Your baby's first evaluation by a physician is a major step for ensuring a smooth transition from the hospital to the baby's new home.  A thorough history and physical exam are necessary for determining if the infant is ready for the "real world."  Many severe medical problems are not immediately apparent in the newborn nursery.  Your physician must pay close attention to clues that may indicate a problem that may develop after the baby is sent home from the hospital.  Often the mother is recovering from the delivery and is too tired and distracted to fully evaluate her infant.

Prenatal History

• Complications during the pregnancy?
  • Mom's health during pregnancy may affect the health of the newborn.
• Premature rupture of membranes?
  • The amniotic sac ("membranes") protects the infant from germs.  If the amniotic fluid drains early, the infant is at a higher risk for developing an infection shortly before or after birth.  Also, the umbilical cord may become compressed without the normal cushioning of amniotic fluid.  This can lead to decreased blood supply to the fetus before birth.
• Abnormal ultrasound findings?
  • Many fetal abnormalities can be noted on prenatal ultrasounds.  These include: spina bifida, cleft lip or palate, omphalocele, diaphragmatic hernia, incomplete closure of the abdominal wall, etc.)
• Maternal diabetes?
  • High blood sugar in the mother may lead to high insulin levels.  Excess amounts of this anabolic hormone may cause increase in the infant's size and/or low blood sugar in the infant after birth.
• Maternal infections?
  • Infections in the mother may cross the placenta, infecting the infant.  Infections that are minor in the mother may cause life-threatening illness in a newborn.  Symptoms of infection in the newborn may be difficult to identify.
• Maternal high blood pressure?
  • High blood pressure during pregnancy can be dangerous to both the mother and infant.  High blood pressure may be associated with a condition called pre-eclampsia or eclampsia in the mother.
• Medications during labor?
  • Many medications that affect the mother may also affect the newborn infant.  Infants born to mothers on pain medications may be born with symptoms of withdrawal or sedation.  Pain medications given to the mother may cause newborn infants to have slow breathing after birth.

Infant condition during labor and delivery

• Fetal distress?
  • There are many ways to determine the health of the baby prior to birth.  Problems before birth may alert the physician to look for problems after birth.
• Heart rate abnormalities?
  • Changes in the heart rate can indicate impending danger to the fetus.  A slow heart rate may indicate lack of blood supply or lack of oxygen to the fetus.  If the heart rate in the fetus responds slowly after contractions, this may also indicate problems.  Fast heart rates may indicate heart problems in the infant (i.e., mother's with lupus may have infants with abnormal heart electrical conduction).
• Decreased fetal movement?
  • Healthy infants tend to be active.  Decreased fetal movement may be a sign of problems.
• Meconium-stained fluid (passage of stool before birth)?
  • Passage of stool in the amniotic sac can be an indication of stress to the infant.  Moreover, meconium in the amniotic fluid may be inhaled by the infant during the first breaths after delivery.  This can lead to a type of pneumonia.
• Too much or too little amniotic fluid?
  • This may be an indication of a fluid leak (i.e., premature rupture of membranes) or abnormal kidney function in the infant.

Delivery

• Vaginal vs. C-section?
  • If a C-section was performed, why?  Was the fetus in distress?  Was the C-section planned?  Did the mother have a prior C-section?
• Breech presentation?
  • Breech infants may be at an increased risk of birth trauma (i.e., hip dysplasia or brachial plexus injury).
• Vacuum or forceps assisted?
  • If excess force was required to deliver the infant, there may be birth-related injuries.
• Difficult delivery?
  • Did the infant have a prolonged period of decreased blood supply from the the placenta?  Was there a period of hypoxia (lack of oxygen to the baby's brain)?

Infant after delivery

• Breathing difficulty?
  • Infants should breath regularly and without excess effort within a few minutes after birth.  Excess fluid on the lungs may lead to rapid breathing or low blood oxygen levels.
• Small or large size?
  • Small infants may have had inadequate supply of blood, oxygen, and/or nutrients during pregnancy.  Drug or tobacco exposure can lead to slow growth in the uterus.
  • Large infants are often due to maternal diabetes.  These infants are exposed to high insulin levels which may lead to excess weight gain in the uterus.
• Low blood sugar?
  • An infant born to a mother with diabetes may produce too much insulin after birth.  This can lead to inappropriately low blood sugar levels.
• Poor feeding?
  • Infants should be vigorous feeders shortly after birth.  Slow feeding or lethargy can be a clue to a medical problem or drug withdrawal symptoms.
• Lethargy?
  • Newborn infants may sleep up to 20 hours per day.  Nonetheless, newborns should wake approximately every 3 hours to feed.  While awake, the infant should be vigorous and should feed well.
• Jittery?
  • Jitteriness can be a sign of medication withdrawal (did the mother receive pain medications?) or neonatal seizures.
• Low body temperature?
  • Low body temperature can be due to improper bundling, prematurity, or illness.
• Fever?
  • High body temperature can be due to over-bundling, over-warming under heat lamps, or illness.

References

Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics, 16th Edition. Philadelphia: W. B. Saunders. 2000.

Hagan JF, Shaw JS, Duncan PM, eds. 2008 Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics.

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