C.

PHYSICAL EXAMINATION TECHNIQUE ◆ Vigorously crying w/ accompanying

activity of arms & legs
➔ Initial examination of newborn infant:
➔ Active & passive tone & any unusual posture
performed as soon as possible after delivery
should be noted
➔ Temp, pulse, RR, color, signs of respiratory
➔ Coarse, tremulous movements w/ ankle or jaw
distress, tone, activity, & level of consciousness:
myoclonus: more common & less significant in
monitored frequently until stabilization
newborn infants than at any other age; occur
➔ High-risk deliveries: examine in delivery room;
when infant is active
focus on congenital anomalies(3-5%),
➔ Convulsive twitching: quiet state
maturation & growth, & pathophysiologic
➔ Edema: produce superficial appearance of good
problems that may interfere w/ normal
nutrition
cardiopulmonary & metabolic adaptation to
➔ Pitting after applied pressure may or may not be
extrauterine life
noted, but the skin of the fingers & toes lacks
➔ After a stable delivery room course, a 2nd &
the normal fine wrinkles when filled with fluid
more detailed examination should be
➔ Edema of eyelids: commonly results from
performed w/in 24 hr of birth
irritation caused by silver nitrate
➔ Infant remains in the hosp >48 hrs: repeat
➔ Generalized edema: prematurity,
assessments performed throughout the hospital
hypoporoteinemia secondary to severe
stay including discharge examination w/in 24 hr
erythroblastosis fetalis, nonimmune hydrops,
discharge
congenital nephrosis, Hurler syndrome,
➔ Healthy infant: mother should be present during
unknown causes
examination; minor insignificant anatomic
➔ Localized edema: suggests congenital
variations may worry the parents & should be
malformation of the lymphatic system
explained carefully & skillfully
◆ When confined to >1 extremities of
➔ Infants should NOT be discharged w/o final
female infant: initial sign of Turner
examination because:
Syndrome
◆ Cyanosis & heart murmurs often
appear/disappear in the immediate
Skin
neonatal period
➔ Vasomotor instability & peripheral sluggishness:
◆ Evidence of disease that has just been
◆ deep redness or purple lividity in a
acquired may be noted
crying infant, whose color may darken
➔ Examine:
profoundly w/ closure of the glottis
◆ Pulse (N: 120-60 beats/min)
preceding a vigorous cry
◆ Respiratory rate (N: 30-60 breaths/min)
◆ harmless cyanosis (acrocyanosis) of the
◆ Temperature
hands & feet, especially when they are
◆ Weight
cool.
◆ Length
➔ Mottling: general circulatory instability;
◆ Head circumference
associated w/ serious illness or related to
➔ Dimensions of any visible/palpable structural
transient fluctuation in skin temperature
abnormality should be assessed
➔ Harlequin color change: extraordinary division
➔ Blood pressure: determined if neonate appears
of the body from forehead to the pubis into red
ill or has a heart murmur
& pale halves; transient & harmless
➔ Pulse oximetry: screen for critical congenital
➔ Significant cyanosis: masked by pallor of
heart disease; part of the routine screening of
circulatory failure or anemia
newborn infants
➔ High hemoglobin content of the 1st few days &
➔ If infant is quiet & relaxed at the beginning of
thin skin: appearance of cyanosis at a higher
the examination: palpation of abdomen or
partial pressure of arterial oxygen (PaO2) than in
auscultation of heart should be performed first
older children
➔ Localized cyanosis differentiated from
General Appearance
ecchymosis: momentary blanching pallor (w/
➔ Physical activity: decreased due to illness/drugs
cyanosis) that occurs after pressure; same
◆ Lying w/ extremities motionless:
maneuver demonstrates icterus
conserve energy for effort of difficult
➔ Pallor: due to anemia, asphyxia, shock, edema
breathing
➔ Early recognition of anemia → diagnosis of
fetomaternal blood transfusion, erythroblastosis
fetalis, subcapsular hematoma of liver or
spleen, subdural hemorrhage, fetal-maternal or
twin-twin transfusion
➔ Without being anemic, postmature infants tend
to have paler & thicker skin than term or
preterm infants
➔ Ruddy appearance of plethora: polycythemia
➔ Vernix & common transitory macular capillary
hemangiomas of the eyelids & neck:
➔ Cavernous hemangiomas: deeper, blue masses;
if large, trap platelets and produce disseminated
intravascular coagulation or interfere w/ local
organ function
➔ Scattered petechiae: seen on presenting part
(scalp or face) after a difficult delivery
➔ Mongolian spots
◆ slate-blue, well-demarcated areas of
pigmentation
◆ seen over the buttocks, back, other part
of the body in >50% black, Native
American, & Asian infants, occasionally
in white
◆ benign patches, no anthropologic
significance
◆ disappear w/in the 1st year
➔ Vernix, skin, cord: stained brownish yellow if
amniotic fluid has been colored by the passage
of meconium during or before birth
➔ Skin of premature infant: thin & delicate, deep
red
➔ Extremely premature infants: almost gelatinous
& translucent skin
➔ Lanugo: fine, soft, immature hair; frequently
covers scalp & brow & cover face of premature
infants
➔ Tufts of hair over the lumbosacral spine:
suggest abnormality such as occult spina bifida,
a sinus tract, or a tumor
➔ Nails: rudimentary in very premature infants,
protrude beyond the fingertips in infants born
post term
➔ Postterm infants: peeling, parchment-like skin;
may mimic ichthyosis congenita
➔ Erythema toxicum
◆ small, white papules on an
erythematous base
◆ develop 1-3 days after birth
◆ benign rash
◆ persist for 1 week
◆ mainly eosinophils
◆ distributed the face, trunk, extremities
➔ Pustular melanosis
◆ benign lesion in black neonates
◆ mainly neutrophils
◆ present at birth as vesiculopustular
eruption around chin, neck, back,
extremities, & palms or soles
◆ lasts 2-3 days
➔ Erythema toxicum & pustular melanosis should
be differentiated from: Herpes simplex &
staphylococcal disease of the skin
➔ Amniotic bands
◆ disrupt the skin, extremities
(amputation, ring constriction,
syndactyly), face (clefts), or trunk
(abdominal or thoracic wall defects)
◆ due to amniotic membrane rupture or
vascular compromise w/ fibrous band
formation
➔ Excessive skin fragility & extensibility w/ joint
hypermobility: Ehlers-Danlos Syndrome, Marfan
Syndrome, congenital contractural
arachnodactyly, & other disorders of collagen
synthesis
Skull
➔ Skull may be molded: first-born & head engaged
in pelvic canal for a considerable time
➔ Caput succedaneum: due to scalp pressure
from the uterus, cervix, or pelvis; circular boggy
area of edema w/ indistinct borders & often w/
overlying ecchymosis
➔ Cephalohematoma: well-circumscribed
fluid-filled mass that does NOT cross suture
lines
➔ Unlike caput succedaneum, cephalohematoma
is often NOT present at delivery but develops
over the 1st few hr of life. Both conditions must
be distinguished from subgaleal hemorrhage
➔ Subgaleal hemorrhage: NOT restricted by
boundaries of sutures; larger & more diffuse;
requires prompt recognition because extensive
bleeding may result in hypovolemic shock;
mortality 20%
➔ Microcephaly: excessively small head
◆ Genetic disorders, congenital infection,
intrauterine drug exposure
➔ Megalencephaly: excessively large head
◆ Hydrocephaly, storage disease,
achondroplasia, cerebral gigantism,
neurocutaneous syndromes, inborn
errors of metabolism, familial disorder
 ➔ Suture lines & size & fullness of anterior &
posterior fontanels: determined digitally by
palpation
➔ Parietal bones: override occipital & frontal
bones
➔ Cranial synostosis: premature fusion of sutures;
hard non movable ridge over the suture &
abnormally shaped skull
➔ Great variation in size of fontanels exists at
birth; if small, anterior fontanel tends to enlarge
during the 1st few mo after birth
➔ Persistence of excessively large anterior
(normal: 20 +10 mm) & posterior fontanels:
associated w/ several disorders
➔ Persistently small fontanels: microcephaly,
craniosynostosis, congenital hyperthyroidism,
wormian bones
➔ Presence of 3rd fontanel: trisomy 21, preterm
infants
➔ Craniotabes: soft areas; occasionally found in
parietal bones at the vertex near sagittal suture;
more common in preterm infants & infants
exposed to uterine compression
➔ Soft areas in occipital region: irregular
calcification & wormian bone formation
associated w/ osteogenesis imperfecta,
cleidocranial dysostosis, lacunar skull, cretinism,
Down syndrome
➔ Atrophic or alopecic scalp areas: aplasia cutis
congenita; sporadic/autosomal dominant;
associated w/ trisomy 13, chromosome 4
deletion, or Johanson-Blizzard syndrome
➔ Deformational plagiocephaly: result of in utero
positioning forces on skull; asymmetric skull &
face w/ ear malalignment; associated w/
torticollis & vertex positioning
➔ Depression of skull (indentation, fracture,
Ping-Pong ball deformity): prenatal onset; result
of prolonged focal pressure by maternal pelvic
bone
Face
➔ Dysmorphic features: epicanthal folds, widely
or narrowly spaced eyes, microphthalmos,
asymmetry, long philtrum, low-set ears; often
associated w/ congenital syndromes
➔ Face may be asymmetric due to:
◆ 7th nerve palsy
◆ Hypoplasia of depressor muscle at the
angle of the mouth
◆ Abnormal fetal posture
➔ When jaw has been held against a shoulder or
extremity during intrauterine period, mandible
may deviate strikingly from the midline
➔ Symmetric facial palsy: absence or hypoplasia of
7th nerve nucleus (Mobius syndrome)
Eyes
➔ Open spontaneously if infant is held up & tipped
gently forward & backward
➔ This maneuver is a result of labyrinthine & neck
reflexes: more successful for inspecting eyes
than forcing the lids apart
➔ Conjunctival & retinal hemorrhages: usually
benign
➔ Retinal hemorrhages
◆ more common w/ vacuum or
forceps-assisted deliveries than
spontaneous vaginal delivery
◆ least common after cesarean section
◆ bilateral, intraretinal, in posterior pole
◆ Resolve in most infants by 2 wk (85%)
◆ Resolve in all infants by 4 wk
➔ Pupillary reflexes: present after 28-30 wk of
gestation
➔ Iris: inspected for colobomas & heterochromia
➔ Cornea >1cm in diameter in term infant (w/
photophobia & tearing) or corneal clouding:
congenital glaucoma; requires prompt
ophthalmologic consultation
➔ Bilateral red reflexes: absence of cataracts &
intraocular pathology
➔ Leukoria (white pupillary reflex): cataracts,
tumor, chorioretinitis, retinopathy of
prematurity, or persistent hyperplastic primary
vitreous; warrants immediate ophthalmologic
consultation
Ears
➔ Deformities of pinnae: occasionally seen
➔ Unilateral or bilateral preauricular skin tags:
occur frequently
➔ If pedunculated skin tags: tightly ligated at base
→ dry gangrene & sloughing
➔ Tympanic membrane: easily seen otoscopically
through the short & straight external auditory
canal; normally appears dull gray
Nose
➔ May be slightly obstructed my mucus
accumulated in narrow nostrils
➔ Nares: should be symmetric & patent
➔ Dislocation of nasal cartilage from vomerian
groove → asymmetric nares
 ➔ Anatomic obstruction of nasal passages
secondary to unilateral or bilateral choanal
atresia → respiratory distress
Mouth
➔ Normal mouth rarely have precocious dentition,
w/ natal (present at birth) or neonatal (eruption
after birth) teeth in lower incisor position or
aberrantly placed; these teeth are shed before
the deciduous ones erupt; extraction NOT
indicated
◆ Ellis-van Creveld
◆ Hallermann-Streiff
➔ Premature eruption of deciduous teeth: more
unsual
➔ Soft & hard palate: inspected & palpated for
complete or submucosal cleft; contour noted if
arch is excessively high or uvula is bifid
➔ Epstein pearls: temporary accumulations of
epithelial cells on the hard palate on either side
of the raphe
➔ Retention cysts: seen on the gums; similar
appearance to epstein pearls
➔ Epstein pearls & retention cysts: disappear
spontaneously w/in a few weeks of birth
➔ Clusters of small, white, or yellow follicles or
ulcers on erythematous bases:
◆ anterior tonsillar pillars
◆ most frequently on 2nd/3rd day of life
◆ unknown cause
◆ clear w/o treatment in 2-4 days
➔ Neonates do NOT have active salivation
➔ Tongue: large
➔ Frenulum: short, but its shortness (tongue-tie
or ankyloglossia) is rarely a reason for cutting it
➔ Problems w/ feedings (breast or bottle) &
frenulum is short → frenulectomy (frenotomy)
➔ Frenotomy: reduce maternal nipple pain &
improve breastfeeding scores more rapidly than
no treatment
➔ Neonates not treated w/ frenotomy: also have
successful feeding
➔ Sublingual mucous membrane: occasionally
forms a prominent fold
➔ Cheeks: fullness on both buccal & external
aspects due to accumulation of fat in the
sucking pads
➔ Sucking pads & labial tubercle on the upper lip
(sucking callus): disappear when suckling ceases
➔ Marble-sized buccal mass: benign idiopathic fat
necrosis
➔ Throat: difficult to see due to low arch of palate;
should be clearly viewed because posterior
palatal or uvular clefts are easy to miss
➔ Tonsils: small
Neck
➔ Short
➔ Abnormalities NOT common but include:
◆ Goiter
◆ Cystic hygroma
◆ Branchial cleft cysts
◆ Teratoma
◆ Hemangioma
◆ Lesions of sternocleidomastoid muscle:
traumatic or caused by fixed positioning
in utero that produces either hematoma
or fibrosis
➔ Congenital torticollis: head turn toward & and
the face turn away from the affected side
➔ Plagiocephaly, facial asymmetry, &
hemihypoplasia: develop if congenital torticollis
is untreated
➔ Redundant skin or webbing in female infant:
intrauterine lymphedema & Turner Syndrome
➔ Clavicles: both palpated for fractures
Chest
➔ Breast hypertrophy: common; milk may be
present (should not be expressed)
➔ Asymmetry, erythema, induration, &
tenderness: mastitis or breast abscess
➔ Supernumerary nipples, inverted nipples, or
widely spaced nipples w/ a shield-shaped chest:
may be seen
➔ Widely spaced nipples w/ a shield-shaped chest:
Turner Syndrome
Lungs
➔ Much can be learned by observing breathing
➔ Normal variations in rate & rhythm:
characteristic & fluctuate according to infant’s
physical activity, state of wakefulness, or
presence of crying
➔ Fluctuations are rapid; respiratory rate: counted
for a full minute w/ infant in resting state,
preferably asleep.
➔ Usual rate for normal term infants: 30-60
breaths/min
➔ Premature infants: rate is higher & fluctuates
more rapidly
➔ Rate consistently >60 breaths/min during
periods of regular breathing that persists for >1
hr after birth: indication to rule out pulmonary,
cardiac, or metabolic (acidosis) etiologies
 ➔ Preterm infants: may breathe w/ Cheyne-Stokes
rhythm (periodic respiration) or w/ complete
irregularity
➔ Irregular grasping, sometimes accompanied by
spasmodic movements of mouth & chin:
strongly indicates serious impairment of
respiratory centers
➔ Breathing of newborn infants at rest:
diaphragmatic; during inspiration, soft front of
thorax drawn inward while abdomen protrudes
➔ If baby is quiet, relaxed, & w/ good color:
“paradoxical movement”; does not signify
insufficient ventilation
➔ Labored respiration w/ retractions: respiratory
distress syndrome, pneumonia, anomalies,
mechanical disturbance of lungs
➔ Weak, persistent, or intermittent groaning,
whining cry, or grunting during expiration:
potentially serious cardiopulmonary disease or
sepsis; warrants immediate attention
➔ When benign, grunting resolves 30-60 min after
birth
➔ Flaring of alae nasi & retraction of intercostal
muscles & sternum: common signs of
pulmonary pathology
➔ Normal breath sounds: bronchovesicular
➔ Diminished breath sounds, rhonchi, retractions,
or cyanosis: always verified w/ chest radiograph;
suspicion of pulmonary pathology
Heart
➔ Normal variation in size & shape of heart →
difficult to estimate size of heart
➔ Location of heart: determined to detect
dextrocardia
➔ Pulse:
◆ 110-140 beats/min at rest
◆ 90 beats/min in relaxed sleep
◆ 180 beats/min during activity
➔ Supraventricular tachycardia: >220 beats/min;
determined better w/ cardiac monitor or ECG
than by auscultation
➔ Preterm infants: higher resting heart rate; 160
beats/min; may have sudden onset of sinus
bradycardia secondary to apnea
➔ Admission to & discharge from nursery: infant’s
pulses palpated in upper & lower extremities to
detect coarctation of the aorta
➔ Transitory murmurs: closing ductus arteriosus
➔ Congenital Heart Disease (CHD): does NOT
initially produce a murmur; many infants w/
persistent murmurs detected during routine
neonatal examination have underlying
malformation
➔ Routine screening for critical CHD using pulse
oximetry: performed between 24-48 hrs of life;
sensitivity 80%; specificity >99%
➔ Pulse oximetry screening w/ SO2 of >95% in the
right hand or either foot, & <3% difference
between right hand & foot: NORMAL screening
test
➔ SO2 of <95%: referred for evaluation & possible
echocardiogram
➔ BP measurements: evaluate ill-appearing infants
& those suspected of CHD
➔ Oscillometric method: easiest & most accurate
noninvasive method
➔ Mean BP values: vary by gestational age
➔ For all neonates: BP is expected to rise in the 1st
72 hrs after birth
Abdomen
➔ Liver: usually palpable as much as 2 cm below
rib margin
➔ Tip of spleen: may be felt
➔ Size & location of each kidney: determined by
deep palpation
➔ No other period in life does the amount of air in
GI tract vary so much, nor is it usually as great
under normal circumstances
➔ Intestinal tract: gasless at birth
➔ Gas: swallowed soon after birth; normally
present in the rectum on radiograph by 24 hrs
➔ Abdominal wall: normally weak (esp in
premature infants)
➔ Diastasis recti & umbilical hernias: common
among black infants
➔ Unusual masses: investigated immediately with
ultrasonography
➔ Renal pathology: cause of most neonatal
abdominal masses
➔ Cystic abdominal masses:
◆ Hydronephrosis
◆ Multicystic-dysplastic kidneys
◆ Adrenal hemorrhage
◆ Hydrometrocolpos
◆ Intestinal duplication
◆ Choledochal, ovarian, omental, or
pancreatic cysts
➔ Solid masses:
◆ Neuroblastoma
◆ Congenital mesoblastic nephroma
◆ Hepatoblastoma
◆ Teratoma
 ➔ Solid flank mass: renal vein thrombosis;
clinically apparent w/ hematuria, hypertension,
& thrombocytopenia
➔ Renal vein thrombosis in infants
◆ Polycythemia
◆ Dehydration
◆ Maternal diabetes
◆ Asphyxia
◆ Sepsis
◆ Nephrosis
◆ Hypercoagulable states (antithrombin III
& protein C deficiency)
➔ Abdominal distention at birth or shortly
afterward:
◆ obstruction or perforation of GI tract
◆ result of meconium ileus
◆ later distention → lower bowel
obstruction, sepsis, or peritonitis
➔ Scaphoid abdomen: diaphragmatic hernia
➔ Abdominal wall defects: omphalocele
(umbilicus); gastroschisis (lateral to midline)
➔ Omphaloceles: Beckwith-Wiedemann,
conjoined twins, trisomy 18, meningomyelocele,
imperforate anus
➔ Omphalitis
◆ Acute local inflammation of the
periumbilical tissue
◆ May extend to abdominal wall,
peritoneum, umbilical vein, or portal
vessels or liver → portal hypertension
➔ Umbilical cord: 2 arteries, 1 vein
➔ Single umbilical artery: increased risk for occult
renal anomaly
Genitals
➔ Genitals & mammary glands
◆ normally respond to transplacentally
acquired maternal hormones
◆ Produce enlargement & secretion of
breasts in both sexes
◆ Prominence of genitals in females, w/
considerable nonpurulent discharge
● These transitory manifestations
require no intervention.
➔ Imperforate hymen or other causes of vaginal
obstruction → hydrometrocolpos & lower
abdominal mass
➔ Normal scrotum at term: large; size increased by
trauma of breech delivery or transitory
hydrocele
➔ Hydrocele: distinguished from hernia by
palpation & transillumination
➔ Tests: in scrotum; palpable in canals in term
infants
➔ Black male infants: dark pigmentation of
scrotum before rest of the skin assumes its
permanent color
➔ Scrotum: may be ecchymotic from breech
presentation or retroperitoneal hemorrhage;
may contain meconium particles associated w/
meconium peritonitis
➔ Prepuce or foreskin of newborn infant: normally
tight & adherent to penile glans at birth; cannot
be retracted
➔ Foreskin: separate naturally over several
months
➔ Severe hypospadias or epispadias: abnormal
sex chromosomes or infant is masculinized
dfemale w/ enlarged clitoris (may be the first
evidence of adrenogenital syndrome)
➔ Erection of penis: common; no significance
➔ Urine: usually passed during or immediately
after birth; period w/o voiding normally follow
➔ Most neonates void by 12 hrs
➔ 95% of preterm & term infants void w/in 24 hrs
Anus
➔ Some passage of meconium: w/in 1st 12 hrs
after birth
➔ 99% of term infants & 95% premature infants:
pass meconium w/in 48 hrs of birth
➔ Anal opening absent or incorrectly located:
physical examination is sufficient for diagnosis
of imperforate anus
➔ Fistula to the skin, urethra, or vagina: newborn
can pass meconium; imperforate anus may not
be suspected unless a careful exam is done
➔ Abdominal radiographs
◆ Confirm distal obstruction
◆ Determine how low the rectum is
➔ Females w/ imperforate anus: careful
examination of vestibule to ensure separate
openings of urethra & vagina
➔ All newborns w/ anorectal malformations:
evaluation for possible cardiac, renal, & spine
anomalies
➔ Dimple or irregularity in skin fold: normally
present in sacrococcygeal midline may be
mistaken for actual or potential neurocutaneous
sinus
Extremities
➔ Effects of fetal posture: noted so that their
cause & usual transitory nature can be
 explained to the mother; important after breech ➔ Most healthy infants in satisfactory condition:
presentations remain in skin-to-skin contact w/ their mothers
➔ Fracture or nerve injury associated w/ delivery: for immediate bonding & nursing
detected more frequently by observation of ➔ Placed in warmers for prompt resuscitation &
extremities in spontaneous or stimulated monitoring:
activity than by any other means ◆ Infants who fail to initiate or sustain
➔ Hands & feet: examined for polydactyly, respiratory effort after stimulation
syndactyly, abnormal dermatoglyphic patterns ◆ Heart rate <100 beats/min
(simian crease) ◆ Persistent central cyanosis
➔ Hips of all infants: examined w/ specific ➔ Apgar scores NOT used to determine need for
maneuvers to rule out congenital dislocation resuscitation or guide steps of resuscitation
➔ Changes in Apgar scores at sequential time
Neurologic Examination points after birth: reflect how well infant is
➔ In utero neuromuscular diseases associated w/ responding to resuscitation
limited fetal motion produce s & sx independent ➔ 5 min score <7: additional scores assigned every
of specific disease 5 min for up to 20 min
➔ Severe positional deformations & contractures ➔ Fetal distress, prematurity, drugs given to
→ arthrogryposis mother during labor: low Apgar score
➔ Other manifestations:
◆ Breech presentations
◆ Polyhydramnios
◆ Failure to breathe at birth
◆ Pulmonary hypoplasia
◆ Dislocated hips
◆ Undescended testes
◆ Thin ribs
◆ Clubfoot
➔ Congenital disorders: hypotonia, hypertonia,
seizures

ROUTINE NEWBORN CARE

➔ Initial steps after delivery: provide warmth,
drying, & tactile stimulation, while evaluating
respiratory effort, heart rate, & color
➔ Full-term, vigorous infants: initially placed on
mother’s abdomen after delivery
➔ Delayed clamping of umbilical cord: (30-60 sec)
recommended to improve transitional
circulation & increase neonatal RBC volume.
➔ Clearing of the mouth of secretions:
◆ gentle suction w/ bulb syringe or soft
catheter MAINTENANCE OF BODY HEAT
◆ indicated if there is excessive (copious)
➔ Newborn infants: at risk for heat loss &
amount of fluid in mouth or nares
hypothermia
➔ Resource-poor countries: gentle wiping of face,
➔ Body surface area (BSA): 3x adult relative to
nose, & mouth w/ soft cloth equally effective as
body weight
bulb syringe
➔ Generation of body heat: depends in large part
➔ Spontaneously breathing neonates w/o distress:
on body weight
require NO assisted method to clear airway
➔ Heat loss: depends on BSA
➔ Apgar score: practical method of systematically
➔ Low-birthweight & preterm infants: insulating
evaluating infants immediately after birth (1 & 5
layer of subcutaneous fat is thin
min of life)
➔ Estimated rate of heat loss in newborn: 4x adult
➔ Usual delivery room conditions (20-25C):
infant’s skin temperature falls 0.3C/min
➔ Deep body temperature: decreases 0.1C/min
during period immediately after delivery
➔ Cumulative loss: 2-3C in deep body temperature
(corresponding to heat loss of 200 kcal/kg)
➔ Heat loss occurs by 4 mechanisms:
◆ Convection of heat energy to cooler
surrounding air
◆ Conduction of heat to the colder
materials touching the infant
◆ Heat radiation from the infant to other
nearby cooler objects
◆ Evaporation from skin & lungs
➔ To compensate for heat loss in term infants
exposed to cold after birth, they develop:
◆ Metabolic acidosis
◆ Hypoxemia
◆ Hypoglycemia
◆ Increased renal excretion of water &
solutes
➔ Heat production: augmented by increasing
metabolic rate & oxygen consumption in part by
releasing norepinephrine → nonshivering
thermogenesis through oxidation of fat (brown
fat); muscular activity may increase
➔ Hypoglycemic or hypoxic infants: cannot
increase their oxygen consumption when
exposed to cold environment; central
temperature decreases
➔ After labor & vaginal delivery: many infants
have mild to moderate metabolic acidosis →
hyperventilating (response more difficult for
infants w/ CNS depression (asphyxia, drugs) &
infants exposed to cold stress in delivery room)
➔ Reduce heat loss: ensure infants are dried &
either wrapped in blankets or placed w/ mother
or under radiant warmers
➔ Skin-to-skin contact w/ mother: optimal
method of maintaining temperature in stable
newborn
➔ Resuscitative measures on covered infant or one
enclosed in incubator is difficult: radiant heat
source used to warm the baby during
resuscitation