythemia), clearance (prematurity, hypothyroidism, breast milk) and recirculation (poor intake, delayed stooling).

Conjugated

Conjugated (direct) bilirubin is water-soluble, does not cause kernicterus, and is never normal: obstruction (biliary atresia, choledochal cyst), hepatitis (infection, metabolic disease, parenteral nutrition) or sepsis. A conjugated fraction above about 34 µmol/L, or above 20 percent of the total, is the trigger.

Risk factors for significant hyperbilirubinemia

Gestational age under 38 weeks (the risk rises with each week earlier)
Isoimmune or other hemolytic disease, G6PD deficiency
A sibling who needed phototherapy
Exclusive breastfeeding with poor intake or excessive weight loss
Cephalhematoma or significant bruising
East Asian ancestry
Jaundice in the first 24 hours

The approach

Measure (transcutaneous, confirmed by serum when high) at the age in hours; visual estimation is unreliable in every skin tone and worse in darker skin
Plot the total serum bilirubin on the hour-specific nomogram for the infant's gestation and risk group; the phototherapy and exchange thresholds are read off the chart, never remembered
Assess feeding, weight loss and output; intake is treatment
Phototherapy converts bilirubin to excretable isomers; intravenous immunoglobulin for isoimmune hemolysis; exchange transfusion for levels at the exchange threshold or any sign of encephalopathy
Follow up after discharge: the peak is after most babies have gone home

Acute bilirubin encephalopathy: Acute bilirubin encephalopathy: lethargy and poor feeding, then a high-pitched cry, hypertonia with retrocollis and opisthotonus, fever, and seizures. An emergency exchange transfusion is indicated on clinical signs regardless of the number.

Basis: Canadian Paediatric Society guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborns; AAP 2022 revision for the risk-based threshold approach. Threshold values are read from the hour-specific nomogram in use at your institution and are deliberately not reproduced here.

The newborn examination

Head to toe, hips and femorals included

General

Colour, tone, posture, activity, cry, dysmorphic features, weight, length and head circumference plotted

Head

Fontanelles (full, sunken, size), sutures, caput and cephalhematoma, the red reflex in both eyes, the ears and their position, the palate by finger and by light

Chest

Respiratory rate and effort (grunting, flaring, retractions), air entry, heart sounds and murmurs, and the femoral pulses, every time

Abdomen

Distension, the umbilicus, liver and spleen edges, masses, the anus (patent, positioned), and the genitalia (testes descended, hypospadias, ambiguity)

Hips

Ortolani and Barlow manoeuvres; a breech birth or family history triggers an ultrasound

Spine and limbs

Sacral dimples or tufts, digits, palmar creases, clavicles, talipes

Neurology

Tone, symmetry of movement, the Moro, suck and grasp reflexes, alertness

Skin

Jaundice (measured, not eyeballed), birthmarks, vesicles, petechiae, mottling

Infection in the newborn

Early-onset (under 72 hours): group B streptococcus and E. coli from the birth canal; risk factors are maternal colonization without adequate prophylaxis, prolonged rupture of membranes, maternal fever, prematurity
Late-onset (after 72 hours): the same organisms plus Listeria, Staphylococcus, and hospital organisms in the preterm
The signs are non-specific: temperature instability (cold as often as hot), poor feeding, lethargy, apnea, tachypnea, jaundice, a full fontanelle
The evaluation is complete (blood, urine, cerebrospinal fluid) and the antibiotics are empiric and immediate; herpes simplex is added when vesicles, seizures, a maternal history or a raised alanine aminotransferase point to it

Hypoglycemia

At risk: small and large for gestational age, preterm, infants of diabetic mothers, the unwell or hypothermic, the poorly feeding
Signs are jitteriness, hypotonia, apnea, seizures, or nothing at all; screen the at-risk before the first feed is late
The Canadian Paediatric Society screening statement uses an intervention threshold around 2.6 mmol/L in the at-risk infant after the first hours; feed, then dextrose gel or intravenous dextrose if not corrected
Persistent hypoglycemia beyond the first days is a hyperinsulinism or endocrine question

Weight in the first weeks

Term infants lose up to about 7 percent of birth weight in the first days, mostly water; more than 10 percent is a feeding assessment
Birth weight is regained by 10 to 14 days; the expected gain after that is roughly 20 to 30 grams a day in the first months
Weight, wet diapers and stools are the three numbers of a feeding review

Respiratory distress in the newborn

Transient tachypnea of the newborn (retained lung fluid, especially after caesarean), respiratory distress syndrome of prematurity (surfactant), meconium aspiration, pneumonia and sepsis, pneumothorax, and the congenital heart lesion presenting as breathlessness
Grunting is the newborn's own positive end-expiratory pressure and is always significant
Saturation in the right hand versus a foot (pre- and post-ductal) screens for duct-dependent heart disease

Newborn screening

The blood spot at 24 to 72 hours screens for hypothyroidism, phenylketonuria and other metabolic diseases, cystic fibrosis, hemoglobinopathies and more, by provincial panel
Hearing screening before discharge; the critical congenital heart disease pulse oximetry screen at 24 to 36 hours
A screen is a screen: a positive result needs confirmation, and the family needs the call the same day

Newborn cases

Eighteen days old, warm, and not interested in feeding18 days old · A term newborn's parents bring him in because he feels hot and has slept through two feeds. He looks all right in the waiting room.Still yellow at three weeks22 days old · A breastfed 3-week-old is thriving but has never lost her jaundice. The health visitor sends her in 'just to check'.

The adult frame, for contrast

ApproachJaundice in the adult frame FluidBacterial CSF, read