Learn — Neonatal nursing

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Neonatal period definition

The neonatal period is the first 28 completed days of life, counted from the moment of birth, and it is divided into an early period of the first 7 days and a late period from day 7 to day 28. It carries more risk than any other 28 days of childhood, so almost every Indian newborn programme, mortality indicator and home-visit schedule is built around this definition.

Early neonatal period is birth to 7 days and late neonatal period is 7 to 28 days; roughly three-quarters of all neonatal deaths occur in the early period, and most of those in the first 24 hours.
About two-thirds of deaths in the first year of life happen within the neonatal period, which is why reducing infant mortality now depends almost entirely on newborn care.
Neonatal mortality rate is the number of neonatal deaths per 1000 live births; the perinatal period runs from 28 weeks of gestation to 7 days after birth and the perinatal mortality rate counts stillbirths plus early neonatal deaths per 1000 total births.
Post-neonatal mortality covers 28 days to 1 year, infant mortality rate covers deaths under 1 year per 1000 live births, and under-five mortality rate covers deaths under 5 years per 1000 live births.
The leading causes of neonatal death in India are prematurity and low birth weight, birth asphyxia and birth trauma, and infections including sepsis, pneumonia and tetanus, followed by congenital anomalies.
Gestational age definitions used alongside it: preterm is birth before 37 completed weeks, term is 37 to under 42 weeks and post-term is 42 weeks and beyond; low birth weight is under 2500 g whatever the gestation.
Home-based newborn care by the ASHA is scheduled to this period. Under the Samagra Shishu Bal Swasthya Karyakram (SSBSK, 2026), which merged HBNC and HBYC, a healthy newborn gets 4 visits on days 3, 7, 14 and 42, with an extra day 1 visit after a home delivery, and an at-risk newborn gets 9 visits on days 1, 3, 5, 7, 10, 14, 21, 28 and 42.
Facility-Based Newborn Care is tiered to it as well: a newborn care corner at every delivery point, a newborn stabilisation unit at the community health centre or first referral unit, and a special newborn care unit at the district hospital.
Sustainable Development Goal 3.2 sets the targets these indicators are measured against — a neonatal mortality rate of 12 or fewer and an under-five mortality rate of 25 or fewer per 1000 live births by 2030.

Kangaroo Mother Care (KMC)

Kangaroo mother care is the care of a low birth weight or preterm baby held continuously skin to skin, upright and prone, on the mother's bare chest, with exclusive breast milk feeding and planned early discharge with follow-up. It is not comfort care but treatment: it holds the baby's temperature, steadies heart rate and breathing, improves breastfeeding and weight gain, and reduces newborn deaths and infections more cheaply than any incubator.

The three components are continuous skin-to-skin contact, exclusive feeding with breast milk, and early discharge with structured follow-up; a mother, father or any consenting adult family member can provide the contact.
WHO now recommends starting kangaroo mother care immediately after birth for all preterm and low birth weight babies, without waiting for an initial period of stabilisation, and continuing it for as long as possible each day.
A session shorter than an hour is counted as unhelpful because the handling itself stresses the baby, so each session should last at least 1 hour and the daily total should be as close to continuous as the family can manage.
Position: the baby wears only a nappy, cap and socks, is placed upright between the breasts chest to chest, the head turned to one side and slightly extended in the sniffing position to keep the airway open, hips flexed and abducted like a frog and the arms flexed.
The baby is secured with a cloth binder whose upper border passes just under the ear, and the mother reclines at about 15 to 30 degrees when she sleeps rather than lying flat.
Babies over about 1800 g can usually start within hours of birth; smaller babies start as soon as they can be handled safely, and a baby needing ventilation or on inotropes waits until that support allows it.
Feeding during kangaroo mother care is expressed breast milk by paladai, spoon or tube, moving to direct breastfeeding as suck and swallow mature, usually with two-hourly feeds and daily weighing.
Expected weight gain is about 15 to 20 g per kg per day, and discharge from a kangaroo mother care ward requires stable temperature in the kangaroo position, good feeding, that weight gain sustained over about 3 consecutive days, no infection and a confident mother.
Documented benefits are lower neonatal mortality, less sepsis and hypothermia, less hypoglycaemia and apnoea, higher rates and longer duration of breastfeeding, shorter hospital stay, better neurodevelopment and stronger mother-infant bonding.
Monitoring during a session is temperature, respiratory rate, colour and feeding, and the mother is taught to recognise and report the danger signs herself, since she is with the baby every minute.

Thermoregulation in neonates

Thermoregulation in the newborn is the balance between the heat a baby makes and the heat it loses, and newborns lose that contest easily because of a large surface area for their mass, thin skin with little subcutaneous fat, an inability to shiver and a body that arrives wet. Hypothermia is not a comfort issue but a cause of death — it drives up oxygen consumption, empties glycogen stores into hypoglycaemia, produces metabolic acidosis and is one of the reasons a small baby dies of sepsis or respiratory distress.

Normal axillary temperature in a newborn is 36.5 to 37.5 degrees Celsius, measured for about 3 minutes with a digital thermometer; rectal temperature is not taken routinely because of the risk of perforation.
WHO hypothermia grades: cold stress or mild hypothermia at 36.0 to 36.4 degrees, moderate hypothermia at 32.0 to 35.9 degrees, and severe hypothermia below 32.0 degrees.
The human touch method needs no thermometer — a warm abdomen with warm feet is normal, a warm abdomen with cold feet is cold stress, and a cold abdomen means hypothermia.
Heat is lost by four routes: evaporation from wet skin, which dominates immediately after birth, conduction to a cold surface such as a weighing scale, convection to moving air from fans, draughts or cold oxygen, and radiation to cold walls and windows without any contact at all.
The WHO warm chain is a linked set of steps — a warm delivery room at 25 to 28 degrees Celsius without draughts, immediate drying and removal of the wet linen, skin-to-skin contact, early breastfeeding, postponing the bath and the weighing, appropriate clothing and bedding including a cap, keeping mother and baby together, warm resuscitation, warm transport, and trained staff.
The head is a large radiating surface in a newborn, so a cap is part of thermal care and not decoration, and the first bath is delayed for at least 24 hours.
Rewarming is graded: cold stress is treated with skin-to-skin contact in a warm room and a temperature recheck within an hour, moderate hypothermia with skin-to-skin contact or a radiant warmer and warm feeds, and severe hypothermia with rapid rewarming under a warmer or in an incubator with continuous monitoring.
Aim to raise the temperature by about 0.5 to 1 degree Celsius an hour and recheck every 15 to 30 minutes until it reaches 36.5 degrees, and check blood glucose at the same time, because hypothermia and hypoglycaemia travel together.
Any baby who is hypothermic without an obvious environmental cause, or who fails to rewarm, is treated as septic until proved otherwise — in a newborn, a low temperature is a commoner sign of infection than a fever.

Temperature regulation in neonates

Temperature regulation in the newborn is the physiology behind the bedside rules: a baby cannot shiver, so it makes heat almost entirely by non-shivering thermogenesis in brown adipose tissue, and it can only do so within a narrow band of environmental temperature called the neutral thermal environment. Knowing that mechanism is what explains why a preterm baby cools within minutes, why cold stress causes hypoglycaemia and acidosis before it causes a low reading, and why the warmer probe goes where it does.

Non-shivering thermogenesis in brown adipose tissue is the newborn's main heat source; shivering thermogenesis, the adult mechanism, is essentially absent at birth.
Brown fat lies between the scapulae, around the neck, in the axillae, in the mediastinum and around the kidneys and adrenals; it is densely packed with mitochondria and blood vessels, which is what gives it its colour.
Noradrenaline released in response to cold activates the uncoupling protein in brown fat mitochondria, which uncouples oxidation from ATP production so the energy is released directly as heat.
Brown fat is laid down mainly in the third trimester, so a preterm baby has very little of it, and once it is used it is not quickly replaced — the smaller the baby, the shorter the defence against cold.
Generating heat costs oxygen and glucose, so cold stress produces increased oxygen consumption, hypoglycaemia, metabolic acidosis, pulmonary vasoconstriction, apnoea and poor weight gain, and the baby can be in trouble before the thermometer looks alarming.
The neutral thermal environment is the narrow range of ambient temperature at which the baby keeps a normal core temperature with the least oxygen consumption and the lowest metabolic rate; it is higher for a smaller and younger baby, and a term baby is usually comfortable in a room at about 24 to 26 degrees Celsius.
Other reasons for vulnerability are a large surface area to body mass ratio, a proportionately large head, thin skin with little subcutaneous fat and poor vasomotor control in the preterm, and being wet at birth.
On a radiant warmer the servo-control probe is placed on the abdominal skin over the liver, held with a reflective patch, never over a bony point and never underneath the baby, and the set point is about 36.5 degrees Celsius; a radiant warmer increases insensible water loss, while a closed incubator conserves both heat and water.
Kangaroo mother care is the most reliable sustained heat source available and outperforms improvised warming, because the mother's chest raises and lowers its own temperature in response to the baby.
Hyperthermia is an axillary temperature above 37.5 degrees Celsius, and the discriminator matters: in overheating from wrapping, a hot room or phototherapy the baby is vasodilated with warm feet and an extended posture, while in sepsis the peripheries are cool and the baby is lethargic and feeds poorly.

Hyperthermia — normal room set up

Neonatal hyperthermia is an axillary temperature above 37.5 degrees Celsius, and it is far more often caused by the equipment and the wrapping than by infection. The room set-up that prevents both it and hypothermia is the warm chain — a delivery room at 25 to 28 degrees Celsius with no draughts, a pre-warmed radiant warmer and linen, immediate drying, skin-to-skin contact and a delayed first bath — and knowing the numbers in that chain is the examinable part.

Normal axillary temperature of a newborn is 36.5 to 37.5 degrees Celsius; below that is cold stress at 36.0 to 36.4, moderate hypothermia at 32 to 35.9 and severe hypothermia below 32, while above 37.5 is hyperthermia.
The delivery room and newborn care area are kept at 25 to 28 degrees Celsius with all fans, air-conditioner vents, open windows and doors controlled, because a draught over a wet newborn removes heat by convection and evaporation faster than any warmer replaces it.
Heat is lost four ways and each has its own nursing answer: evaporation (dry immediately, remove the wet linen), conduction (pre-warm the weighing scale, the mattress and the stethoscope), convection (close the draughts) and radiation (keep the cot away from cold outer walls and windows).
A radiant warmer is run in servo mode with the skin probe on the abdomen over the liver, reflective side up, never under the baby and never over a bony point, set to a skin temperature of about 36.5 degrees Celsius; manual mode is for short procedures only and needs temperature checks every 15 to 30 minutes because it will overheat a baby.
Overheating is dangerous in its own right: it causes apnoea, tachycardia, tachypnoea, irritability, sweating in a term baby, and large insensible water losses leading to dehydration and hypernatraemia; a preterm baby under a warmer can lose several times the fluid a nursed baby loses.
The discriminator between equipment fever and sepsis is the skin-to-core gradient and the periphery: an overheated baby is flushed, warm to the toes, sweaty and has warm extremities with a narrow core-peripheral gap, whereas a septic baby is often cold peripherally with a widening gap, lethargic, feeding poorly and may be hypothermic rather than hot.
Kangaroo mother care is the safest warming method available in an Indian facility and at home — the baby is nursed skin to skin between the mother's breasts, upright, in a cap, socks and nappy, for as long a stretch as possible each day, and it also improves breastfeeding and weight gain.
The first bath is delayed at least 24 hours (and until the baby is stable and normothermic), the cap and dry linen stay on, and axillary temperature is monitored every 4 hours in a stable baby and hourly or more often in a sick one or one under a warmer.

Meconium aspiration syndrome

Meconium aspiration syndrome is respiratory distress in a baby born through meconium-stained liquor, when aspirated meconium obstructs the airways, inactivates surfactant and sets up a chemical pneumonitis. It matters because it is a term and post-term problem in an otherwise mature baby, it causes ball-valve air trapping with a real risk of pneumothorax, and it is the classic route into persistent pulmonary hypertension of the newborn.

Meconium staining is a sign of fetal distress and of maturity: it is rare before 34 weeks and commonest post-term, and the risk factors are post-dates, intrauterine growth restriction, placental insufficiency, oligohydramnios and any cause of fetal hypoxia in labour.
The lung injury is threefold — partial airway obstruction giving a ball-valve effect with air trapping and hyperinflation, complete obstruction giving atelectasis, and chemical pneumonitis with surfactant inactivation — which is why the chest is barrel-shaped and the pneumothorax risk is high.
The current NRP position is that a non-vigorous baby born through meconium-stained liquor is NOT routinely intubated for tracheal suctioning; that baby gets the initial steps and prompt positive-pressure ventilation, and intubation is reserved for airway obstruction that cannot be cleared. Routine intrapartum suctioning of the mouth and nose on the perineum is also no longer recommended.
Vigorous means good tone, good respiratory effort and a heart rate above 100 a minute; a vigorous meconium-stained baby needs only routine care with the mother and observation, whatever the thickness of the liquor.
The chest radiograph shows patchy coarse infiltrates alternating with areas of hyperinflation, flattened diaphragms and an increased anteroposterior diameter, and it must be looked at again for pneumothorax whenever the baby suddenly deteriorates.
Persistent pulmonary hypertension of the newborn is the complication that kills: the baby stays hypoxic out of proportion to the radiograph, with a pre-ductal to post-ductal saturation difference; management is minimal handling, adequate oxygenation and ventilation, correction of acidosis, and inhaled nitric oxide or ECMO at centres that have them.
Sudden deterioration with a fall in saturation, a drop in the heart rate, asymmetric chest movement and shifted heart sounds means pneumothorax; transillumination at the cot side supports it and needle aspiration or an intercostal drain relieves it.
Surfactant replacement and antibiotics are used in severe disease because the meconium inactivates surfactant and a pneumonia cannot be excluded on the film; supportive care means thermoneutrality, glucose monitoring, minimal handling and careful fluid management.

Respiratory distress syndrome

Respiratory distress syndrome, or hyaline membrane disease, is respiratory failure in a preterm baby caused by a deficiency of pulmonary surfactant, so the alveoli collapse at end-expiration and the work of breathing rises until the baby tires. It is the commonest cause of respiratory distress in babies born before 34 weeks, the risk rises steeply as gestation falls, and it is the condition whose incidence antenatal corticosteroids and early CPAP were designed to cut.

Surfactant is produced by type II pneumocytes from about 24 weeks and reaches adequate amounts by about 34 to 35 weeks; a lecithin to sphingomyelin ratio of 2 or more in amniotic fluid indicates lung maturity.
Onset is within the first 6 hours of life and it worsens over 48 to 72 hours before improving with the natural diuresis: tachypnoea over 60 a minute, expiratory grunting, nasal flaring, intercostal and subcostal retractions and cyanosis, with reduced air entry and a shrinking chest.
Distress is scored, not eyeballed — the Silverman-Andersen score (chest movement, intercostal retraction, xiphoid retraction, nasal flaring and expiratory grunt, each 0 to 2, where a higher score is worse) and the Downes score are the two used on Indian units.
The chest radiograph shows a diffuse reticulogranular ground-glass appearance with air bronchograms, low lung volumes and, when severe, a white-out that obscures the heart border.
Antenatal corticosteroids are the single most effective prevention: betamethasone 12 mg intramuscularly, two doses 24 hours apart, or dexamethasone 6 mg intramuscularly every 12 hours for four doses, given to the mother between 24 and 34 weeks when preterm birth is expected, ideally at least 24 hours and up to 7 days before delivery.
Early nasal CPAP at about 5 to 6 cm of water in the delivery room is first-line, because it keeps the alveoli open and reduces the need for intubation; surfactant is given through the endotracheal tube when the baby needs a rising oxygen concentration or CPAP fails, often as the INSURE approach of intubate, give surfactant, extubate to CPAP.
Distinguish it from transient tachypnoea of the newborn, which follows a caesarean or a rapid delivery in a near-term baby, peaks early and settles within 24 to 72 hours with wet-looking lung fields and fluid in the fissure, and from congenital pneumonia and meconium aspiration.
Complications to nurse for are air leak and pneumothorax, patent ductus arteriosus, intraventricular haemorrhage, bronchopulmonary dysplasia (an oxygen requirement persisting at 36 weeks corrected age) and retinopathy of prematurity, which is why the oxygen is targeted and not run wide open.

Neonatal resuscitation — NRP algorithm

Neonatal resuscitation is the ordered set of actions that establishes effective ventilation in a baby who does not breathe at birth, and the NRP algorithm is the sequence in which they are done and reassessed. About one baby in ten needs some help to start breathing and about one in a hundred needs extensive resuscitation, and because almost every neonatal arrest is respiratory in origin, ventilation — not chest compressions and not drugs — is the intervention that saves the baby.

Three questions at birth decide everything: is the baby term, does the baby have good tone, and is the baby breathing or crying? Yes to all three means routine care in skin-to-skin contact with the mother; any no means the baby goes to the radiant warmer for the initial steps.
The initial steps take about 30 seconds — provide warmth, position the head in the neutral or slightly extended sniffing position, clear the airway only if secretions obstruct it (mouth before nose), dry, remove the wet linen and stimulate by rubbing the back or flicking the soles.
The whole of the first minute is the golden minute: effective positive-pressure ventilation must be running by 60 seconds of life in a baby who is apnoeic, gasping, or whose heart rate is below 100 a minute.
Positive-pressure ventilation is delivered at 40 to 60 breaths a minute with a starting inflation pressure of about 20 to 25 cm of water; the first and most reliable sign that it is working is a rising heart rate, and the second is visible chest rise.
Oxygen is started at 21 percent for babies of 35 weeks and over and at 21 to 30 percent for babies under 35 weeks, then titrated against a pre-ductal probe on the right hand to the minute-by-minute targets, which climb from around 60 to 65 percent at 1 minute to 85 to 95 percent at 10 minutes.
If the heart rate remains under 60 a minute after 30 seconds of ventilation that visibly moves the chest, preferably through an endotracheal tube or laryngeal mask, start chest compressions at a ratio of 3 compressions to 1 breath — 90 compressions and 30 breaths in a minute — using the two-thumb encircling technique, depressing one third of the anteroposterior diameter, and raise the oxygen to 100 percent.
Adrenaline is given only when the heart rate stays under 60 a minute despite effective ventilation and 60 seconds of coordinated compressions: 0.01 to 0.03 mg/kg intravenously through the umbilical venous catheter, which is 0.1 to 0.3 mL/kg of the 1 in 10,000 (0.1 mg/mL) solution, repeated every 3 to 5 minutes; the endotracheal route is a larger dose and is a stopgap while access is obtained.
Volume expansion with 10 mL/kg of normal saline or O-negative blood over 5 to 10 minutes is for the baby who is not responding and has a history of blood loss or looks shocked; naloxone and sodium bicarbonate are not part of the initial algorithm.
Delayed cord clamping of at least 30 to 60 seconds is recommended for vigorous term and preterm babies who do not need resuscitation, and India runs this algorithm through NSSK, with the same warm chain and the same golden minute.

Haemorrhagic disease of newborn

Haemorrhagic disease of the newborn, now called vitamin K deficiency bleeding, is bleeding caused by a deficiency of the vitamin K-dependent clotting factors II, VII, IX and X in a baby whose stores are low at birth. It matters because it is almost entirely preventable by a single intramuscular injection at birth, and because the late form presents with intracranial haemorrhage in an exclusively breastfed baby who was never given that injection.

Newborns are vitamin K deficient by nature: transfer across the placenta is poor, the gut is not yet colonised by vitamin K-producing bacteria, and breast milk is a poor source, which is why exclusively breastfed babies without prophylaxis are the ones at risk.
Early vitamin K deficiency bleeding occurs within the first 24 hours and is nearly always due to maternal drugs that interfere with vitamin K — phenytoin, phenobarbitone, carbamazepine, rifampicin, isoniazid and warfarin.
Classic disease occurs between day 2 and day 7 and presents as bleeding from the umbilical stump, the gastrointestinal tract (melaena, haematemesis), the circumcision site, the nose or the puncture sites.
Late disease occurs from 2 weeks to 6 months, is strongly associated with exclusive breastfeeding without prophylaxis and with cholestasis or malabsorption, and presents with intracranial haemorrhage in a large proportion of cases — which is why it carries the highest mortality and the risk of permanent handicap.
The blood picture is a prolonged prothrombin time with a normal platelet count and normal fibrinogen; the aPTT is prolonged in more severe disease, and this pattern separates it from disseminated intravascular coagulation, where platelets and fibrinogen also fall, and from swallowed maternal blood, where the baby is well and the Apt test identifies maternal haemoglobin.
Prophylaxis is vitamin K1 (phytomenadione) 1 mg intramuscularly as a single dose in the thigh within an hour of birth for every newborn over 1000 g, with 0.5 mg for babies of 1000 g or less; oral regimens are less reliable and are the reason late disease is still seen.
Treatment of established bleeding is vitamin K1 given slowly by the intravenous or subcutaneous route, together with fresh frozen plasma at 10 to 20 mL/kg when the bleeding is active or severe, because plasma replaces the factors within minutes while vitamin K takes hours.

Cardio-pulmonary function — good skin colour

Good skin colour in a child is not a cosmetic observation but the visible end point of adequate cardiac output and oxygenation — pink, warm, dry skin with a capillary refill under 2 seconds means the tissue beds are being perfused and oxygenated. It matters because a child compensates for shock by shutting down the skin long before the blood pressure falls, so the periphery is the earliest window on the circulation and hypotension is a late and ominous finding.

The bedside package of good cardiopulmonary function is a pink, warm, dry skin with capillary refill under 2 seconds, equal strong central and peripheral pulses, a heart rate and respiratory rate normal for age, clear equal breath sounds with no grunting or retraction, a normal conscious level and a urine output of at least 1 mL/kg/h in an infant or young child.
Capillary refill is tested by pressing a nail bed or the sternum for 5 seconds at the level of the heart in a warm room; under 2 seconds is normal, and IMNCI and WHO use a refill of 3 seconds or more, along with cold hands and a weak fast pulse, as a sign of shock.
A child compensates by tachycardia and vasoconstriction, so the sequence of decline is cool mottled peripheries and a narrowing pulse pressure first, weak peripheral pulses next, and a falling blood pressure last — hypotension in a child is decompensated shock and arrest is close behind.
A weak or absent peripheral pulse with a still-palpable central pulse is a serious finding; the sites are the brachial or femoral pulse in an infant and the carotid or femoral pulse in an older child, because an infant's short neck makes the carotid unreliable.
Acrocyanosis, blue hands and feet with a pink tongue and trunk, is normal in the first 24 to 48 hours of life and after cold exposure; it is peripheral, not central, and it does not mean hypoxaemia.
Mottling, a grey or ashen colour, a pale nail bed with slow refill, and cool skin that begins at the toes and moves upward are the signs to document by level — noting where the warm-cold line sits and whether it is climbing is more useful than repeating that the child looks unwell.
Colour must be read in the mucous membranes, tongue, conjunctivae, palms and nail beds in Indian children, because skin pigmentation hides both pallor and cyanosis; anaemia is looked for in the conjunctiva, tongue and palms, not the cheeks.
Normal urine output is roughly 1 to 2 mL/kg/h in infants and young children and about 0.5 to 1 mL/kg/h in adolescents, and a falling output is one of the earliest measurable signs that perfusion has dropped.

Post-natal period findings

The postnatal examination of a newborn is a systematic head-to-toe check in the first hours and days of life whose purpose is to separate the large group of transient, normal findings from the small group of danger signs. Most of what alarms a mother - the greasy coating, the grey patch on the back, the swollen breasts, the pink stain in the nappy - is physiological and needs naming and documenting rather than treating, and the nurse who can name them buys the trust that makes the danger-sign teaching stick.

Normal measurements and vital signs at term: weight 2.5 to 4 kg, length about 50 cm, head circumference about 33 to 35 cm with the chest circumference 2 to 3 cm smaller until the two become equal at around a year; heart rate 120 to 160 per minute, respiratory rate 30 to 60 per minute counted for a full minute, and axillary temperature 36.5 to 37.5 degrees Celsius.
Physiological weight loss of up to 7 to 10% of birth weight occurs over the first 3 to 5 days and is regained by day 10 to 14; a loss of more than 10%, or failure to regain birth weight by two weeks, means the feeding must be assessed.
Physiological jaundice appears AFTER 24 hours, peaks on day 3 to 5 in a term baby and day 5 to 7 in a preterm, and clears by day 14 in term and day 21 in preterm babies. Jaundice within the first 24 hours, jaundice reaching the palms and soles, or jaundice persisting beyond those limits is pathological and needs bilirubin measurement.
Normal skin findings: vernix caseosa, lanugo, milia on the nose, erythema toxicum neonatorum on days 1 to 3 sparing the palms and soles, congenital dermal melanocytosis (Mongolian spots) over the lumbosacral area and buttocks which fade by 2 to 5 years, salmon patches on the nape and eyelids, cutis marmorata on cooling and peeling of the skin in a post-term baby.
Effects of transplacental maternal hormones that resolve without treatment: breast engorgement with a little milk in either sex, pseudomenstruation or a mucoid vaginal discharge on days 3 to 5, and oedema of the scrotum or labia. The breast bud is never squeezed - it causes abscess and mastitis.
Brick-red or pink staining of the nappy in the first days is uric acid crystal deposition and is harmless; it must be distinguished from true haematuria, which stains the whole nappy pink and is not confined to a powdery patch.
Elimination: urine is passed within 24 hours and meconium within 48 hours in essentially all normal term babies. Meconium is passed on days 1 to 3, transitional green stool on days 3 to 4 and yellow seedy milk stool thereafter; failure to pass urine in 24 hours or meconium in 48 hours must be reported.
Head: caput succedaneum is present at birth, is soft and pitting, CROSSES suture lines and settles in a few days; cephalhaematoma appears hours after birth, is fluctuant, is limited by suture lines because it is subperiosteal, takes weeks to resolve and can cause jaundice and anaemia. The posterior fontanelle closes by 6 to 8 weeks and the anterior at 12 to 18 months.
Primitive reflexes that must be present and must later disappear: Moro (goes by 3 to 6 months), rooting and sucking (3 to 4 months), palmar grasp (3 to 4 months), asymmetric tonic neck (6 to 7 months), stepping (2 to 3 months) and plantar grasp (9 to 10 months). Absent, asymmetrical or persistent reflexes are abnormal.
Cord: two arteries and one vein - a single umbilical artery prompts a check for renal anomalies. The stump separates by 5 to 10 days; dry cord care with nothing applied is standard in a facility, while 7.1% chlorhexidine gel is applied to the stump for home deliveries under the national newborn care programme.

Skin variations in children

A large part of what appears on a newborn's and infant's skin is transient and physiological, and the nurse's task is to recognise it, name it for the parents and record it rather than treat it. Knowing the benign list is what makes the abnormal visible: the same head-to-toe skin examination has to pick out the haemangioma near an eye or an airway, the six or more cafe-au-lait patches, the non-blanching purpura of meningococcal disease and the bruise on a baby who cannot yet move.

Congenital dermal melanocytosis (Mongolian spots): slate-grey or blue-grey macules over the lumbosacral area and buttocks, present at birth and very common in Indian babies, caused by melanocytes arrested in the dermis. They need no treatment and fade by about 2 to 5 years, but must be documented with site and size on day one so they are never later mistaken for bruising.
Milia: 1 to 2 mm pearly white papules of retained keratin on the nose, chin and cheeks that disappear within a few weeks and must never be squeezed; the same lesions on the palate or gums are called Epstein pearls.
Erythema toxicum neonatorum: blotchy erythematous macules each with a central white or yellow papule, appearing on days 1 to 3 on the trunk and limbs and SPARING the palms and soles, resolving within a week, with eosinophils on a smear of the pustule contents. A pustular rash in a newborn that DOES involve the palms and soles suggests congenital syphilis or staphylococcal infection instead.
Nevus simplex (salmon patch, stork bite, angel kiss): a flat pink capillary patch on the nape, glabella or eyelids that blanches on pressure and deepens when the baby cries; the facial patches fade within the first year. A port-wine stain differs in being unilateral, segmental and permanent, and one involving the ophthalmic division of the trigeminal nerve raises the possibility of Sturge-Weber syndrome with seizures and glaucoma.
Infantile haemangioma: usually absent at birth, appears in the first weeks, proliferates for about 6 to 12 months and then involutes slowly over years. Most need only reassurance and measurement, but oral propranolol is given when the lesion threatens vision, the airway (a beard-distribution lesion), the nose or lip, or when it ulcerates.
Other normal variants: cutis marmorata on cooling, the transient harlequin colour change, sucking blisters on the forearm, neonatal acne and sebaceous hyperplasia, physiological desquamation in a post-term baby, and miliaria rubra or prickly heat, which is extremely common in the Indian summer and is treated by cooling, loose cotton clothing and light bathing rather than by creams and powders.
Six or more cafe-au-lait macules larger than 5 mm before puberty (or larger than 15 mm after puberty) suggest neurofibromatosis type 1, and hypopigmented ash-leaf macules seen best under a Wood lamp, especially in an infant with spasms, suggest tuberous sclerosis.
Diaper dermatitis spares the skin folds when it is simple irritant napkin rash, and INVOLVES the folds with satellite pustules when it is candidal - the discriminator that decides between a barrier cream and a topical antifungal.
A large congenital melanocytic naevus carries a small lifelong risk of melanoma and needs dermatological follow-up, and any pigmented lesion that grows disproportionately, bleeds or ulcerates is referred rather than watched.

Cradle cap (seborrheic dermatitis)

Infantile seborrhoeic dermatitis is a self-limiting inflammatory scaling of the sebum-rich areas of a baby's skin - the scalp, where it is called cradle cap, and also the eyebrows, behind the ears, the neck folds, the axillae and the nappy area - driven by residual maternal androgens stimulating the sebaceous glands together with colonisation by Malassezia yeast. It begins in the first weeks of life, peaks at around 3 months and clears by 8 to 12 months without scarring or hair loss, and the single most useful thing the nurse does is to stop the parents scrubbing it off.

The lesions are thick, greasy, adherent yellow to brown scales on a mildly red base, and the crucial clinical observation is that the baby is COMFORTABLE - not scratching, sleeping and feeding normally - because seborrhoeic dermatitis does not itch.
That comfort is the discriminator from infantile atopic eczema, which begins after about 3 months, is dry rather than greasy, itches intensely so the baby is irritable and rubs, affects the cheeks and the extensor surfaces in infancy, and characteristically SPARES the nappy area, whereas seborrhoeic dermatitis involves the folds and the nappy area.
Other differentials: scalp psoriasis (thicker, silvery, well-demarcated, with nail pitting); tinea capitis (scaling with broken hairs, patchy alopecia and occipital lymph nodes, which needs ORAL griseofulvin or terbinafine because topical treatment does not reach the hair follicle); and scabies (itchy, involves palms, soles and axillae, with affected family members).
Treatment is emollient and patience: apply coconut, mineral or olive oil or white soft paraffin to the scales, leave it for a few hours or overnight to soften them, then loosen them with a soft brush and wash with a mild baby shampoo, repeating daily while the scaling lasts. Scales are never picked or scraped off dry, which causes bleeding, infection and distress.
For persistent, extensive or inflamed disease add ketoconazole 2% shampoo or cream, or a short course of a low-potency topical corticosteroid such as 1% hydrocortisone, and treat a secondarily infected or candidal nappy area with a topical antifungal such as clotrimazole.
It is not caused by poor hygiene, by an allergy, by the mother's diet or by any food the baby is taking, so no change of feed is needed - and saying so plainly is what prevents unnecessary formula changes and stopped breastfeeding.
It resolves on its own; the only lasting harm comes from aggressive scrubbing, harsh medicated shampoos in the eyes, or applying strong topical steroids to a baby's thin skin for weeks.

Ophthalmia neonatorum

Ophthalmia neonatorum is any conjunctivitis with discharge occurring within the first 28 days of life, acquired in most cases from the mother's genital tract during birth. It is never treated as a trivial sticky eye, because gonococcal infection can invade an intact cornea and perforate it within a day or two and blind the baby, and because chlamydial infection of the eye is a marker of a nasopharyngeal infection that will present as pneumonia weeks later.

The timing of onset points to the cause and is the most heavily examined part of the topic: chemical irritation appears within the first 24 hours and settles in a day or two; gonococcal conjunctivitis appears on days 2 to 5; chlamydial conjunctivitis appears on days 5 to 14; and herpes simplex appears around days 6 to 14.
Gonococcal ophthalmia is hyperacute: copious thick purulent discharge that reaccumulates as fast as it is wiped, marked lid oedema so tense that the eye can barely be opened, chemosis, and a real risk of corneal ulceration, perforation and permanent blindness.
Chlamydia trachomatis is the commonest infective cause overall and is milder - a mucopurulent discharge with lid swelling and, in the untreated infant, an afebrile pneumonia at about 4 to 12 weeks with a staccato cough and eosinophilia. That is why chlamydial eye disease is treated SYSTEMICALLY and not with drops alone.
Herpes simplex conjunctivitis comes with vesicles on the lid margin or elsewhere on the skin and a serosanguinous discharge, and may be the first sign of disseminated neonatal herpes; it can cause dendritic keratitis.
Laboratory work before the first dose: conjunctival swabs for Gram stain (gram-negative intracellular diplococci indicate gonococcus), culture, Giemsa stain for chlamydial intracytoplasmic inclusions, and nucleic acid amplification testing for both organisms, with herpes simplex polymerase chain reaction where vesicles are present.
Gonococcal treatment is a SINGLE dose of ceftriaxone 25 to 50 mg/kg intramuscularly or intravenously to a maximum of 125 mg, together with frequent saline irrigation of the eye until the discharge clears; cefotaxime is substituted in a jaundiced baby or one receiving calcium-containing intravenous fluids, because ceftriaxone displaces bilirubin and precipitates with calcium.
Chlamydial treatment is oral erythromycin 50 mg/kg per day in four divided doses for 14 days, because topical treatment does not clear the nasopharyngeal carriage that causes the later pneumonia; parents are warned about the association of erythromycin with hypertrophic pyloric stenosis in the first weeks of life. Herpes simplex needs intravenous acyclovir for 14 to 21 days with ophthalmology involvement.
Prophylaxis at birth is a single application of erythromycin 0.5% eye ointment (or tetracycline 1% ointment) to both eyes within about an hour of delivery; povidone-iodine 2.5% drops are used in some settings, and silver nitrate by Crede method has been abandoned because it caused chemical conjunctivitis.
Treating the baby alone guarantees relapse: both parents must be treated for gonorrhoea and chlamydia and screened for other sexually transmitted infections including syphilis and HIV, with counselling given in private and without blame.
Nursing technique matters and is examinable: strict hand hygiene and eye protection because gonococcal discharge can infect the nurse's own eye, a separate swab for each eye wiping once from the inner to the outer canthus and discarding it, saline irrigation as often as hourly in gonococcal disease until the discharge stops, instillation of drops into the lower fornix, isolating or cohorting the baby, and NEVER padding the eye, which traps the discharge against the cornea.

Kramer rule (neonatal jaundice)

Kramer's rule is the bedside method of judging how high a newborn's bilirubin has risen from how far down the body the yellow colour has spread, because jaundice in the newborn appears in a fixed cephalocaudal order — face first, palms and soles last. It divides the body into five zones and gives each an approximate bilirubin value, so a nurse in a ward with no bilirubinometer can decide within seconds which baby needs a blood level tonight and which can wait for the routine round.

Zone 1 is the head and neck and corresponds to a total serum bilirubin of roughly 4 to 8 mg/dL, with 5 mg/dL as the figure usually quoted in examinations.
Zone 2 is the trunk down to the umbilicus (about 5 to 12 mg/dL, quoted as 10), zone 3 runs from the umbilicus to the knees (about 8 to 16 mg/dL, quoted as 12) and zone 4 is the arms and the legs below the knees (about 11 to 18 mg/dL, quoted as 15).
Zone 5 is the palms and the soles and means a bilirubin of about 15 to 20 mg/dL or more, so yellow palms and soles are never a mild finding and always earn an urgent serum level.
The examination is done by pressing a finger on the skin over a bony prominence — forehead, sternum or shin — and reading the colour of the blanched skin as the finger lifts, in bright daylight; tube light and a warm room make a jaundiced baby look pink and a pink baby look jaundiced.
Kramer's rule only screens. Phototherapy and exchange transfusion are decided on a measured total serum bilirubin plotted against the baby's age in hours on the hour-specific nomogram, read together with the gestation and the risk factors, because a bilirubin value without an age in hours means nothing.
Jaundice visible in the first 24 hours of life is pathological until proved otherwise and points to haemolysis — Rh or ABO incompatibility, G6PD deficiency or sepsis; physiological jaundice appears after 24 hours, peaks on day 3 to 5 in a term baby (day 5 to 7 in a preterm baby) and clears by 14 days.
The other markers of pathological jaundice are a rise of more than 5 mg/dL in a day, a level above the phototherapy threshold for that hour of life, jaundice persisting beyond 14 days in a term or 21 days in a preterm baby, and a conjugated (direct) bilirubin above 2 mg/dL or more than 20 per cent of the total.
The estimate is least reliable in dark skin, in a preterm or anaemic baby, and in a baby already under phototherapy, whose skin bleaches while the blood level stays high; transcutaneous bilirubin becomes unreliable for the same reason once the lights are on, so the blood level is the reference from then on.
Feeding is treatment: a baby fed 8 to 12 times in 24 hours passes more stool and clears more bilirubin through the gut, which is why breastfeeding support and not plain water or dextrose belongs in the care plan of a jaundiced newborn.

APGAR scoring

The Apgar score is a rapid, repeatable numerical summary of a newborn's condition in the first minutes of life, devised by Virginia Apgar in 1953 and made of five signs — Appearance (colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone) and Respiration (respiratory effort) — each graded 0, 1 or 2 for a total out of 10. It is recorded at 1 and 5 minutes to document how the baby made the transition to extrauterine life and how it answered the care given, and it is deliberately not the trigger for resuscitation, which begins on the baby's breathing and heart rate inside the first minute of life, long before any score is written.

Appearance: 0 for a baby blue or pale all over, 1 for a pink body with blue hands and feet (acrocyanosis) and 2 for a completely pink baby — very few babies are pink all over at 1 minute, which is why a score of 10 at 1 minute is rare.
Pulse: 0 for no heartbeat, 1 for a heart rate below 100 beats per minute and 2 for 100 or more; the heart rate is the most important single sign in the score and the one that drives every resuscitation decision.
Grimace, the reflex response to suction of the nostril or to flicking the sole: 0 for no response, 1 for a grimace or feeble cry and 2 for a cry, cough, sneeze or active withdrawal.
Activity, meaning tone: 0 for a limp baby, 1 for some flexion of the limbs and 2 for active movement with the limbs well flexed. Respiration: 0 for apnoea, 1 for slow irregular breathing or a weak cry and 2 for a good strong cry.
Interpretation: 7 to 10 is normal, 4 to 6 is moderate depression and 0 to 3 is severe depression; the score is assigned at 1 and 5 minutes and then repeated every 5 minutes up to 20 minutes for as long as it stays below 7.
The score never starts or stops a resuscitation. The three questions at birth are term gestation, good tone, and breathing or crying; if any answer is no, the initial steps and then positive-pressure ventilation begin inside the golden first minute and the score is filled in afterwards.
A low score is not the same as birth asphyxia — prematurity, maternal sedation or general anaesthesia, magnesium sulphate given to the mother, congenital malformations and neuromuscular disease all depress the score in a baby who is not hypoxic.
Outcome follows the 5-minute and later scores rather than the 1-minute score, and hypoxic-ischaemic injury is not diagnosed on the score alone: it needs a low score together with cord arterial acidaemia (pH below 7.0 or base deficit of 12 mmol/L or more), encephalopathy and multi-organ dysfunction.
During pulse oximetry in the delivery room the probe goes on the right hand, because that reading is pre-ductal, and the expected pre-ductal saturation climbs slowly — about 60 to 65 per cent at 1 minute, 70 to 75 per cent at 3 minutes, 80 to 85 per cent at 5 minutes and 85 to 95 per cent at 10 minutes — so a blue-looking baby with a good heart rate at 1 minute is not automatically an oxygen problem.
When a baby is being resuscitated the expanded Apgar form is used, which records alongside each score the oxygen, positive-pressure ventilation, intubation, chest compressions and adrenaline in progress at that time point.

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