A GUIDE TO NEONATAL ASSESSMENT:

PARAMETERS AND VALUES

TABLE 1a
Apgar score

Sign 0 1 2
Heart rate Nil <100 >100
Respiratory effort Absent Gasping or irregular Regular or crying
Muscle tone Flaccid Some tone Active
Response to stimulation None Grimace Cry or cough
Colour White Blue Pink centrally

Page | 1 J Petty
 Table 2: Clinical Assessment Guide
System Normal
Non-ventilated
Respiratory Effortless breathing, periodic, rate, 30-
60, bilateral chest movement, pink in
colour, quiet chest sounds
Ventilated
Even, bilateral chest movement, air
entry clear and bilateral, no secretions
evident, ETT fixed and secure
Adequate MBP, capillary refill less than
Cardiovascular 2 seconds, urine output at least
1ml/kg/hour, pink in colour, warm skin,
toe-core temperature difference 1-2
degrees Celsius, palpable pulses,
adequate heart rate
Adequate systemic perfusion and urine
Fluid status and output (see above), normal fontanelles,
balance palpable peripheral pulses, good stain
turgor, normal sodium level, specific
gravity of urine 1.010 – 1.020, weight
gain appropriate for age, equal fluid
balance (in and out) for 24 hr balance
Soft, non-tender abdomen, bowel
Gastro-intestinal sounds, nil/minimal aspirate from
stomach which is clear and mucousy,
bowels open and normal stool, no
vomiting, tolerance of feeds if
applicable, blood sugar > 2.6 mmols.
Consider:
Neurological 1. tone
(includes 2. movement
pain/stress) 3. response to stimuli
4. level of consciousness
Normal flexed posture (term) or
extended limbs (if preterm),
normal/present reflexes according to
gestation and age, reactions to stimuli
as appropriate to gestation, normal
tone and movements, no presence of
pain or stress (i.e. behaviour). Cues
such as facial expression, excessive
movements, tone changes, vital signs,
adequate sedation.
Abnormal
(requiring action)
Tachypnoea, nasal flaring,
recession, apnoea, oxygen
requirement, grunting,
cyanosis, stridor/wheeze
Chest movement ceases,
uneven/unilateral, excess
secretions, absent breath
sounds on one or both sides
MBP below desired limit,
pale, cool skin,
low/diminishing urine output,
capillary refill > 2 seconds,
widening toe-core
temperature difference,
weak, thready pulse,
bradycardia
Poor systemic perfusion and
low urine output
(1ml/kg/hour) (see above) or
polyuria (> ml/kg/hr), sunken
or bulging fontanelles, dry
skin, fast and thready pulses,
high or low specific gravity,
large increases or decreases
in weight, large positive or
negative fluid balance
Distended, tender, hard
abdomen, no bowel sounds
or bowel actions, stool
bloody/too loose / green/
large and/or increasing
stomach aspirates, bile
aspirates, vomiting, failure to
tolerate feeds, hypo
/hyperglycaemia(<2.6 or > 7)
Abnormal posture and tone,
e.g. hypo or hypertonia,
unresponsive or less
responsive to stimuli,
abnormal movements such
as convulsions, excessive
wakefulness or lack of
consciousness. Presence of
pain or stress according to
cues.
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Immunological Signs of infection not evident
Thermoregulation Normal body temperature for age and
appropriate environmental
temperature, if on ‘servo’, normal
temperature range for abdominal
probe.
Skin and general Normal skin for gestation, e.g.: frail and
appearance red in the preterm, and well formed in
term, pink mucous membranes, no
excoriation, no signs of jaundice,
umbilical area clean, I.V. sites healthy
Other: Consider family needs and involvement in care as part of overall assessment.
Signs of infection may be
non-specific and include
respiratory distress, colour
change, changes to pulse
oximetry values, oxygen
requirement, changes in vital
signs, apnoea, abnormal
values on blood gas – e.g.
metabolic acidosis, white cell
count and platelets and
sodium drops for example.
Temperature < 36.5 or > 37.3
– i.e. thermal instability or
stress.
Broken, excoriated skin,
rashes, and tissued I.V. sites
or suspected, clinically
jaundiced, blue mucous
membranes.
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 TABLE 3
Normal Vital Signs
Comparing the neonate to older age groups
NORMAL HEART RATES
AGE AWAKE SLEEPING

NEONATE (PRETERM) 100-200/minute 120-180

NEONATE (TERM) 100-180 80-160
INFANT 100-160 75-160
TODDLER 80-110 60-90
PRESCHOOLER 70-110 60-90
SCHOOL 65-110 60-90

NORMAL BLOOD PRESSURE

AGE SYSTOLIC DIASTOLIC

BIRTH(12HR, <1KG) 39-59 16-36

BIRTH(12 HR, 3KG) 50-70 24-45
NEONATE (96 HR) 60-90 20-60
INFANT(6 MONTH) 87-105 53-66
TODDLER(2 YEAR) 95-105 53-66
SCHOOL AGE 97-112 57-71
ADULT 112-128 66-80

N.B. IN NICU, IT IS VITAL TO CONSIDER THE MEAN ARTERIAL BLOOD PRESSURE. As a general
guideline, weeks in gestation should correspond with mean BP although in NICU, a MBP of >
30 mmHg is the aim, except for term and in PPHN (>40)

NORMAL RESPIRATORY RATES

PRETERM 40 - 80 BPM
TERM NEONATES 30 - 70
INFANTS 30 - 60
TODDLERS 24 - 40
PRESCHOOL 22 - 34
SCHOOL/ADULT 18 – 30

TEMPERATURE
CENTRAL (AXILLA) 36.6 – 37.2 degrees Celsius (Thomas, 1994)
ABDOMINAL (PROBE) 36.6 – 37.2 (preterm) 35.5 – 36.5 degrees (term)
PERIPHERAL 34.6 – 36.2 (i.e core-toe temperature difference should
be no more than 2 degrees Celsius and greater than 1
degree difference)

PERFUSION
CAPILLARY REFILL less than 2 seconds
URINE OUTPUT minimum of 1 ml / kg hour

CIRCULATING BLOOD VOLUMES

NEONATES 80-90 MLS / KG (term)

100 MLS / KG
INFANTS 75-80
CHILDREN 70-75
ADULTS 65-70

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 PULSE OXIMETRY

Oxygen Saturation (Sa02) at birth

Acceptable pre-ductal SpO2

2 min 60%
3 min 70%
4 min 80%
5 min 85%
10 min 90%
(Resuscitation Council, 2010)

Oxygen Saturation (Sa02) Neonatal

Keep limits 95-100% in term babies and those that have persistent pulmonary
hypertension of the newborn.

Keep limits 89-93% for preterm babies requiring oxygen before their eyes have
vascularised fully. For preterm babies in air only, the upper limit can be set to
100%.

Transcutaneous oxygen and CO2

Aim for the same values as blood gas values

Pa02 6.5 – 10 kPa (preterm) / 6.5 – 12 (infant / child)
paCO2 4-6 kPa

OXYGENATION INDEX

FiO2 x MAP x 100

---------------------
Oxygen Index (OI) =
PaO2 (in mmHg)

NB; Pa02 is in mmHg (to convert Kpa to mmHg, multiply by 7.5)

http://www.medcalc.com/oxygen.html

TIDAL VOLUMES

NEONATES 4-6 MLS / KG

CHILDREN 6- 10 MLS / KG

GLUCOSE
> 2.6 MMOLS in the at-risk / sick neonate
4-6 mmol. after the newborn period and in children / adults

NB All values are averages & should serve as a guideline. Individual differences /
variations always apply.

(ADAPTED FROM ; Rennie and Roberton, 2002, Rennie, 2005, Boxwell, 2010)

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 TABLE 4
BLOOD GAS VALUES

CORD BLOOD GAS VALUES

pH / PCO2 / PO2 / Base Excess (BE)

Venous = 7.28 – 7.35 / 5-6 kPa / 3.8 -5 kPa / -4

Arterial = 7.25 - 7.28 / 6.5 kPa / 2.4 -3 kPa / -4

(Averages. Citations differ slightly)

Pomerance (2002)

Normal Neonatal Blood gas values

pH C02 02 Bicarbonate Base

7.35 – 7.44 4 –6 kpa 7-12 kpa 18 – 25 mmols +4 to -4
6.5 – 10 kpa
(preterm)

(Reference Cameron and Haines, 2000)

FOR ‘Uncompensated’ gas (i.e. pH is abnormal)

Low ph & high Co2 =- respiratory acidosis

Low pH and large base deficit /low bicarb. = metabolic acidosis
High pH and low CO2 = respiratory alkalosis
High pH and large base excess /high bicarb = metabolic alkalosis

FOR ‘compensated’ gas (ie ph is normal but other values are out of range)

PH CO2 Bicarb Problem

Low normal High High Compensated Respiratory acidosis
High normal Low Low Compensated Respiratory alkalosis
Low normal Low Low Compensated Metabolic acidosis
High normal High High Compensated Metabolic alkalosis

VARIATIONS –

Different sources may cite slight variations.

In addition, these values above are general values for healthy, term neonates. For
the sick, preterm neonate and for neonates in oxygen, it is necessary to keep the
pa02 at 6.5 – 10 kpa.
In addition, capillary and venous values of 02 should not be used for assessing
oxygen status (except cord values)
The neonate with chronic lung disease will have a compensated high CO2- i.e.
normal pH, high CO2 and high bicarbonate

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 TABLE 5
BLOOD VALUES

Electrolytes – normal values

Alkaline Phosphatase (0-2 years) 100-350 iu

Ammonia < 40-50 mols
Amylase 8-85 iu
Aspartate Transaminase (AST) 15-45 u/L
Bicarbonate 18-25 mmol/L
Bilirubin (total) 2-24 mol/L
Bilirubin (conjugated) up to 4 mol/L
Calcium (ionised) 1.2-1.3 mmol/L
Calcium (total) 2.1-2.6 mmol/L
Chloride 9-110 mmol
Creatinine 60-120 micromol/L
Glucose 3.6-5.4 mmoll
Insulin <15 mu/L
Iron 9-27 mol/L
Lactate (venous) 1-1.8 mmol/L
Magnesium 0.7-1 mmol/L
Phosphate 1.3-2.1 mmol/L
Potassium 3.5-5.5 mmol/L
Protein (total) 57-80 g/L
Albumin 33-47 g/L
Globulin 17-38 g/L
Plasma Osmolarity 270-295 mmol/kg
Sodium 135-145 mmol/L
Urea 1.0-8.5 mmol/L
CSF protein up to 0.3 g/L

Full blood count values

Term infants

Cord blood 24 hours 1 week

Mean Hb (g/dl) 16.8 18.4 17
Range WBC (x10/9/L) 10-26 14-31 6-15
Platelets (x10/9/L) 150-400
Preterm infants

Mean Hb (g/dl) 14.5

Range WBC (x10/9/L) 5-19 5-21 6-18
Platelets (x10/9/L) 100-350
(Rennie and Roberton, 2002)

28wks 34 wks Term Day 1 Day 3 Day 7 Day 14

Hb 14.5 15 16.8 18.4 17.8 17 16.8
Hct % 45 47 53 58 55 54 52

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 General ranges for year 1 of life

Haematocrit(PCV – packed cell volume) 0.35 - 0.45 (35-45%)

Haemoglobin 9 - 14.5 g/dl
Platelets 150 - 400 x 10 /L
White cells 6 - 18
Neutrophils 2 - 8.5
Lymphocytes 1 - 5-4
Monocytes 0.2 - 0.8

Clotting values
TERM

Test (seconds) Day 1 Day 5 Day 30 Adult

Prothrombin time (PT) 13 12.4 11.8 12.4
Partial thromboplastin time (PTT) 42.9 42.6 40.4 33.5
Fibrinogen (g/l) 2.83 3.12 2.7 2.78
(NB Values are averages and variations around the mean exist by + or minus 1-1.5 seconds)

PRETERM

Test (seconds) Day 1 Day 5 Day 30 Adult

Prothrombin time (PT) 13 12.5 11.8 12.4
Partial thromboplastin time (PTT) 53.6 50.5 44.7 33.5
Fibrinogen (g/l) 2.43 2.8 2.54 2.78
(NB Values are averages and variations around the mean exist by + or minus 1-1.5 seconds)

(Rennie and Roberton, 2002)

SUMMARY -
Prothrombin time 12 – 18 seconds
PTT 29-52 seconds
TT 8-12 seconds
Fibrinogen 1 – 8-4 g/L

(Skinner, 2000)

Other values

C.R.P < 2 mg/L (although a trend is most important)

Lactate < 5 mmols / L

Setting alarm limits

The norms above should be considered plus the norm for that individual baby and
condition. However, a general guide is as follows ….
Heart rate – 100 - 200
Respiratory rate – 30 - 80
Blood pressure – Mean >30 and less than 60. Aim for higher in the term neonate
and in PPHN (> 40)
Saturation - In air 90-100% / In oxygen 89-93%
Tc02 / Pa02 - 6.5 -10

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 Urinalysis checklist

PH The average urine is slightly acidic and usually 5-6 but can vary from
4.8 – 8.5. Urine pH can be helpful in the diagnosis of renal problems /
competency, metabolic disturbances, blood gas compensation.

Specific gravity A quick and convenient test for monitoring the concentrating and
diluting power of the kidney, recognising dehydration and fluid
overload. Range = 1.000 to 1.030. Low concentration (nearer 1.000)
may be caused by high fluid intake. High concentration (nearer 1.030)
may be caused by inadequate fluid intake

Bilirubin Presence of bilirubin is indicative of hepatic disease. Should be

negative.

Urobilinogen Normally present in urine at 0.1 – 1.9 EU / dl.

Protein Urine can contain a very small amount of protein (trace) but high
levels can indicate infection, renal disease, immature kidneys. Should
be negative or no more than a trace.

Blood Presence of blood suggests renal disease and/or infection or bleeding

disorders. Should be negative

Ketones Breakdown products of fatty acid metabolism caused by inadequate

nutrition. Should be negative

Glucose Presence of glucose is indicative of Hyperglycaemia, stress, metabolic

disorders, renal incompetency. Should be negative

Expected weight gain and fluid balance

Plot weight on centile chart according to gestation

All newborns lose 10 - 15% birthweight in the 5-7 days with weight gain
commencing by 7-10 days (Rennie, 1992). Weight is usually regained by 3
weeks (Spence, 2000).
Fluids and drugs are calculated on birthweight until this has been regained –
then, generally, calculations are on current weight.
Normal intrauterine growth is 10-15 grammes / kg / day although preterm
neonates rarely achieve this
Neonates should be weighed every 24 hours if possible. Length and head
circumference are also important to measure once weekly in conjunction
with weight as these are indices of skeletal and organ growth whereas weight
can be influenced by fluid changes and fat deposition (Spence, 2000).
Supplementation with multivitamins / folic acid / iron (or by breast milk fortifier
/ added low-birthweight formula) is required in the neonate born preterm
when they are on full feeds and TPN has been discontinued (after 3 weeks
age)
Urine output should be minimum of 1ml/kg/day on day 1, then 2-3 mls / kg /
day thereafter.

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 REFERENCES

Boxwell, G. (ed) (2010) Neonatal Intensive Care Nursing (2nd edition) .

London: Routledge.

Hockenberry, M. J. and Wilson, D. (2006) Wong's Nursing Care of Infants and

Children. 8th ed. St Louis: Mosby.

Johnstone, P. (2003) The Newborn Child. 9th ed. Edinburgh: Churchill

Livingstone.

Lissauer, T. and Fanaroff, A. (eds) (2006) Neonatology at a Glance. Oxford:

Blackwell.

Merenstein, G. and Gardner, S. (eds) (2006) Handbook of Neonatal Intensive

Care. 6th ed. London: Mosby.

Pomerance J (2002) Perinatal / Neonatal Case Book Umbilical Cord Blood

Gas casebook Journal of Perinatology, 22, 504-505

Rennie and Roberton NRC (2002) A Manual of Normal Intensive Care

London, Edward Arnold

Rennie J (2005) Roberton's Textbook of Neonatology (4th edition) Churchill

Livingstone; Oxford

Resuscitation Council (2010) Newborn life support manual (3rd edition). Resus
Council, London www.resus.org.uk/

Skinner S (2000) Understanding Clinical investigations – a quick reference

manual Bailliere Tindall, London / Philadelphia

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