Author: Dr. Armida Fernandez, MD, DCH (Paed.)
A neonate experiences rapid change of physiology at birth and during the initial few days of life. This is the period when many infants would fall sick and may even die. Care at birth and during first few days of life is therefore very important and can lay a good foundation for the neonatal period and beyond.
This article is intended to provide evidence-based guidelines for care of a normal neonate at birth and beyond.
A normal neonate for the purpose of this protocol has been defined as follows:
- Birth weight greater than 2500 g
- Gestation greater than 37 wk
- Birth weight between 10th to 90th percentiles
- No need for resuscitation at birth
- Normal Apgar scores
- No postnatal illness such as respiratory distress, sepsis, hypoglycemia or polycythemia, congenital malformation.
- Absence of maternal illness or intrapartum event that may put the neonate at a risk of illness (eg. Gestational diabetes, antepartum haemorrhage.
This protocol does not cover the following neonates:
- Low birth weight
- Small or large for dates (birth weight <10th or >90th percentiles for gestation)
Care of baby at birth and within first hour(s) of birth
- Skilled birth attendance: One health provider (physician or nurse) trained in neonatal resuscitation must be physically available at the time of birth of all infants irrespective of risk status (high or low). It is emphasized that this person must actually be present in the delivery room before the birth of the baby. It is not good enough to have someone on call. The resuscitation corner must be physically located in the delivery room itself. Details of resuscitation is provided elsewhere. If delivery anticipated to be high risk, more advanced neonatal resuscitation may be required.
- It is important to call out the time of birth loudly – this helps in accurate recording of the time and alerts other personnel in case any help is needed. In these cases, 2 persons should be present to manage the baby.
- Universal precaution: Health providers must exercise universal precaution in all cases while caring for infants at birth as per their hospital policy. This should include wearing proper gowns, gloves, boots and goggles.
- Asepsis at birth: it is important to prevent infection at birth by observing five cleans – (1) clean hands after appropriate hand-hygiene and wearing sterile gloves (2) clean surface – use a clean and sterile towel to dry and cover the baby (3) cut the umbilical cord with a clean and sterile blade/scissor (4) use a clean tie for the cord (5) do not apply anything to the cord.
- Prevention and management of hypo-thermia: hypothermia at birth is common and has a detrimental effect on the health of the infant. Hypothermia should be prevented by paying special attention to temperature maintenance in the baby. The delivery room should be warm (atleast 250C) and free from a draft of air. The infant should be received in a pre-warmed sterile linen sheet. The infant should be dried thoroughly including the head and face areas. The wet linen should not be allowed to remain in contact with the infant. The infant should be placed in skin-to-skin (STS) contact with the mother immediately after birth. In addition to maintaining normal temperature of the infant, STS promotes early breastfeeding and decreases the pain and bleeding in the mother. The infant should be made to wear the caps and socks.
- Cutting of umbilical cord: Umbilical cord cutting must be delayed for about 2 minutes in order to allow the transfer of an additional amount of blood from the placenta to the infant. A meta-analysis including 15 trials, comparing early versus delayed cord clamping in nearly 2000 neonates showed that delayed cord clamping has been associated with benefits from 2 to 6 months, viz. improved hematologic status (hematocrit), iron status (ferritin/ stored iron) and a clinical anemia. Even though, there was an increase in polycythemia among infants in whom late clamping was done, this appeared to be benign.
- Clamping of the cord: The umbilical cord should be clamped 2-3 cms away from the abdomen using a commercially available clamp, a clean and autoclaved thread or a sterile rubber band. The rubber band could be a better option than a thread, as once the cord starts shriveling; the rubber band would still maintain its grip while the thread might loosen up. Inspect the cord every 15-30 minutes for initial few hours after birth for early detection of any oozing from the cord.
- Cleaning of baby: the infant should be cleaned at birth with a clean and sterile cloth in order to remove blood clots or meconium on the body, if any. The white greasy material on the skin, the vernix, protects skin of the infant and helps maintain temperature. One should not attempt to remove vernix from the body by any means, as it can result in trauma to skin and increases chance of infections. It gets absorbed on its own after sometime.
- Placement of identity band: Each infant must have an identity band containing the name of the mother, the hospital registration number, the gender and birth weight of the infant. The foot prints for identification makes it messy, the quality of prints are generally of poor quality and therefore the same should be avoided.
- Communication with the family: The health provider attending the birth of the infant must communicate with the mother and other family members regarding time and weight at birth, gender and well being of the infant. The infant should be shown to the family with particular attention given to the fact that family members get to know the gender and the identity tag on the infant. This would avoid any confusion regarding identity of the infant.
- Bedding in: There is no indication of separating a normal infant (normal delivery or caesarean section) from the mother for routine observation in the nursery. During the initial couple of hours after birth, infants are awake and very active and this opportunity should be utilized for bonding and initiation of breastfeeding. Separation of a normal infant from the mother even for a couple of hours for ‘observation’ has a significant adverse impact on successful breastfeeding.
- Recording of weight: All the infants should be weighed at birth or within 24 hr on a scale with at least 50 gm sensitivity. The weighing scale is periodically calibrated. Weight recording requires a considerable skill and therefore the health providers must be adequately trained to do so. The same weighing scale should be used for serial monitoring of weight of the infant, if required. Place either a single-use paper towel or a sterile cloth towel on the weighing scale beneath the infant.
- Assignment of Apgar score — Apgar score has a limited value for initial stabilization and prediction of subsequent neuro-sensory outcomes. However, it does predict mortality in short term and helps defining the need for nursery admission. Therefore Apgar should be recorded at 1, 5 and 10 minutes. Extended Apgar scores at 15 and 20 minutes should be recorded if initial scores are below 7.
- Examination at birth: The infant should be examined thoroughly for cardio-respiratory stability, malformation or trauma and determination of gestation. There is no need for routine passage of catheter in the stomach for detection of esophageal atresia, in the nostrils for detection of choanal atresia or into the rectum for detection of anorectal malformation. Body temperature of the infant must be recorded by axillary route using an electronic thermometer. If a mercury thermometer is used, use it for three minutes. Use of rectal thermometer is associated with risk of trauma and infection and therefore must be avoided.
- Vitamin K: Neonates are at risk to vitamin K deficiency in view of low transplacental transfer and poor breast milk content. Vitamin K deficiency can result in severe bleeding during early infancy. Vitamin K in dose of 0.5 to 1 mg to term and 0.5 mg to preterm infants must be routinely administered intramuscularly to all neonates to prevent vitamin K deficiency bleeding. Two large randomized trials, compared a single dose of intramuscular vitamin K with placebo/ nothing and assessed effect on clinical bleeding. One dose of vitamin K reduced clinical bleeding at 1-7 days, including bleeding after circumcision, and improved biochemical indices of coagulation status. The lower doses of vitamin K have been studied by one RCT, which reported doses of 0.5 mg to be as affective as 1 mg. Vitamin K1 preparation is preferable to K3 preparation. There was only one study comparing the efficacy of vitamin K1 versus vitamin K3, which found comparable PIVKA II levels with both preparations. The study also found no increased hemolysis in the vitamin K3 group in the doses used for prophylaxis. However in view of unavailability and cost, K3 preparation is a reasonable alternative to K1. Oral preparation is unavailable in India and require multiple dosing to prevent late onset vitamin K deficiency bleeding.
- Prevention of tetanus: If the mother has not received adequate tetanus immunization during pregnancy, the infant should be given a tetanus toxoid dose and concurrent tetanus immunoglobulin 250 IU intramuscularly to prevent tetanus neonatorum.
- Stomach wash: There is no role of routine stomach wash after birth to prevent any kind of gastritis. If the infant is born through meconium stained liquor, the stomach can be aspirated to remove the stomach content to prevent vomiting in early neonatal period.
Care after birth during initial few days of life
- Cord care: the umbilical cord must be kept dry and open. The nappy should be folded just below the umbilical stump.
- Exclusive breastfeeding (EBF): EBF is the most important public health intervention for preventing a large number of newborn and U-5 deaths. It is estimated that at 100% coverage, it can save more than half of total newborn and 13% of U-5 deaths globally. Successful breastfeeding requires a systematic approach to initiate, support and maintain breastfeeding. This amounts to educating mothers and families about the benefits during antenatal period, supporting the mother for initiation of breastfeeding soon after birth, managing appropriately various breastfeeding conditions during early postpartum period and psychological support to the mother. Provision of a dedicated lactation counselor significantly increases the chances of successful breastfeeding.
- Oil massage: Oil massage is a low cost traditional practice well ingrained in Indian culture. There are 2 Indian studies that focused on the oil massage in the term babies and their benefits in terms of health, growth and skin condition. Both the studies have shown oil massage, promoted weight gain in healthy neonates. However, a paucity of data still exists as to which oil should be used for this purpose. Care should be taken not to use oils with additives or oils with irritants.
- Vitamin D supplementation: Vitamin D deficiency seems to have acquired epidemic proportions in infants, children and adults. In view of poor vitamin D content in breast milk and limited opportunity to sun exposure in infants, vitamin D deficiency is common in healthy breastfed infants. Various studies and survey in both developed and developing countries have reported 50 to 100% of the normal breastfed neonates to be deficient. Moreover, the mothers in developing countries like India are also deficient adding to the problem. There are 2 high quality randomized controlled trial which evaluated the effect of routine vitamin D supplementation in a dose of 400 IU/day to exclusively breastfed neonates starting in the first month of life. There was a significant (100%) reduction in the biochemical deficiency of vitamin D in both the studies. The results of the same can be logically extrapolated to our setting as the problem is more alarming. Hence, as recommended by the other academies (American Academy of Pediatrics 2008). It is recommended to supplement 400 IU/day of Vitamin D to all infants irrespective to type of feeding.
Examination for jaundice: All the infants must be examined for the development and severity of jaundice twice a day for first few days of life. Visual assessment in daylight is the preferred method. Transcutaneous assessment of jaundice using newer generation devices is helpful and may reduce the need for blood sampling. However initial and running cost constitute an important barrier.
The American Academy of Pediatrics recommends routine measurement of serum total bilirubin on a blood sample or by transcutaneous bilirunimotry in all neonates. However there is no data on cost-benefit of this approach. In view of the feasibility and cost involved, the same can not be recommended in Indian settings.
- Vaccination: All the normal newborns must be offered the birth immunization (Hep B, OPV & BCG) before discharge, as per their State policy. Hepatitis B immunization at birth can prevent perinatal transmission of hepatitis B infection in majority of cases.
- Bathing: Routine bathing in the hospital should be avoided in view of unavailability of safe water and risk of hypothermia. The infant can be sponged as required. Infant can be bathed at birth taking care of risk of hypothermia.
- Sleep Position:
- No Indian study has looked into the sleep position of the healthy normal neonates and its relation to sudden infant death syndrome (SIDS). The American Academy of Pediatrics, in its systematic review-cum-policy statement (1992) identified 7 studies comparing “usual sleeping position” of infants who died of SIDS and controls. Six reported a significant correlation of prone position with SIDS. Though many were associated with some flaw in study design, when considered together, these studies present substantial evidence of an association of prone position and SIDS, independent of other variables. However, no published report has suggested the converse – i.e., a reduced incidence of SIDS with the supine position. No studies were conducted in the hospital or facility setting.
- All healthy neonates who are born at term and have no medical complications should preferably be placed down for sleep on their back.
- Kajal application: Application of the kajal or soorma is very common in the rural community (70%). This is usually applied by the mother with the ring or the middle finger and is a source of infection. There are rare reports of lead poisoning. Hence, routine kajal application should be discouraged.
- Discharge: Whenever possible the baby should undergo an observation period of 48 to 72 hours in the health facilitiy (for establishment of breast feeding and observation for any morbidity including jaundice. The following criteria should be met in all the babies prior to discharge planning:
- The routine formal examination of the newborn has been performed and documented.
- The newborn has received the immunization as per schedule
- The mother is confident and trained to take care of the neonate
- The new born is not having a significant jaundice or any other illness requiring close observation by a health provider.
- The new born is breastfeeding adequately. The adequacy of feeds can be determined by:
- Passage of urine 6 to 8 times every 24 hours.
- Baby sleeping well for 2 to 3 hours after feeds.
- There is no excessive weight loss (normally babies do not lose more than 8 to 10% in initial 3 to 4 days).
- The mother has been counseled regarding routine newborn care and her queries are answered.
- Follow-up advice should be communicated to the mother of the baby. Babies, particularly born to primigravida mothers should be called for follow-up visit at 48 hours of discharge if discharged before 48 hours. The breastfeeding and the jaundice in these babies should be evaluated.
- Ideally the infant should be discharged after 48-72 hours after birth once breastfeeding has been well established; the infant has been immunized and free from any illness including significant jaundice. Adequacy of breastfeeding must be assessed in all infants and the same would be indicated by the passage of urine at 6 times/24 hr., onset of transitional stools, baby sleeping well for 2-3 hours after feeding. If there is any concern about adequacy of breastfeeding, the infant can be weighed on the same weighing scale that was used to weigh the infant at birth. Excessive weight loss (normal 8-10% of birth weight by 3-4 days of age) would indicate inadequate breastfeeding. Adequate support must be provided to the mother to enhance the lactation in the mother.
- All the infants should have a routine formal examination before discharge. The examination should be performed with the infant naked and in optimum light in the presence of the mother using a proforma (so as not to miss anything). The examination includes assessment of vital signs, heart murmurs, palpation of femoral pulses, and presence of jaundice and adequacy of breastfeeding. The mother should be provided opportunity to ask questions and clarify her doubts.
- Measure weight at discharge if feeding problems are present. Document if there is any excess weight loss. Normal weight loss 7-8% by 3-4 days of age.
- There are no Indian studies reporting the readmission rates, breastfeeding failures, and morbidity characteristics, with which the early discharged babies get re-admitted, A Cochrane has shown that the breastfeeding failure may be as high as 50% with re-admission rates nearing 2% if the babies are discharged early.
- In an Indian setting, this has to be investigated. However, If the infant has been discharged within 2-3 days after birth, a follow up visit should be scheduled after 2-3 days for assessing adequacy of breastfeeding and examination for jaundice.
Advice on Discharge:
- Exclusive Breastfeeds: All mothers should be ad- vised to exclusively breastfeed the babies till 6 months of age. All the advantages of breast milk, short term and long term should be discussed with the mother to facilitate a success.
- Immunization: The schedule of immunization should be explained to the mother and the date of the next immunization should be mentioned on the discharge
- The follow-up date for the babies discharged early (within 48 hours) for assessment of jaundice should be communicated to the parents.
- The danger signs should be documented and the mother should be educated to recognize the same and report early when they are recognized.
- Difficulty in feeding
- Lethargy (movement only when stimulated)
- Fast breathing (RR>60/min)
- Severe in drawing of the chest.
- Temperature of more than 37.5 degrees C or below 35.5 degrees C
- Metabolic screening: Routine metabolic screen can help timely detection of a variety of metabolic disorders. It involves significant cost, coordination between clinical team and metabolic screening lab, tracking of infants after discharge and requires availability and affordability of treatment of diagnosed disorder. The candidate diseases for routine metabolic screening in India include congenital hypothyroidism, G6PD deficiency and possibly congenital adrenal hyperplasia. Currently there is no data on epidemiology of various metabolic disorders and cost-benefits and feasibility of routine metabolic screen in India. An ongoing multicentric study of ICMR is likely to answer some of these questions. Based on the available data, it is not justified to start routine metabolic screening in India.
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