The newborn: first twenty-four hours

In one day a newborn switches from placental to pulmonary gas exchange, rewires its circulation, takes over its own temperature, and starts producing its own glucose. Every early complication is one of those four transitions going badly.

The first priorities, in order

1. Establish and maintain the airway. Clear the mouth before the nose, because suctioning the nose first can trigger a gasp that aspirates whatever is in the mouth.
2. Dry thoroughly, remove wet linen, and provide warmth. Skin to skin with a cap on the head. Heat loss drives everything else wrong.
3. Assess and score at one and five minutes.
4. Identify with matching bands before mother and infant are ever separated, then support the first feeding.

Expected, not alarming

• Bluish hands and feet with a pink trunk in the first hours.
• Irregular breathing with brief pauses of a few seconds, without color change.
• Molding, caput succedaneum, milia, congenital dermal melanocytosis, vernix, and lanugo.
• A first void within the first day and a first meconium stool within two days.
• Weight loss in the first days, regained by about two weeks.

Escalate

• Grunting, nasal flaring, retractions, or a sustained respiratory rate above sixty.
• Central cyanosis of the lips, tongue, and trunk.
• Jaundice appearing within the first twenty-four hours, which is pathologic rather than physiologic.
• Temperature instability in either direction.
• Persistent jitteriness, which in the infant of a diabetic mother or in the large or small newborn points to hypoglycemia.
• No void by the end of the first day.

Margin notecold babies burn sugar, then stop breathing well.

Watch outjaundice in the first twenty-four hours is always pathologic and always reported.

TakeawayKeep the newborn warm and breathing, because cold stress is the engine that drives hypoglycemia and respiratory distress.

→ BOOK 12 · P8 for scoring and transition · → BOOK 13 · P4 for reflexes and the schedule · → P53