Introduction to Newborn Period

INTRODUCTION The newborn period is defined as the first 28 days of life. In practice, however, sick or very immature infants may require neonatal care for many months. There are four levels of newborn care. Level 1 refers to basic care of well newborns, neonatal resuscitation, and stabilization pri...

INTRODUCTION The newborn period is defined as the first 28 days of life. In practice, however, sick or very immature infants may require neonatal care for many months. There are four levels of newborn care. Level 1 refers to basic care of well newborns, neonatal resuscitation, and stabilization prior to transport. Level 2 refers to specialty neonatal care of premature infants greater than 1500 g or more than 32 weeks' gestation. Level 3 is subspecialty care of higher complexity neonates without limitations based on newborn size and gestational age. Level 4 includes availability of specialized pediatric surgery, cardiac surgery, and extracorporeal membrane oxygenation (ECMO). Level 4 care is often part of a perinatal center offering critical care and transport to the high­risk mother and fetus as well as the newborn infant. THE NEONATAL HISTORY The newborn medical history has three key components: 1. Maternalandpaternalmedicalandgenetichistory\ 2. Maternalpastobstetrichistory\ 3. Currentantepartumandintrapartumobstetrichistory The mother's medical history includes chronic medical conditions, medications taken during pregnancy, unusual dietary habits, smoking history, substance abuse history, occupational exposure to chemicals or infections of potential risk to the fetus, and any social history that might increase the risk for parenting problems and child abuse. Family illnesses and a history of congenital anomalies with genetic implications should be sought. The past obstetric history includes maternal age, gravidity, parity, blood type, and pregnancy outcomes. The current obstetric history includes the results of procedures during the current pregnancy such as ultrasound, amniocentesis, screening tests (rubella antibody, hepatitis B surface antigen \[HBsAg\], serum quadruple screen for genetic disorders, HIV \[human immunodeficiency virus\]), and antepartum tests of fetal well­being (eg, biophysical profiles, nonstress tests, or Doppler assessment of fetal blood flow patterns). Pregnancy­related maternal complications such as urinary tract infection, pregnancy­induced hypertension, eclampsia, gestational diabetes, vaginal bleeding, and preterm labor should be documented. Significant peripartum events include duration of ruptured membranes, maternal fever, fetal distress, meconium­stained amniotic fluid, type of delivery (vaginal or cesarean section), anesthesia and analgesia used, reason for operative or forceps delivery, infant status at birth, resuscitative measures, and Apgar scores. ASSESSMENT OF GROWTH & GESTATIONAL AGE It is important to know the infant's gestational age because normal behavior and possible medical problems can be predicted on this basis. The date of the last menstrual period is the best indicator of gestational age with early fetal ultrasound providing supporting information. Postnatal physical characteristics and neurologic development are also clues to gestational age. Table 2--1 lists the physical and neurologic criteria of maturity used to estimate gestational age by the Ballard method. Adding the scores assigned to each neonatal physical and neuromuscular sign yields a score corresponding to gestational age. New Ballard score for assessment of fetal maturation of newly born infants.a aSee text for a description of the clinical gestational age examination.\ Reproduced with permission from Ballard JL, Khoury JC, Wedig K, et al: New Ballard Score, expanded to include extremely premature infants. J Pediatr 1991 Sep;119(3):417--423. Birth weight and gestational age are plotted on standard grids to determine whether the birth weight is appropriate for gestational age (AGA), small for gestational age (SGA, also known as intrauterine growth restriction \[IUGR\]), or large for gestational age (LGA). Birth weight for gestational age in normal neonates varies with gender, race, maternal nutrition, access to obstetric care, and environmental factors such as altitude, smoking, and drug and alcohol use. Whenever possible, standards for newborn weight and gestational age based on local or regional data should be used. Birth weight related to gestational age is a screening tool that should be supplemented by clinical data when entertaining a diagnosis of IUGR or excessive fetal growth. These data include the infant's physical examination and other factors such as parental size and the birth weight--gestational age of siblings. An important distinction, particularly in SGA infants, is whether a growth disorder is symmetrical (weight, length, and occipitofrontal circumference \[OFC\] all ≤ 10%) or asymmetrical (only weight ≤ 10%). Asymmetrical growth restriction implies a problem late in pregnancy such as pregnancy­induced hypertension or placental insufficiency. Symmetrical growth restriction implies an event of early pregnancy: chromosomal abnormality, drug or alcohol use, or congenital viral infections. SGA infants, when compared with AGA infants of the same gestational age, have increased morbidity and mortality rates. In general, the outlook for normal growth and development is better in asymmetrically growth­restricted infants whose intrauterine brain growth has been spared. page2image143092080 Knowledge of birth weight in relation to gestational age allows anticipation of some neonatal problems. LGA infants are at risk for birth trauma. LGA infants of diabetic mothers (IDMs) are also at risk for hypoglycemia, polycythemia, congenital anomalies, cardiomyopathy, hyperbilirubinemia, and Downloaded 2022­9­19 5:26 P Your IP is 206.192.168.17 hypocalcemia. SGA infants are at risk for fetal distress during labor and delivery, polycythemia, hypoglycemia, and hypocalcemia. Chapter 2: The Newborn Infant, Danielle Smith **Page 2 / 75** ©2022 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility EXAMINATION AT BIRTH hypertension or placental insufficiency. Symmetrical growth restriction implies an event of early pregnancy: chromosomal abnormality, drug or irregularly irregular heart rate, usually caused by premature atrial contractions, is common, benign, and usually resolves in the first days of life. alcohol use, or congenital viral infections. SGA infants, when compared with AGA infants of the same gestational age, have increased morbidity and University of New Mexico mortality rates. In general, the outlook for normal growth and development is better in asymmetrically growth­restricted infants whose intrauterine Access Provided by: brain growth has been spared.\ Knowledge of birth weight in relation to gestational age allows anticipation of some neonatal problems. LGA infants are at risk for birth trauma. LGA page3image142979056 infants of diabetic mothers (IDMs) are also at risk for hypoglycemia, polycythemia, congenital anomalies, cardiomyopathy, hyperbilirubinemia, and hypocalcemia. SGA infants are at risk for fetal distress during labor and delivery, polycythemia, hypoglycemia, and hypocalcemia. EXAMINATION AT BIRTH The extent of the newborn physical examination depends on the condition of the infant and the setting. Examination in the delivery room consists largely of observation plus auscultation of the chest and inspection for congenital anomalies and birth trauma. Major congenital anomalies occur in 1.5% of live births and account for 20%--25% of perinatal and neonatal deaths. Because infants are physically stressed during parturition, the delivery room examination should not be extensive. The Apgar score (Table 2--2) should be recorded at 1 and 5 minutes of age. In severely depressed infants, scores can be recorded out to 20 minutes. Although the 1­ and 5­minute Apgar scores have almost no predictive value for long­term outcome, serial scores provide a useful description of the severity of perinatal depression and the response to resuscitative efforts. Table 2--2. Infant evaluation at birth---Apgar score.a aOne and 5 minutes after complete birth of the infant (disregarding the cord and the placenta), the following objective signs should be observed and recorded. bTested after the oropharynx is clear. Data from Apgar V, Holaday DA, James LS, et al: Evaluation of the newborn infant---second report. J Am Med Assoc 1958 Dec 13;168(15):1985--1988. Skin color is an indicator of cardiac output because of the normal high blood flow to the skin. Stress that triggers a catecholamine response redirects cardiac output away from the skin to preserve oxygen delivery to more critical organs. Cyanosis and pallor are thus two useful signs suggestive of inadequate cardiac output. Skeletal examination at delivery serves to detect obvious congenital anomalies and to identify birth trauma, particularly in LGA infants or those born after a protracted second stage of labor where a fractured clavicle or humerus might be found. The placenta and umbilical cord should be examined at delivery. The number of umbilical cord vessels should be determined. Normally, there are two arteries and one vein. In 1% of deliveries (5%--6% of twin deliveries), the cord has only one artery and one vein. This minor anomaly slightly increases the risk of associated defects. The placenta should be examined at delivery. Small placentas are always associated with small infants. The placental examination also includes identification of membranes and vessels (particularly in multiple gestations) as well as placental infarcts or clots (placental abruption) on the maternal side. EXAMINATION IN THE NURSERY The purpose of the newborn physical examination is to identify abnormalities or anomalies that might influence the infant's well­being and to evaluate  Downloaded 2022­9­19 5:26 P Your IP is 206.192.168.17 for any acute illness or difficulty in the transition from intrauterine to extrauterine life. The examiner should have warm hands and a gentle approach. Chapter 2: The Newborn Infant, Danielle Smith **Page 3 / 75** Start with observation, then auscultation of the chest, and then palpation of the abdomen. Examination of the eyes, ears, throat, and hips should be ©2022 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility\ performed last, as these maneuvers are most disturbing to the infant. The heart rate should range from 120 to 160 beats/min and the respiratory rate page3image142910608page3image142910400 from 30 to 60 breaths/min. Systolic blood pressure on day 1 ranges from 50 to 70 mm Hg and increases steadily during the first week of life. An examination also includes identification of membranes and vessels (particularly in multiple gestations) as well as placental infarcts or clots (placental page4image143060144 abruption) on the maternal side. EXAMINATION IN THE NURSERY University of New Mexico Access Provided by:  The purpose of the newborn physical examination is to identify abnormalities or anomalies that might influence the infant's well­being and to evaluate for any acute illness or difficulty in the transition from intrauterine to extrauterine life. The examiner should have warm hands and a gentle approach. Start with observation, then auscultation of the chest, and then palpation of the abdomen. Examination of the eyes, ears, throat, and hips should be performed last, as these maneuvers are most disturbing to the infant. The heart rate should range from 120 to 160 beats/min and the respiratory rate from 30 to 60 breaths/min. Systolic blood pressure on day 1 ranges from 50 to 70 mm Hg and increases steadily during the first week of life. An irregularly irregular heart rate, usually caused by premature atrial contractions, is common, benign, and usually resolves in the first days of life. Approximately 15%--20% of healthy newborns have one minor anomaly (a common variant that would not influence the infant's well­being, eg, a unilateral transverse palmar \[simian\] crease, or a single umbilical artery). Those with a minor anomaly have a 3% risk of an associated major anomaly. Approximately 0.8% of newborns have two minor anomalies, and 0.5% have three or more, with a risk of 10% and 20%, respectively, of also having a major malformation. Other common minor anomalies requiring no special investigation in healthy infants include preauricular pits, a shallow sacral dimple without other cutaneous abnormality within 2.5 cm of the anus, and three or fewer café au lait spots in a white infant or five or fewer in an African­American infant. Skin Observe for bruising, petechiae (common over the presenting part), meconium staining, and jaundice. Visible jaundice in the first 24 hours is never normal, and generally indicates either a hemolytic process or a congenital hepatitis, either of which requires further evaluation. Peripheral cyanosis is commonly present when the extremities are cool or the infant is polycythemic. Generalized cyanosis merits immediate evaluation. Pallor may be caused by acute or chronic blood loss or by acidosis. In dark­skinned infants, pallor and cyanosis should be assessed in the lips, mouth, and nail beds. Plethora suggests polycythemia. Dry skin with cracking and peeling of the superficial layers is common in postterm infants. Edema may be generalized (hydrops) or localized (eg, on the dorsum of the feet in Turner syndrome). Check for birthmarks such as capillary hemangiomas and mongolian spots (bluish­black pigmentation over the back and buttocks). There are many benign skin eruptions such as milia, miliaria, erythema toxicum, and pustular melanosis that are present in the newborn period. See Chapter 15 for a more in­depth description of these conditions. Head Check for cephalohematoma (a swelling over one or both parietal bones that is contained within suture lines) and caput succedaneum (edema of the scalp over the presenting part that crosses suture lines). Subgaleal hemorrhages (beneath the scalp) are uncommon but can cause extensive blood loss into this large potential space, resulting in hypovolemic shock. Skull fractures may be linear or depressed and may be associated with cephalohematoma. Check for the presence and size of the fontanelles. The anterior fontanelle varies from 1 to 4 cm in any direction; the posterior fontanelle should be less than 1 cm. A third fontanelle is a bony defect along the sagittal suture in the parietal bones and may be seen in genetic syndromes, such as trisomy 21. Sutures should be freely mobile but are often overriding just after birth. Craniosynostosis, a prematurely fused suture causing an abnormal cranial shape, is more easily diagnosed a few days or more after birth. Face Unusual facies may be associated with a specific syndrome. Bruising from birth trauma (especially with face presentation) and forceps application should be identified. Face presentation may cause soft tissue swelling around the nose and mouth and significant facial distortion. Facial nerve palsy is most obvious during crying; the unaffected side of the mouth moves normally, giving an asymmetric grimace. Eyes Subconjunctival hemorrhages are a frequent result of birth trauma. Less commonly, a corneal tear (presenting as a clouded cornea), or a hyphema (a layering of blood in the anterior chamber of the eye) may occur. Ophthalmologic consultation is indicated in such cases. Extraocular movements should be assessed. Occasional uncoordinated eye movements are common, but persistent irregular movements are abnormal. The iris should be inspected for abnormalities such as speckling (Brushfield spots seen in trisomy 21) and colobomas. Retinal red reflexes should be present and symmetrical. Dark spots, unilateral blunted red reflex, absent reflex, or a white reflex all require ophthalmologic evaluation. Leukokoria can be caused by glaucoma (cloudy cornea), cataract, or tumor (retinoblastoma). Infants with suspected or known congenital viral infection should have a retinoscopic examination with pupils dilated to look for chorioretinitis. Nose page4image143054320 Downloaded 2022­9­19 5:26 P Your IP is 206.192.168.17\ ECxhaamptinere2th: eThneosNeefworbsoirzne Iannfadnsth, aDpaen.iIenlleutSermoitchompression can cause deformities. Because infants younger than 1 month are obligate nose**P**b**a**r**g**ea**4**th**/**e**7**r**5**s, ©2022 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility\ any nasal obstruction (eg, bilateral choanal atresia or stenosis) can cause respiratory distress. Unilateral choanal atresia can be diagnosed by occluding each naris, although patency is best checked by holding a cold metal surface or small mirror under the nose, and observing the fog from both nares. Purulent nasal discharge at birth suggests congenital syphilis ("snuffles"). should be assessed. Occasional uncoordinated eye movements are common, but persistent irregular movements are abnormal. The iris should be inspected for abnormalities such as speckling (Brushfield spots seen in trisomy 21) and colobomas. Retinal red reflexes should be present and symmetrical. Dark spots, unilateral blunted red reflex, absent reflex, or a white reflex all require ophthalmologic evaluation. Leukokoria can be caused Access Provided by: by glaucoma (cloudy cornea), cataract, or tumor (retinoblastoma). Infants with suspected or known congenital viral infection should have a retinoscopic examination with pupils dilated to look for chorioretinitis.  Nose Examine the nose for size and shape. In utero compression can cause deformities. Because infants younger than 1 month are obligate nose breathers, any nasal obstruction (eg, bilateral choanal atresia or stenosis) can cause respiratory distress. Unilateral choanal atresia can be diagnosed by occluding each naris, although patency is best checked by holding a cold metal surface or small mirror under the nose, and observing the fog from both nares. Purulent nasal discharge at birth suggests congenital syphilis ("snuffles"). Ears Malformed or malpositioned (low­set or posteriorly rotated) ears are often associated with other congenital anomalies. Preauricular pits and tags are common minor variants, and may be familial. Any external ear abnormality may be associated with hearing loss. Mouth Epithelial (Epstein) pearls are benign retention cysts along the gum margins and at the junction of the hard and soft palates. Natal teeth may be present and sometimes must be removed to prevent their aspiration. Check the integrity and shape of the palate for clefts and other abnormalities. A small mandible and retraction of the tongue with cleft palate is seen with Pierre Robin sequence and can present as respiratory difficulty, as the tongue occludes the airway; prone positioning can be beneficial. A prominent tongue can be seen in trisomy 21 and Beckwith­Wiedemann syndrome. Excessive oral secretions suggest esophageal atresia or a swallowing disorder. Neck Redundant neck skin or webbing, with a low posterior hair line, is seen in Turner syndrome. Cervical sinus tracts may be seen as remnants of branchial clefts. Check for masses: midline (thyroglossal duct cysts), anterior to the sternocleidomastoid (branchial cleft cysts), within the sternocleidomastoid (hematoma and torticollis), and posterior to the sternocleidomastoid (cystic hygroma). Chest & Lungs Check for fractured clavicles (crepitus, bruising, and tenderness). Check air entry bilaterally and the position of the mediastinum by locating the point of maximum cardiac impulse and assessment of heart tones. Decreased breath sounds with respiratory distress and a shift in the heart tones suggests pneumothorax (tension) or a space­occupying lesion (eg, diaphragmatic hernia). Pneumomediastinum causes muffled heart sounds. Expiratory grunting and decreased air entry are observed in hyaline membrane disease. Rales are not of clinical significance at this age. Heart Cardiac murmurs are common in the first hours and are most often benign; conversely, severe congenital heart disease in the newborn infant may be present with no murmur at all. The two most common presentations of heart disease in the newborn infant are (1) cyanosis and (2) congestive heart failure with abnormalities of pulses and perfusion. In hypoplastic left­sided heart and critical aortic stenosis, pulses are diminished at all sites. In aortic coarctation and interrupted aortic arch, pulses are diminished in the lower extremities. Abdomen Check for tenderness, distention, and bowel sounds. If polyhydramnios was present or excessive oral secretions are noted, pass a soft catheter into the stomach to rule out esophageal atresia. Most abdominal masses in the newborn infant are associated with kidney disorders (eg, multicystic or dysplastic, and hydronephrosis). When the abdomen is relaxed, normal kidneys may be felt but are not prominent. A markedly scaphoid abdomen plus respiratory distress suggests diaphragmatic hernia. Absence of abdominal musculature (prune belly syndrome) may occur in association with renal abnormalities. The liver and spleen are superficial in the neonate and can be felt with light palpation. A distended bladder may be seen as well as palpated above the pubic symphysis. Genitalia & Anus Male and female genitals show characteristics according to gestational age (see Table 2--1). In the female infant during the first few days, a whitish vaginal discharge with or without blood is normal. Check the patency and location of the anus. Downloaded 2022­9­19 5:26 P Your IP is 206.192.168.17 Chapter 2: The Newborn Infant, Danielle Smith **Page 5 / 75** Skeleton ©2022 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility University of New Mexico Check for obvious anomalies such as absence of a bone, clubfoot, fusion or webbing of digits, and extra digits. Examine for hip dislocation by attempting to dislocate the femur posteriorly and then abducting the legs to relocate the femur noting a clunk as the femoral head relocates. Look for abnormalities. The liver and spleen are superficial in the neonate and can be felt with light palpation. A distended bladder may be seen as well as Screening for critical congenital heart disease is standard practice in newborn nurseries. The goal of screening is to identify newborn infants with palpated above the pubic symphysis. Genitalia & Anus University of New Mexico Access Provided by: page6image142759200 Male and female genitals show characteristics according to gestational age (see Table 2--1). In the female infant during the first few days, a whitish vaginal discharge with or without blood is normal. Check the patency and location of the anus. Skeleton Check for obvious anomalies such as absence of a bone, clubfoot, fusion or webbing of digits, and extra digits. Examine for hip dislocation by attempting to dislocate the femur posteriorly and then abducting the legs to relocate the femur noting a clunk as the femoral head relocates. Look for extremity fractures and for palsies (especially brachial plexus injuries) and evidence of spinal deformities (eg, scoliosis, cysts, sinuses, myelomeningocele). Arthrogryposis (multiple joint contractures) results from chronic limitation of movement in utero that may result from lack of amniotic fluid or from congenital neuromuscular disease. Neurologic Examination Normal newborns have reflexes that facilitate survival (eg, rooting and sucking reflexes), and sensory abilities (eg, hearing and smell) that allow them to recognize their mother soon after birth. Although the retina is well developed at birth, visual acuity is poor (20/400) because of a relatively immobile lens. Acuity improves rapidly over the first 6 months, with fixation and tracking becoming well developed by 2 months. Observe the newborn's resting tone. Normal­term newborns should exhibit flexion of the upper and lower extremities and symmetrical spontaneous movements. Extension of the extremities should result in spontaneous recoil to the flexed position. Assess the character of the cry; a high­pitched cry with or without hypotonia may indicate disease of the central nervous system (CNS) such as hemorrhage or infection, a congenital neuromuscular disorder, or systemic disease. Check the following newborn reflexes: 1. Suckingreflex:Thenewbornsucksinresponsetoanippleinthemouth;observedby14weeks'gestation.\ 2. Palmargrasp:Evidentwiththeplacementoftheexaminer'sfingerinthenewborn'spalm;developsby28weeks'gestationanddisappearsbyage4 months. 3. Moro(startle)reflex:Holdtheinfantsupinewhilesupportingthehead.Allowtheheadtodrop1--2cmsuddenly.Thearmswillabductatthe shoulder and extend at the elbow with spreading of the fingers. Adduction with flexion will follow. This reflex develops by 28 weeks' gestation (incomplete) and disappears by age 3 months. CARE OF THE WELL NEONATE The primary responsibility of the level 1 nursery is care of the well neonate---promoting mother--infant bonding, establishing feeding, and teaching the basics of newborn care. Staff must monitor infants for signs and symptoms of illness, including temperature instability, change in activity, refusal to feed, pallor, cyanosis, early or excessive jaundice, tachypnea, respiratory distress, delayed (beyond 24 hours) first stool or first void, and bilious vomiting. Several preventive measures are routine in the normal newborn nursery. Prophylactic erythromycin ointment is applied to the eyes within 1 hour of birth to prevent gonococcal ophthalmia. Vitamin K (1 mg) is given intramuscularly or subcutaneously within 4 hours of birth to prevent hemorrhagic disease of the newborn. All infants should receive hepatitis B vaccine. Both hepatitis B vaccine and hepatitis B immune globulin (HBIG) are administered if the mother is positive for HBsAg. If maternal HBsAg status is unknown, vaccine should be given before 12 hours of age, maternal blood should be tested for HBsAg, and HBIG should be given to the neonate before 7 days of age if the test is positive. Cord blood is collected from all infants at birth and can be used for blood typing and Coombs testing if the mother is type O or Rh­negative to help assess the risk for development of jaundice. Bedside glucose testing should be performed in infants at risk for hypoglycemia (IDMs, preterm, SGA, LGA, or stressed infants). Values below 45 mg/dL should be confirmed by laboratory blood glucose testing and treated. Hematocrit should be measured at age 3--6 hours in infants at risk for or those who have symptoms of polycythemia or anemia (see section Hematologic Disorders in the Newborn Infant). State­sponsored newborn genetic screens (for inborn errors of metabolism such as phenylketonuria \[PKU\], galactosemia, sickle cell disease, hypothyroidism, congenital adrenal hyperplasia, and cystic fibrosis) are performed prior to discharge, after 24--48 hours of age if possible. In many Downloaded 2022­9­19 5:26 P Your IP is 206.192.168.17 states, a repeat test is required at 8--14 days of age because the PKU test may be falsely negative when obtained before 48 hours of age. Not all state­ Chapter 2: The Newborn Infant, Danielle Smith **Page 6 / 75** mandated screens include the same panel of diseases. Many states now include an expanded screen that tests for other inborn errors of metabolism Bedside glucose testing should be performed in infants at risk for hypoglycemia (IDMs, preterm, SGA, LGA, or stressed infants). Values below 45 mg/dL should be confirmed by laboratory blood glucose testing and treated. Hematocrit should be measured at age 3--6 hours in infants at risk for or those Access Provided by: who have symptoms of polycythemia or anemia (see section Hematologic Disorders in the Newborn Infant).\ State­sponsored newborn genetic screens (for inborn errors of metabolism such as phenylketonuria \[PKU\], galactosemia, sickle cell disease, page7image142643680 As long as the mother is comfortable, nurse at both breasts as long as baby is actively sucking. Try to nurse both sides each feeding, aiming at 10 min per side. Expect some nipple tenderness. Consider hand expressing or pumping a few drops of milk to soften the nipple if the breast is too firm for the baby to latch on. University of New Mexico  hypothyroidism, congenital adrenal hyperplasia, and cystic fibrosis) are performed prior to discharge, after 24--48 hours of age if possible. In many states, a repeat test is required at 8--14 days of age because the PKU test may be falsely negative when obtained before 48 hours of age. Not all state­ mandated screens include the same panel of diseases. Many states now include an expanded screen that tests for other inborn errors of metabolism such as fatty acid oxidation defects and amino or organic acid disorders. Some states also screen for severe combined immunodeficiency syndrome. Screening for critical congenital heart disease is standard practice in newborn nurseries. The goal of screening is to identify newborn infants with structural heart disease significant enough to require intervention within the first year of life prior to symptoms developing. Newborn infants are screened by pulse oximetry on the second day of life. Infants that screen positive are evaluated by echocardiogram prior to hospital discharge. Infants should routinely be positioned supine to minimize the risk of sudden infant death syndrome (SIDS). Prone positioning is contraindicated unless there are compelling clinical reasons for that position. Bed sharing with adults and prone positioning are associated with increased risk of SIDS. FEEDING THE WELL NEONATE A neonate is ready for feeding if he or she (1) is alert and vigorous, (2) has no abdominal distention, (3) has good bowel sounds, and (4) has a normal hunger cry. These signs usually occur within 6 hours after birth, but fetal distress or traumatic delivery may prolong this period. The healthy full­term infant should be allowed to feed every 2--5 hours on demand. EARLY DISCHARGE OF THE NEWBORN INFANT Discharge at 24--36 hours of age is safe and appropriate for some newborns if there are no contraindications (Table 2--4) and if a follow­up visit within 48 hours is ensured. Most infants with cardiac, respiratory, or infectious disorders are identified in the first 12--24 hours of life. The exception may be the infant for whom maternal intrapartum antibiotic prophylaxis for maternal group B streptococcal (GBS) colonization or infection was indicated. The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend that such infants be observed in hospital for at least 48 hours if their mothers received no or inadequate intrapartum antibiotic prophylaxis, or cefazolin. Hospital observation beyond 24 hours may not be necessary for well appearing full­term infants whose mothers received adequate intrapartum chemoprophylaxis and for whom ready access to medical care can be ensured if needed. Other problems, such as jaundice and breast­feeding problems, typically occur after 48 hours and can usually be dealt with on an outpatient Contraindications to early newborn discharge. Contraindications to early newborn discharge 1\. Jaundice ≤ 24 h\ 2. High risk for infection (eg, maternal chorioamnionitis); discharge allowed after 24 h with a normal transition 3. Known or suspected narcotic addiction or withdrawal\ 4. Physical defects requiring evaluation\ 5. Oraldefects(clefts,micrognathia) Relative contraindications to early newborn discharge (infants at high risk for feeding failure, excessive jaundice) 1\. Prematurity or early­term infant (\< 38 weeks' gestation) 2\. Birthweight\