1. When examining a newborn, systematically look for subtle congenital anomalies (e.g., ear abnormalities, sacral dimple) as they may be associated with other anomalies and genetic syndromes.
  2. In a newborn, where a concern has been raised by a caregiver (parent, nurse),
    1. Think about sepsis, and
    2. Look for signs of sepsis, as the presentation can be subtle (i.e. not the same as in adults, non-specific, feeding difficulties, respiratory changes)
    3. Make a provisional diagnosis of sepsis.
  3. Resuscitate newborns according to current guidelines
  4. Maintain neonatal resuscitation skills if appropriate for your practice.
  5. When a parent elects to bottle feed, support their decision in a non-judgemental manner.
  6. In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (e.g., hips, heart, hearing).
  7. When discharging a newborn from hospital,
    1. Advise parent(s) of warning signs of serious or impending illness, and
    2. Develop a plan with them to access appropriate care should a concern arise.


  • Pregnancy/Prenatal care
    • Planned/Expected
    • Routine tests (Blood type, antibody)
    • Maternal infection screening (Gono/chlam, syphilis, HIV, HBV/HCV)
    • Hypertension, Diabetes
    • GBS
    • Genetic screening
  • Labour
    • ROM duration
    • Meconium
  • Delivery
    • APGAR, resuscitation
  • Previous OB history
  • Family history

Physical Exam

  • General appearance
    • Colour
    • Tone/position
    • Cry
    • Respiratory effort
      • RR, nasal flaring, accessory muscle use, indrawing, grunting
  • Vital signs (O2 saturation prior to discharge r/o congenital heart disease)
    • HR 120-160, RR 40-60, sBP 60-90, T36.5-37.5
  • Measurements (for 40w gestation)
    • Length (51cm +/-3cm)
    • Weight (3.5kg +/-0.6kg)
    • Head circumference (35cm +/-2cm)
    • Head
      • Fontanelles
      • Sutures r/o craniosynostosis
      • Swelling
        • Caput succedaneum/edema (resolves within 48h)
        • Cephalohematoma (limited by suture lines, resolves within months)
        • Subgaleal hemorrhage (not limited by suture lines, due to repeated vaccuum/coagulopathy, close observation r/o hemorrhagic shock)
        • Encephalocele/meningocele (midline)
    • Ear abnormalities
      • Pitting, tags
      • Dysplasia/malformed ears
      • Helix should be along outer cantus of eye r/o low set ears
      • Hearing screen
    • Eyes
      • Pupil, iris, sclera, eyelid
      • Palpebral fissures
      • Red reflex r/o retinoblastoma
      • Conjunctivitis
        • Chemical (mild, first 24h after eye prophylaxis)
        • Gonorrheal (severe, day 2-7)
          • Cefotaxime 100mg/kg IV/IM x 1
        • Chlamydial (day 5-14d)
          • Erythromycin PO 50mg/kg divided QID x 2w
        • HSV (vesicles elsewhere)
          • Acyclovir 45mg/kg/day IV + Topical acyclovir 3% ointment 5x/d x 14-21d
    • Facial nerve palsies
    • Mouth r/o cleft lip/palate
    • Neck r/o mass/cyst
  • Heart
    • Murmur
      • Pathological:
        • Grade III+
        • Single second heart sound (cyanotic heart disease)
        • Holosystolic, continuous, harsh
        • Diastolic murmur
    • Cap refill
    • Femoral pulses
      • Decrease femoral pulses (aortic stenosis)
      • Bounding pulses (PDA)
    • Hepatomegaly
    • Pulse oximetry ≥ 95% right hand/foot (r/o congenital heart disease)
  • Lungs
  • Abdo
    • r/o organomegaly
    • r/o abdominal wall defect
      • omphalocele (sac covering defect) or gastroschisis
    • r/o inguinal hernia
  • Hips r/o developmental dysplasia of the hip until 1yo or walking
    • 4-6 weeks
      • Hip instability
        • Barlow (adduct, force posteriorly)
        • Ortolani (abduct, force anterior)
    • Late signs
      • Limited abduction
      • Short leg (assymetry)
        • Galeazzi (knee level while flexed)
        • Asymmetric thigh folds
    • Risk:
      • Frank breech, family history, female, low fluid (oligohydramnios), first born
      • Abnormal exam
    • Consider ultrasound (static and dynamic imaging) for <6 months, X-ray (AP) >6 months old
    • Consider referral to orthopedics for abnormal exam or imaging
  • Genitalia
    • r/o ambiguous genitalia (pituitary/adrenal)
    • Testes descent
    • Anus (imperforate anus)
  • Neuro
    • Midline nevus/lipoma, Sacral dimple r/o neural tube defect (spina bifida, encephalocele)
    • Tone
    • Movement
      • Brachial plexus injury
        • C5-7 (Erb-Duchenne), waiter's tip
        • C8-T1 (Klumpke's), claw-hand
    • Primitive Reflexes
      • Moro reflex, Grasp reflex, ATNR (Fencing) reflex, Galant reflex, Rooting reflex, Stepping reflex, Parachute reflex
        • Disappear by 3-6 months old
      • Babinski reflex usually disappears by 1-2 years old
  • Hands/feet (digits, absent radius, movement)
  • Skin
    • Jaundice
    • Cyanosis
    • Nevus flammeus (port-wine stain)
      • r/o Sturge-Weber (over trigeminal nerve)
    • Hemangioma
    • Cafe-au-lait r/o McCune-Albright syndrome

Rule out associated anomalies

    • Vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities
    • Coloboma of the eye, heart defects, choanal atresia, retraction of growth and/or development, genital and/or urinary abnormalities, and ear abnormalities and deafness
  • Down Syndrome
    • Flat facial profile, slanted palpebral fissures, anomalous (low-set, dysplastic) ears, hypotonia, poor Moro reflex, dysplasia of midphalanx of fifth finger, transverse palmar (Simian) crease, excessive skin at nape of the neck, hyperflexibility of joints, dysplasia of pelvis
  • Fetal Alcohol Spectrum Disorder (FASD)
    • Short palpebral fissures, thin vermillion border, and smooth philtrum, microcephaly

Treatment at birth

  • 0.5% erythromycin ointment (1cm ribbon in each eye)
  • Vitamin K 0.5mg IM
  • Universal hearing screen
  • r/o Hyperbilirubinemia (transcutaneous screen in first 24h)
  • r/o Hypoglycemia (preterm, postterm, diabetic mothers, LGA)
  • HBV vaccination, immunoglobulin as indicated

Criteria for discharge

  • Normal stable vital signs x 12 hours
  • Urination, stooling
  • Two successful feedings
  • No physical abnormalities requiring continued care
  • No excessive bleeding

Discharge from hospital instructions

  • Return to hospital if signs of
    • Infection r/o sepsis
      • Fever <3 months old
      • Decreased alertness (somnolence)
      • Irritability unable to console
      • Vomiting
      • Skin Changes (eg, jaundice, cyanosis)
    • Dehydration
      • Poor feeding
      • Weight loss or poor weight gain
      • <3 wet diapers per day or no urinary output x 7h
      • Decreased tears
    • Breathing problems
      • Rapid breathing (>60/min)
      • Apnea
      • Using neck, chest, abdo muscle to breathe
      • Wheezing/noise breathing
    • Any other concern
  • Weight
    • May lose up to 10% within the first few days, but return back to birthweight at 14 days
        • Should gain 20-30g/d for first month
  • Feedings
    • Avoid juices/water until solid foods (usually 4-6 months of age)
    • No honey until 1yo
    • Feed on demand, max q3-4h
    • Formula
      • Avoid heated in microwave (burn risk)
    • Breastfeeding
      • Technique
      • Consult physician before taking new medication
      • Vitamin D 400 units daily if breastfeeding
  • Urination
    • Six+ wet diapers per day
  • Umbilical cord should fall off by 2w
    • Regular cleaning and dry
    • Watch for signs of infection (red, purulence)
  • Prevention of SIDS
    • Back to sleep, same room, different bed
    • Smoking cessation
  • Car seat
    • Back seat, rear-facing
  • Follow-up (eg. 48-72h)


Signs and Symptoms of Sepsis

  • Respiratory distress, respitory failure
  • Hypotension, poor perfusion
  • Tachycardia
  • Temperature instability
  • Lethargy, hypotonia
  • Apnea
  • Feeding intolerance

Risk factors for Sepsis

Early-onset (Mother's GU: GBS, Ecoli, Coag-neg Staph, H influenzae, L monocytogenes)

  • Intrapartum maternal fever ≥38°C
  • Maternal chorioamnionitis (maternal fever, leukocytosis, maternal/fetal tachycardia, uterine tenderness, foul odour of amniotic fluid)
  • Maternal GBS colonization
    • Inadequate GBS antibiotic prophylaxis (eg. <4h prior to delivery)
  • Prolonged ROM ≥ 18h
  • Premature, LBW, Congenital anomalies, low APGAR (≤6)

Late-onset 4-90d (Caregiving environment: Coag-neg Staph, S aureus, E coli, Klebsiella, Pseudomonas, Enterobacter, Candida, GBS, Serratia, Actineobacter, Anaerobes)

  • Poor hygiene
  • Low gestational age, LBW
  • Indwelling central venous/umbilical catheter
  • Ventilator treatment

See shock for management


  • Gluc <3.3 mmol/L (note that before 48h of life, may be normal to have lower glucose if not symptomatic)
  • Symptoms
    • Lethargy, hypotonic
    • Jitter/tremors
    • Diaphoresis
    • Tachypnea or apnea
    • Hypothermia
    • Seizures
    • Poor suck/feedings

See Hyperbilirubinemia/Jaundice