Overview of the routine management of the healthy newborn infant

INTRODUCTION — After birth, most term and late preterm newborn infants ≥35 weeks gestation make a successful transition to extrauterine life and require only routine newborn care.

This topic will provide a summary of routine care for healthy newborn infants ≥35 weeks gestation. The assessment of the newborn is discussed in greater detail elsewhere. (See "Assessment of the newborn infant".)

DELIVERY ROOM CARE

Initial management — After delivery, immediate care includes drying the newborn, clearing the airway of secretions, and providing warmth. (See "Neonatal resuscitation in the delivery room", section on 'Initial steps'.)

For newborns who are at increased risk of requiring resuscitation, a clinician skilled in neonatal resuscitation should be present at the time of delivery. The identification of high-risk infants and their care is discussed separately. (See "Neonatal resuscitation in the delivery room", section on 'High-risk delivery'.)

Assessment and disposition — A delivery room assessment of the neonate's clinical status is quickly performed by assessing the newborn’s gestational age (GA), muscle tone, and respiratory effort [1].

Newborns who meet all of the following criteria can be cared for in the normal nursery (neonatal level of care 1) [2]:

●GA ≥35 weeks

●Good muscle tone

●Strong respiratory drive (ie, crying and breathing without difficulty)

Newborns who meet these criteria do not require immediate intervention and should be given to the mother. Well appearing newborns should remain with the mother and be placed skin-to-skin (kangaroo care) to promote infant-maternal bonding and early initiation of breastfeeding [3]. Medical staff should instruct and assist the mother on safe positioning of the newborn during kangaroo care and breastfeeding, and directly observe the first breastfeeding session. (See "Initiation of breastfeeding", section on 'Skin-to-skin contact'.)

Newborns <35 weeks GA generally require a higher level of care (neonatal level of care 2, 3, or 4), depending on their GA and clinical status.

Newborns who are limp and/or apneic require resuscitation, as discussed in detail separately. (See "Neonatal resuscitation in the delivery room".):

Apgar score — The Apgar score provides a universally accepted method to assess the status of the newborn infant immediately after birth.

The score is determined by assessing five variables, each of which is assigned a value of 0, 1, or 2. The Apgar score calculator may be used to determine the score (calculator 1). The following variables are included in the Apgar score:

●Heart rate

●Respiratory effort

●Muscle tone

●Reflex irritability

●Color

The Apgar score is assessed at one and five minutes after birth. If the five-minute score is ≤6, a 10-minute score should be assessed.

Approximately 90 percent of neonates have five-minute Apgar scores of 7 to 10, and generally require no further intervention. Newborns with Apgar scores in this range have spontaneous breathing or crying, good muscle tone, and good color. They can be admitted to the level 1 newborn nursery for routine care (provided they are ≥35 weeks gestation).

Infants with five-minute Apgar scores ≤6 require further evaluation and possible intervention. Approximately 1 percent of newborns require resuscitation at birth. This is discussed in greater detail separately. (See "Neonatal resuscitation in the delivery room".)

The Apgar score should not be used as a prognostic tool. Although studies have found that lower Apgar scores are associated with higher rates of neonatal mortality and morbidity [4], the Apgar score does not accurately predict outcomes in individual patients [5].

Transitional period — The transitional period between intrauterine and extrauterine life is during the first four to six hours after birth. Physiological changes that can occur during the transitional period include decreasing pulmonary vascular resistance (PVR) with increased blood flow to the lungs, lung expansion with clearance of alveolar fluid and improved oxygenation, and closure of the ductus arteriosus. (See "Physiologic transition from intrauterine to extrauterine life".)

During this time, the clinical status of the newborn should be assessed every 30 to 60 minutes to ensure further interventions and/or evaluations beyond routine care are no longer required for successful transition to extrauterine life. The following clinical parameters are monitored beginning in the delivery room and continuing in the mother/infant's room (rooming in) or nursery:

●Temperature − The normal axillary temperature should be between 36.5 to 37.5ºC (97.7 to 99.5ºF) for an infant in an open crib [1,6]. Initial hyperthermia may be reflective of maternal fever or the intrauterine environment. Persistent hyperthermia or hypothermia may be a sign of sepsis. Hypothermia may contribute to metabolic disorders such as hypoglycemia or acidosis. (See "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm neonates".)

●Respiratory rate − The normal respiratory rate is 40 to 60 breaths per minute, and should be counted over a full minute. Tachypnea may be a sign of respiratory or cardiac disease. Apnea may be secondary to exposure to maternal medications (eg, maternal anesthesia or sedation), a sign of neurologic impairment, or sepsis.

●Heart rate − The normal heart rate is 120 to 160 beats per minute, but may decrease to 85 to 90 per minute in some term newborns during sleep. Heart rates that are too high or low may be a sign of underlying pathology, such as cardiac disease, sepsis, and metabolic derangements.

●Color − Central cyanosis (lips, tongue, and central trunk) may be indicative of respiratory or cardiac disease. (See "Approach to cyanosis in the newborn".)

●Tone − Hypotonia may be secondary to exposure to maternal medications or maternal fever during labor [7], or be indicative of an underlying syndrome (Down syndrome), sepsis, neurologic impairment, or metabolic derangement (eg, hypoglycemia). (See "Clinical features, diagnosis, and treatment of neonatal encephalopathy" and "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia", section on 'Clinical presentation'.)

Respiratory disease and suspected cardiac disease in the newborn are discussed in greater detail separately. (See "Overview of neonatal respiratory distress and disorders of transition" and "Identifying newborns with critical congenital heart disease".)

NEWBORN NURSERY CARE

General assessment — Newborns admitted to the newborn nursery should have a thorough evaluation performed within 24 hours of birth to identify any abnormalities or conditions that may alter the normal newborn course and/or require intervention (eg, birth defects, birth injuries, jaundice, cardiopulmonary disorders, signs of sepsis). The assessment of the newborn infant including review of the maternal, family, and prenatal history, and a complete examination is discussed in detail separately. (See "Assessment of the newborn infant".)

Eye care — In the neonate, the risk of contracting gonococcal conjunctivitis is reduced by prophylactic administration of ophthalmic antibiotic agents shortly after birth [8,9]. Ocular prophylaxis is safe, easy to administer, and an inexpensive method to prevent sight-threatening gonococcal ophthalmia. In the United States, routine prophylaxis against gonococcal ophthalmia neonatorum with erythromycin ophthalmic ointment is recommended by the US Preventive Services Task Force, the American Academy of Pediatrics (AAP), and the Centers for Disease Control and Prevention (CDC) [10-12]. (See "Gonococcal infection in the newborn", section on 'Ophthalmia neonatorum'.)

The agents used for gonococcal prophylaxis are not effective in preventing neonatal chlamydial conjunctivitis. The most effective measure to prevent neonatal chlamydial conjunctivitis is identification and timely treatment of chlamydial infections in pregnant women. This is discussed separately. (See "Chlamydia trachomatis infections in the newborn", section on 'Prevention' and "Prenatal care: Initial assessment", section on 'Chlamydia'.)

●Choice of agent – Erythromycin ophthalmic ointment is the only approved agent available in the United States for prevention of gonococcal ophthalmia neonatorum. Erythromycin ophthalmic ointment causes less chemical conjunctivitis than does silver nitrate solution. However, silver nitrate is more effective as a prophylaxis for penicillinase-producing Neisseria gonorrhoeae than erythromycin and should be used in areas where that organism is prevalent [13,14]. One percent silver nitrate solution and 1 percent tetracycline are not commercially available in the United States.

Povidone-iodine solution (2.5 percent) also may prevent ocular gonococcal infection with less toxicity and at lower cost than other agents, although further confirmatory studies are needed. This preparation is not commercially available in the United States.

●Technique – The ophthalmic antibiotic should be applied in each eye within two hours of birth, regardless of mode of delivery. If prophylaxis is delayed, a monitoring system should be established to ensure that all newborns receive prophylaxis. The efficacy of longer delays is not known.

After wiping each eyelid with sterile cotton gauze, the prophylactic agent is placed in each of the lower conjunctival sacs [15]. When administering erythromycin, the 0.5 percent ophthalmic ointment is used, applying a 1 cm ribbon to each eye. The agent should be spread by gentle massage of the eyelids, and excess solution or ointment can be wiped away after one minute. The eyes should not be irrigated after the application because doing so may reduce efficacy.

●Side effects – The principal side effect is chemical (noninfectious) conjunctivitis. This condition typically appears within the first 24 hours after administration and resolves by 48 hours. It is most often seen after application of silver nitrate.

Vitamin K — We recommend administration of prophylactic vitamin K for all newborns to prevent vitamin K deficient bleeding (VKDB; previously referred to as hemorrhagic disease of the newborn) [16,17].

●Dosing – Vitamin K1 (phytonadione) is administered as a single dose given intramuscularly (IM) within six hours of birth. The dose depends upon the newborn’s birthweight [16,18]:

•>1500 g: 1 mg IM

•≤1500: 0.3 mg/kg to 0.5 mg/kg IM; intravenous vitamin K is not recommended for prophylaxis in preterm infants

●Efficacy – The efficacy of routine vitamin K administration is supported by several small clinical trials carried out in the 1960s to 1990s which demonstrated that vitamin K compared with placebo improves biochemical indices of coagulation status [19,20]. The efficacy of vitamin K in this setting is also supported by observational studies and decades of clinical experience demonstrating that rates of VKDB declined dramatically following widespread adoption of this practice [21-23].

●IM versus oral administration – An oral vitamin K preparation for newborn prophylaxis is not available in the United States [24]. However, oral regimens are used for newborn prophylaxis in some European countries [21,22,25-27]. Based on the available observational evidence, a single IM dose of vitamin K appears to be more effective in preventing late-onset VKDB compared with oral vitamin K regimens. For example, in a surveillance study from Australia, the incidence of late-onset VKDB was higher in the era when oral vitamin K was used for prophylaxis compared with the later era when IM vitamin K was used (2.5 versus 0.61 per 100,000 live births, respectively) [28].

In countries where oral vitamin K is the standard, IM rather than oral prophylaxis may be preferred in higher-risk newborns, including:

•Preterm neonates

•Neonates receiving antibiotics

•Neonates with liver disease

•Neonates with diarrhea (due to potential reduced absorption of the oral preparation)

It is important to recognize that VKDB may still develop despite IM or oral administration of vitamin K in neonates with liver disease [29].

●Parental refusal – The rate of parental refusal of newborn vitamin K appears to be increasing in the United States and other countries [30-32]. Approximately one-half of severe cases of VKDB are associated with parental refusal of vitamin K therapy during the birth hospitalization [28-30]. In a national surveillance study from Australia, there were six cases of fatal VKDB-related intracranial hemorrhage reported over 24 years; three of the six cases occurred in infants who were not given vitamin K due to parental refusal [28].

It is imperative that parents are counseled about the potential dire consequences of VKDB (eg, intestinal hemorrhage, intracranial hemorrhage with subsequent neurodevelopmental impairment and possible death) if their newborn does not receive vitamin K.

Additional details regarding VKDB are provided separately. (See "Overview of vitamin K", section on 'Vitamin K-deficient bleeding in newborns and young infants'.)

Umbilical cord — The postpartum care of the umbilical cord for reducing the risk of infection (omphalitis) is dependent upon the quality of the care at delivery and postnatally. If there is an increased risk for omphalitis, especially in a clinical setting of low resources, the use of antiseptic agents (eg, triple dye, alcohol, silver sulfadiazine, and chlorhexidine) for cord care is an excellent and inexpensive option that reduces neonatal morbidity and mortality. However, in developed countries where aseptic care is routine in the clamping and cutting of the umbilical cord, additional topical care beyond dry cord care is not needed to prevent omphalitis. (See "Care of the umbilicus and management of umbilical disorders", section on 'Cord care'.)

Hepatitis B vaccination — Universal hepatitis B vaccination is recommended for all newborns, as summarized in the tables (table 1A-B) and discussed in detail separately. (See "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Routine infant immunization'.)

Assessment for risk of sepsis — The evaluation and management of newborns who are at risk for early-onset group B streptococcal infection are discussed in detail separately. (See "Management of neonates at risk for early-onset group B streptococcal infection".)

Routine newborn screening — Routine newborn screening prior to discharge includes the following, which are discussed in separate topic reviews (see "Overview of newborn screening"):

●The "blood spot" screening panel – These screening tests are analyzed on drops of blood placed on special paper. Blood is collected for an initial screen between 24 and 48 hours after birth. The specific disorders screened for vary from region to region. They generally include the following:

•Inborn errors of metabolism (see "Newborn screening for inborn errors of metabolism")

•Endocrinopathies such as congenital hypothyroidism congenital adrenal hyperplasia (see "Clinical features and detection of congenital hypothyroidism", section on 'Newborn screening' and "Clinical manifestations and diagnosis of classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency in infants and children", section on 'Newborn screening')

•Primary immunodeficiencies (see "Newborn screening for inborn errors of immunity")

•Hemoglobinopathies (see "Diagnosis of sickle cell disorders", section on 'Newborn screening')

•Cystic fibrosis (see "Cystic fibrosis: Clinical manifestations and diagnosis", section on 'Newborn screening')

•Other disorders, which vary from region to region

●Screening for hearing loss (see "Screening the newborn for hearing loss")

●Pulse oximetry screening to detect critical congenital heart disease (see "Newborn screening for critical congenital heart disease using pulse oximetry")

●Screening for hyperbilirubinemia (see "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening")

●Screening for hypoglycemia in at-risk newborns (see "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia", section on 'Screening')

Feeding — Newborns should be fed early and frequently to avoid hypoglycemia. The frequency, duration, and volume of feeds will be dependent upon whether the newborn is breastfed or receives formula. Each feeding should be recorded, and if the newborn is fed formula, the volume of feeding should also be recorded.

Breastfeeding is recommended because of its increased benefits for both the infant and mother compared with formula feeding, except when medically contraindicated. (See "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding" and "Breastfeeding: Parental education and support", section on 'Contraindications to breastfeeding'.)

●Breastfed infants should be fed as soon as possible after delivery, preferably in the delivery room. They should receive at least 8 to 12 feeds per day during the newborn hospitalization. Rooming-in, skin-to-skin contact, frequent demand feedings in the early postpartum period, and lactation support increase the rate of successful breastfeeding. (See "Breastfeeding: Parental education and support" and "Initiation of breastfeeding".)

●Healthy newborns who are fed formula should be offered standard 19 to 20 kcal/oz (19 to 20 kcal per 30 mL) iron-containing infant formula. Healthy newborns are fed on demand, but the duration between feedings should not exceed four hours. The volume of feedings should be at least 0.5 to 1 oz (15 to 30 mL) per feed during the first few days after birth.

●Pasteurized, human donor milk may be available in some nurseries for the healthy, breastfed newborn who may require supplementation.

Weight loss — Term newborns may lose up to 10 percent of their birth wight (BW) in the first few days after birth and typically regain their BW by 10 to 14 days [33,34]. Exclusively breastfed infants delivered by cesarean section tend to have greater weight loss in the first week of life. This was demonstrated in a study using data from a large health maintenance organization, where 25 percent of exclusively breastfed infants delivered by cesarean section had >10 percent weight loss at 72 hours of age [34]. In this study, infants born vaginally returned to BW more quickly than those delivered by cesarean section. For infants born vaginally, 86 percent achieved BW by 14 days and 95 percent by 21 days. For infants born by cesarean delivery, 76 percent achieved BW by 14 days and 92 percent by 21 days.

Excessive weight loss should be evaluated with a complete feeding assessment, ongoing lactation support for breastfeeding mothers, and interventions as deemed necessary. Weight loss nomograms based on mode of delivery and for exclusively breastfed infants have been developed [33,34]. (See "Initiation of breastfeeding", section on 'Assessment of intake'.)

Newborn circumcision — The risks, benefits, and procedures for newborn circumcision are discussed separately. (See "Neonatal circumcision: Risks and benefits" and "Neonatal circumcision: Techniques".)

First bath — The optimal timing for the first bath is uncertain. Common practice in many birthing centers is to delay bathing for 6 to 24 hours after birth [31,35]. The rationale for this practice is that it may improve initiation of breastfeeding.

However, bathing should be performed soon after delivery if there is clinical concern for transmittable infectious exposures (eg, newborn infants born to mothers with active herpes simplex virus [HSV] genital lesions or with a history of HIV or hepatitis B or C) [31].

In addition, clinicians should be mindful of cultural differences in the perceived need for earlier newborn bathing (eg, to remove the vernix, meconium, or excess blood because of concern of appearance) [31].

Assessing for jaundice — During the birth hospitalization, newborns should be routinely assessed every 8 to 12 hours and at discharge for the presence of jaundice. However, the extent of visible jaundice on physical examination is not a reliable method to estimate bilirubin levels. Thus, routine bilirubin screening using either transcutaneous bilirubin or total serum bilirubin measurement is suggested for all newborns prior to discharge. This is discussed in detail separately. (See "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening".)

Postnatal parental education — The parents/caregivers should receive training and demonstrate competence or understanding of the following infant care tasks [36]:

●The importance and benefits of breastfeeding. (See "Breastfeeding: Parental education and support" and "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding" and "Patient education: Breastfeeding (The Basics)" and "Patient education: Deciding to breastfeed (The Basics)".)

●If breastfeeding, positioning the infant and determining adequate latch and swallowing. (See "Initiation of breastfeeding".)

●Appropriate frequency of urination and stooling, and normal and abnormal appearance of urine and stool. In particular, acholic stools that appear either white or pale can be an early finding of biliary atresia. (See "Biliary atresia", section on 'Signs and symptoms'.)

●Umbilical cord, skin, and genital care. (See "Care of the umbilicus and management of umbilical disorders", section on 'Umbilical cord at birth' and "Neonatal circumcision: Techniques", section on 'Post-circumcision care'.)

●Recognition of the signs of common neonatal illnesses that may require medical attention, particularly jaundice and fever. (See "Patient education: Jaundice in babies (The Basics)" and "Patient education: Jaundice in newborn infants (Beyond the Basics)" and "Patient education: Sepsis in newborn babies (The Basics)".)

●Proper infant safety, including supine sleeping position and sleeping on a firm mattress, installation and use of car safety seat, and hand hygiene. (See "Sudden infant death syndrome: Risk factors and risk reduction strategies", section on 'Sleep position' and "Sudden infant death syndrome: Risk factors and risk reduction strategies", section on 'Sleep environment' and "Patient education: Sudden infant death syndrome (SIDS) (The Basics)".)

●Strategies that parents/caregivers can use to reduce pain during their infant’s routine immunizations, which are discussed separately. (See "Standard immunizations for children and adolescents: Overview", section on 'Reducing injection pain'.)

HOSPITAL LENGTH OF STAY — The optimal length of stay (LOS) for the birth hospitalization varies for each mother-infant pair. It should be long enough to permit detection of early neonatal problems and to ensure that the family is able and prepared to care for the infant at home [36]. The decision regarding timing of discharge is made jointly with the family/caregivers and the obstetric and neonatal care providers. Factors involved in this decision include the health of the mother, the health and stability of the newborn, the ability and confidence of the mother to care for the infant, the adequacy of support systems at home, and access to appropriate follow-up care [36-38].

Discharge criteria — The following minimum criteria and conditions should be met before discharge, as recommended by the American Academy of Pediatrics (AAP) [36]:

●No neonatal abnormality requiring continued hospitalization was detected during the hospital course, or on physical examination at discharge. (See "Assessment of the newborn infant".)

●The infant's vital signs are within normal ranges and are stable for at least 12 hours before discharge. Normal ranges are as follows:

•Respiratory rate <60 per min

•Heart rate between 120 and 160 beats per minute (a resting heart rate as low as 85 is acceptable for term infants)

•Axillary temperature 36.5 to 37.5ºC (97.7 to 99.5ºF)

●The infant has urinated and passed at least one stool spontaneously. Almost all term infants will have urinated and passed at least one stool during the first 24 hours of life [39].

●The infant has completed at least two successful feedings. If the infant is breastfeeding, a knowledgeable care provider should observe a feeding and document successful performance of latching, swallowing, and infant satiety. If the infant is bottle-fed, observation and documentation of successful feeding based on the ability to coordinate sucking, swallowing, and breathing while feeding. (See "Initiation of breastfeeding" and "Neonatal oral feeding difficulties due to sucking and swallowing disorders".)

●If the infant was circumcised, there is no evidence of excessive bleeding at the circumcision site for at least two hours prior to discharging home.

●If the infant is jaundiced, the clinical significance has been determined and appropriate plans for management and follow-up have been instituted. (See "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening".)

●The infant has been screened and monitored for early-onset sepsis based upon risk factors and clinical appearance. (See "Management of neonates at risk for early-onset group B streptococcal infection".)

●Maternal prenatal screening results (eg, blood type and antibody screen, syphilis screening, hepatitis B surface antigen, HIV screening) have been reviewed and any necessary follow-up testing and/or intervention for the newborn has been completed and reviewed. (See "Assessment of the newborn infant", section on 'Prenatal screening tests'.)

●Initial hepatitis B vaccine has been administered to the newborn. (See "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Routine infant immunization'.)

●All recommended newborn screening procedures have been completed, including "blood spot" screening for metabolic and genetic disorders, hearing screening, hyperbilirubinemia screening, pulse oximetry screening for critical congenital heart disease, and screening for hypoglycemia in at-risk newborns. (See "Overview of newborn screening".)

●The parents/caregivers have received training and demonstrated competency in the care of the newborn, as described above. (See 'Postnatal parental education' above.)

●Confirmation that an appropriate car seat has been obtained and the parents/caregivers have demonstrated to hospital personnel the ability to place the infant in the proper position and use the car seat properly. (See "Discharge planning for high-risk newborns", section on 'Car seat/bed use'.)

●Family members or other support persons, including health care professionals with knowledge about newborn care, are available to the parents/caregivers and the infant after discharge.

●A medical home for continuing infant care has been identified and timely communication of pertinent birth hospitalization information has been sent to the care providers of the medical home. The timing of follow-up is discussed below. (See 'Follow-up visit' below.)

●Family, environmental, and social risk factors have been assessed and addressed (eg, substance abuse, child abuse or neglect, domestic violence, mental illness, lack of social support, lack of reliable income). Barriers to follow-up care are assessed and addressed (eg, transportation, access to telephone communication).

Early discharge — In most cases, the above criteria are met at ≥48 hours after birth. Depending on the preferences of the parents/caregivers, earlier discharge (at <48 hours) may be reasonable if all the above criteria are met. However, the parents/caregivers should be informed that early newborn discharge is associated with increased risk of subsequently needing readmission to the hospital [40,41]. Newborns who are discharged at <48 hours after birth should generally have follow-up within 48 hours after discharge. If an appropriately timed follow-up appointment cannot be ensured, discharge should be deferred until an appointment can be made. (See 'Follow-up visit' below.)

In a meta-analysis of 10 clinical trials involving 6918 newborns randomly assigned to early versus standard discharge, 28-day readmission rates were higher in the early discharge group (6.8 versus 4.3 percent; relative risk 1.59, 95% CI 1.27-1.98) [41]. LOS in the early discharge groups in these trials varied considerably, ranging from 12 hours to up to 3.5 days. Similarly, LOS in the standard discharge groups ranged from 48 hours to >5 days.

It is uncertain whether early discharge is associated with higher, lower, or similar healthcare costs compared with standard discharge. Some studies have reported higher postnatal care costs associated with early discharge [41,42]; while others have reported lower costs with early discharge [41].

Discharge legislation — In the United States, because of concerns that early discharge could adversely affect maternal and infant health outcomes, both state and federal governments passed postpartum discharge laws in the late 1990s (Newborns' and Mothers' Health Protection Act [NMHPA]) to prevent extremely short LOS. In general, these laws require insurance plans to cover postpartum stays of up to 48 hours for infants born by vaginal deliveries and up to 96 hours for cesarean deliveries [43]. The impact of legislation ensuring insurance coverage for a minimum of 48 hours has increased the LOS of newborn infants and their mothers and appears to have decreased neonatal readmission rates and emergency department visits [40,44,45].

HOME BIRTH — We agree with the policy statement from the American Academy of Pediatrics that home birth is not recommended in developed countries due to the two- to threefold increase in infant mortality when compared with outcomes following delivery in medical facilities [46]. Pediatric healthcare providers should offer information about the increased risk of neonatal mortality and complications associated with planned home births to expecting parents who are considering a home birth.

In particular, pregnant individuals with conditions associated with increased risk of perinatal complications (eg, intrauterine growth restriction, diabetes) should be strongly encouraged to deliver in a medical facility.

Nevertheless, recognizing that home births do and will continue to occur, care for the newborn delivered at home should be consistent with the care provided to newborns born in medical facilities [46]. Planned home births are safest when they are part of an integrated regulated, system with multiple well-qualified providers for both the care of the mother and infant, appropriate risk assessment, and ability for seamless transfer, if necessary. (See "Planned home birth", section on 'Program organization'.)

●Delivery – Presence of two care providers at delivery, one of whom has primary responsibility for the newborn infant.

●Transitional care – During the first four to eight hours, the newborn should be kept warm, and a detailed physical examination is performed that includes assessment of gestational age. During this period, ongoing monitoring is conducted every 30 minutes and includes assessment of respiratory and heart rate, color, and tone until the newborn's status is determined normal and stable for at least two hours. If the gestational age is <37 weeks or the infant is ill appearing (eg, sepsis), the infant should be transferred to a medical facility for continued observation and management. (See 'Transitional period' above and "Late preterm infants" and "Management and outcome of sepsis in term and late preterm neonates".)

●Routine newborn care – Infants born at home should receive all the procedures and ongoing evaluations that are routinely administered at birthing centers, including (see 'Newborn nursery care' above):

•Eye care prophylaxis to prevent gonococcal conjunctivitis (see 'Eye care' above)

•Vitamin K prophylaxis (see 'Vitamin K' above)

•Hepatitis B vaccination (see "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Routine infant immunization')

•Newborn screening, including "blood spot" screening for metabolic and genetic disorders, hearing screening, hyperbilirubinemia screening, pulse oximetry screening for critical congenital heart disease, and screening for hypoglycemia in at-risk newborns (see "Overview of newborn screening")

•Feeding assessment and counseling (see 'Feeding' above and "Initiation of breastfeeding")

●Follow-up care – Identify a medical home for continuing care and communicate pertinent birth hospitalization information. (See 'Follow-up visit' below.)

FOLLOW-UP VISIT — The early newborn follow-up visit is conducted at an identified medical home by a health care provider competent in the assessment of newborns. This visit can take place in the home or a clinic, based on the needs of the family and availability of the provider.

Timing — The timing of the first follow-up visit depends on the length of the birth hospitalization and whether there are risk factors for feeding difficulties, dehydration, and/or severe hyperbilirubinemia:

●For infants hospitalized ≥48 hours and without any concerning risk factors, the initial well-baby visit is typically within three to five days after discharge.

●For infants hospitalized <48 hours, follow-up should occur within 48 hours of discharge [36,47].

●Earlier follow-up (within 24 to 48 hours after hospital discharge) is warranted for any of the following (regardless of length of hospital stay):

•Gestational age <37 weeks

•Newborns who lose >8 percent of their birth weight (see 'Weight loss' above)

•Newborns with certain risk factors for severe hyperbilirubinemia (table 2) and/or elevated predischarge bilirubin levels (table 3) (see "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening", section on 'Outpatient follow-up')

•Newborns who were treated with phototherapy during the birth hospitalization (see "Unconjugated hyperbilirubinemia in term and late preterm newborns: Initial management", section on 'Follow-up testing')

If an appropriately timed follow-up appointment cannot be ensured, discharge should be deferred until an appointment can be made.

This approach is generally consistent with guidance from the American Academy of Pediatrics (AAP). Support for this approach comes from a study using data from a large health care system, which showed that early follow-up visits were associated with lower readmission rates among infants whose birth hospitalization was <48 hours [47].

Issues to address — Each of the following should be addressed during the follow-up visit [36]:

●Assess the general health of the newborn − Review birth hospitalization information (pregnancy, delivery, complications during the hospital course), and pertinent events after discharge. Perform a physical examination of the infant including measurement of the weight, and assessment for signs of dehydration and extent of jaundice. In addition, the clinician should identify new problems, review feeding pattern, including stool and urine output.

●Assess the quality of mother-infant interaction.

●Assess infant behavior.

●Reinforce maternal and family education in infant care for feeding, supine sleeping position, and child safety seats, and encourage and support breastfeeding (if appropriate).

●Review results of outstanding laboratory tests including the newborn blood spot screen. (See "Overview of newborn screening", section on 'Follow-up of positive or equivocal results'.)

●Perform any necessary tests such as bilirubin check if warranted based upon the predischarge bilirubin level (table 3) or if the infant has clinically significant jaundice. (See "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening", section on 'Outpatient follow-up'.)

●Establish a relationship with the medical home. Verify the plan for health care maintenance and the medical home.

●Assess parental well-being, including symptoms of postpartum depression in the mother. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Screening'.)

READMISSIONS — Approximately 3 to 7 percent of newborns are readmitted to the hospital within 30 days after discharge from the newborn nursery [41,48,49]. Common reasons for readmission include feeding-related difficulties and hyperbilirubinemia.

Risk factors for newborn readmission include [41,49-51]:

●Lower gestational age

●Early discharge (see 'Early discharge' above)

●Young and/or inexperienced parents

●Difficulty establishing infant feeding during the birth hospitalization

●Having one or more risk factor for severe or progressive hyperbilirubinemia (table 2)

Identifying newborns who are at risk for readmission can be useful so that additional support and anticipatory care can be provided to at-risk families.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Caring for your newborn (The Basics)" and "Patient education: Newborn appearance (The Basics)" and "Patient education: Deciding to breastfeed (The Basics)" and "Patient education: Breastfeeding (The Basics)" and "Patient education: Jaundice in babies (The Basics)" and "Patient education: Screening for hearing loss in newborns (The Basics)")

●Beyond the Basics topics (see "Patient education: Jaundice in newborn infants (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Delivery room care – Immediately after an uncomplicated delivery, routine care includes drying the newborn, clearing the airway of secretions, and providing warmth. Approximately 90 percent of newborns will not require further intervention in the delivery room, and these newborns should be given to their mothers for skin-to-skin contact and initiation of breastfeeding. (See 'Delivery room care' above.)

●Transitional period – Most newborn infants make a successful transition to extrauterine life and require only routine care immediately after birth. During the transitional period (first four to six hours of life), optimal routine care, which begins in the delivery room, includes promoting early bonding with skin-to-skin contact and early initiation of breastfeeding. The clinical status of the newborn is monitored every 30 to 60 minutes to determine whether further intervention is required. (See 'Transitional period' above.)

●Routine assessment – A thorough assessment should be performed within 24 hours of birth to identify any abnormality that would alter the newborn course or identify a medical condition that should be addressed during the first days of after birth. The assessment includes a review of the maternal, family, and prenatal history and a complete physical examination. Additional details are provided separately. (See "Assessment of the newborn infant".)

●Eye care – For all newborns, we recommend administering ophthalmic antibiotic therapy shortly after birth to prevent gonococcal conjunctivitis (ophthalmia neonatorum) (Grade 1B). We suggest using erythromycin (0.5 percent ointment, 1 cm ribbon in each eye) rather than other agents (Grade 2C). Reasonable alternatives, which are not available in the United States, include 1 percent silver nitrate solution, 1 percent tetracycline ointment, or 2.5 percent povidone-iodine solution. We prefer erythromycin over these agents because it is less likely to cause chemical conjunctivitis. (See 'Eye care' above and "Gonococcal infection in the newborn", section on 'Ophthalmia neonatorum'.)

●Vitamin K – For all newborns, we recommend prophylactic administration of vitamin K to prevent vitamin K deficient bleeding (VKDB) (Grade 1B). We suggest intramuscular (IM) rather than oral preparations of vitamin K (Grade 2C). Based upon the available observational data, the IM route appears to be more effective for preventing both early and late VKDB. However, oral vitamin K is routinely used for prophylaxis in some parts of the world. (See 'Vitamin K' above.)

●Hepatitis B vaccination – Universal hepatitis B vaccination is recommended for all newborns, as summarized in the tables (table 1A-B) and discussed in detail separately. (See "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Routine infant immunization'.)

●Assessment for risk of sepsis – The evaluation and management of newborns who are at risk for early-onset group B streptococcal infection are discussed in detail separately. (See "Management of neonates at risk for early-onset group B streptococcal infection".)

●Newborn screening – Routine newborn screening prior to discharge includes the following, which are discussed in separate topic reviews (see "Overview of newborn screening"):

•The "blood spot" screening panel, which generally includes screening tests for:

-Inborn errors of metabolism (see "Newborn screening for inborn errors of metabolism")

-Endocrinopathies such as hypothyroidism and congenital adrenal hyperplasia (see "Clinical features and detection of congenital hypothyroidism", section on 'Newborn screening' and "Clinical manifestations and diagnosis of classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency in infants and children", section on 'Newborn screening')

-Primary immunodeficiencies (see "Newborn screening for inborn errors of immunity")

-Hemoglobinopathies (see "Diagnosis of sickle cell disorders", section on 'Newborn screening')

-Cystic fibrosis (see "Cystic fibrosis: Clinical manifestations and diagnosis", section on 'Newborn screening')

-Other disorders, which vary from region to region

•Screening for hearing loss (see "Screening the newborn for hearing loss")

•Pulse oximetry screening to detect critical congenital heart disease (see "Newborn screening for critical congenital heart disease using pulse oximetry")

•Screening for hyperbilirubinemia (see "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening")

•Screening for hypoglycemia in at-risk newborns (see "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia", section on 'Screening')

●Discharge criteria – The minimum criteria that should be met prior to discharge include (see 'Discharge criteria' above):

•Normal and stable vital signs for at least 12 hours before discharge

•Evidence of urination and stooling

•Completion of two successful feedings

•No physical abnormalities requiring continued care

•No evidence of excessive bleeding (especially in infants who are circumcised)

•Successful training of the family to provide ongoing care at home

●Follow-up visit – At discharge, a medical home should be identified and an appropriately timed follow-up visit should be made (see 'Follow-up visit' above):

•For infants hospitalized ≥48 hours, the initial well-baby visit is typically within three to five days after discharge. (See 'Timing' above.)

•For infants hospitalized <48 hours, follow-up should occur within 48 hours of discharge. (See 'Timing' above.)

•Earlier follow-up (within 24 to 48 hours after hospital discharge) is warranted for newborns with risk factors for feeding difficulties and/or severe hyperbilirubinemia. (See 'Timing' above.)

The follow-up visit should include assessment of the general health and behavior of the newborn infant, the infant-mother interaction, parent's well-being, verification of ongoing health care, and parental education. (See 'Issues to address' above.)