Newborn examination, essential newborn care and kangaroo care

Overview

The neonatal period is the first 28 days of life. The early neonatal period is the first 7 days and the late neonatal period runs from day 8 to day 28. Most neonatal deaths happen in the first week, so the first examination and the first hours of care matter most.

Every newborn needs a short check at birth, a full examination within the first day, and a simple package of essential newborn care. This chapter covers what is normal, what is not, and the routine care given to every baby.

Classification of newborns

Average birth weight is about 3.2 kg. Full details are in the prematurity and low birth weight chapter.

History before the examination

• Antenatal: maternal age and parity, diabetes, hypertension, infections, tetanus vaccination, smoking, scans, liquor volume (oligohydramnios or polyhydramnios).
• Labour and delivery: gestation, rupture of membranes for more than 18 hours, maternal fever, meconium-stained liquor, mode of delivery, presentation, drugs and anaesthesia given to the mother.
• At birth: did the baby cry at once, Apgar scores at 1 and 5 minutes, any resuscitation.
• Family: consanguinity, previous neonatal deaths, jaundice needing exchange in a sibling, congenital anomalies.

Doing the examination

Wash hands, keep the room warm (about 25-28°C), undress the baby fully and work quickly so the baby does not get cold. Measure weight, length and head circumference and plot them. Estimate gestational age (rapid visual signs or the Ballard score).

Normal vital signs

Head-to-toe checklist

Primitive reflexes

• The Moro reflex appears at about 28 weeks of gestation.
• An asymmetrical Moro suggests Erb palsy, a fractured clavicle or humerus, or hemiplegia.
• An absent Moro suggests a floppy or very ill baby; persistence of primitive reflexes beyond 4-6 months suggests neurological damage.

Common benign findings in the first days

• Most newborns pass urine within 24 hours (Nelson: more than 95% on the first day) and meconium within 48 hours (Nelson: 99% of term babies). A baby who passes no stool in the first 24 hours needs watching for Hirschsprung disease or other obstruction.

Temperature control

The newborn loses heat fast because of a large surface area, a wet skin at birth and little fat. Heat is lost in four ways:

• Neutral thermal environment: the surrounding temperature at which the baby keeps a normal core temperature with the least oxygen use and heat production.
• Term babies make heat from brown fat (around the scapulae and kidneys) under sympathetic control; they cannot shiver effectively.
• Hypothermia is a core temperature below 36°C. It causes poor feeding, lethargy, bradycardia, hypoglycaemia, metabolic acidosis, sclerema, DIC and death. Preterm, SGA and asphyxiated babies are at most risk.
• Rewarming should be slow, about 0.6-1.0°C per hour, under a radiant warmer, in an incubator or by skin-to-skin contact.
• Prevention: dry the baby (especially the head), cover with a dry cloth and cap, skin-to-skin contact, keep the delivery room warm, and delay the first bath for at least 6-24 hours; early bathing is a common cause of neonatal hypothermia.

Essential newborn care

Immediate steps at birth

1. Dry the baby thoroughly and remove the wet cloth.
2. Assess breathing; if breathing well, place the baby skin-to-skin on the mother's chest and cover both.
3. Clamp and cut the cord with clean instruments.
4. Start breastfeeding within the first hour.
5. Give vitamin K, eye care and birth vaccines; weigh and examine the baby.

Breastfeeding

• Start within the first hour; give colostrum, the thick yellowish first milk, which is rich in antibodies.
• Feed on demand, day and night, at least 8 times in 24 hours.
• Exclusive breastfeeding until about 6 months, then add complementary foods and continue breastfeeding to 2 years or beyond.
• Breast milk is the best food for both term and preterm babies.
• Signs of not getting enough milk: weight loss above 10%, few wet nappies, few stools, feeds fewer than 8 times a day.
• Term babies who are exclusively breastfed need vitamin D 400 IU a day.

Vitamin K

• Newborns are born with low vitamin K: little crosses the placenta, the gut has no bacteria to make it, and breast milk contains little.
• Without it, factors II, VII, IX and X fall, causing vitamin K deficiency bleeding (haemorrhagic disease of the newborn).
• Dose: 1 mg IM at birth to every newborn. If the oral route is used, three doses are needed (birth, discharge and 3-4 weeks).
• Forms of bleeding:

• PT and APTT are prolonged; platelets, fibrinogen and bleeding time are normal.
• Treatment of a bleeding baby: IV vitamin K at once (do not wait for results); fresh frozen plasma for serious bleeding.

Cord care

• Clean hands, clean blade and a clean tie at delivery.
• Keep the stump clean and dry; nothing should be applied in hospital births with good hygiene (dry cord care).
• In home births and resource-limited settings, chlorhexidine digluconate applied to the stump once a day for 7 days reduces cord infection (omphalitis). Check the current national guideline for the preparation used.
• Traditional applications (ghee, ash, dung) increase the risk of omphalitis and neonatal tetanus.
• Danger signs: redness spreading to the skin or pus from the umbilicus.

Vaccination at birth

• BCG (intradermal, right upper arm) and OPV-0 are given at birth under the Pakistan EPI.
• Hepatitis B vaccine 0.5 mL IM is given at birth. If the mother is HBsAg positive, also give HBIG 0.5 mL IM at a separate site, ideally within 12 hours of birth.
• Pakistan's national schedule gives BCG, OPV-0 and hepatitis B at birth (National Immunization Policy 2022, checked 6 November 2026).

Other routine care

• If the mother is blood group O or Rh negative, check the baby's group and direct Coombs test; an Rh-negative mother of an Rh-positive baby needs anti-D.
• Lay babies on their back to sleep.
• Teach the mother the danger signs: not feeding well, convulsions, fast breathing (60 or more per minute), severe chest indrawing, fever (37.5°C or more), low temperature (below 35.5°C), moving only when stimulated, jaundice in the first day or of palms and soles, red or pus-draining umbilicus.

Kangaroo mother care

Kangaroo mother care (KMC) means holding the baby skin-to-skin upright on the mother's bare chest, with both covered together.

• Warmth: the mother's body heat keeps the baby warm. Akbar recommends KMC for a baby who does not need active resuscitation, and the same kangaroo technique for rewarming a cold child.
• Feeding: the baby stays at the breast, so breastfeeding starts early and goes well.
• Bonding: closeness strengthens the bond between mother and baby.
• Best suited to small but stable babies who breathe on their own, especially low birth weight babies (Park); it can carry on at home after discharge.

The four components of KMC (Park):

1. Skin-to-skin positioning of the baby on the mother's chest.
2. Nutrition through breastfeeding.
3. Earlier discharge with care continuing at home.
4. Support for the mother and family in caring for the baby.

• It is not for unstable babies who need resuscitation, ventilation or close monitoring under a warmer or in an incubator.

Quick revision

• Neonatal period 28 days; early neonatal 7 days.
• Normal RR 40-60/min; HR 100-150/min; axillary temperature 36.5-37.2°C.
• Weight loss up to 10%, regained by about day 10.
• Caput crosses sutures; cephalhaematoma does not and can cause jaundice.
• Vitamin K 1 mg IM at birth; classic bleeding days 2-7; PT and APTT long, platelets normal.
• Cord: clean and dry; chlorhexidine in home or resource-limited births.
• Birth vaccines: BCG, OPV-0, hepatitis B (plus HBIG if mother HBsAg positive).
• Breastfeed within 1 hour, on demand, exclusively to 6 months.
• KMC: skin-to-skin on the mother's chest, covered together; warmth, breastfeeding, bonding; stable small babies.

Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics; Park's Textbook of Preventive and Social Medicine).

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