26.1 The Newborn: Normal Findings and Variants, EINC (Unang Yakap), APGAR, Neonatal Resuscitation, Routine Care & Newborn Screening, Jaundice, Respiratory Distress, Hypoglycemia and Neonatal Sepsis

Why this area matters

The TOS newborn competencies are to:

• assess a normal newborn and its physiologic and anatomic variants;
• arrive at a diagnosis in common newborn disorders such as respiratory distress syndrome and metabolic problems;
• apply well-baby and preventive care.

Neonatal deaths make up a large share of under-five deaths in the Philippines. Most of them come from prematurity, birth asphyxia and infection. The DOH Essential Intrapartum and Newborn Care protocol, newborn screening and kangaroo mother care target exactly these causes.

The normal newborn and its variants

• Normal vital signs and measurements:
  • heart rate 120 to 160 bpm;
  • respiratory rate 40 to 60 per minute;
  • temperature 36.5 to 37.5°C;
  • term birth weight 2,500 to 4,000 g.
• Gestational age is estimated by the Ballard score, which uses neuromuscular and physical maturity.
• Normal variants that need only reassurance:
  • Mongolian spots: blue-gray patches over the sacrum, very common in Filipino infants. Document them so they are not mistaken for bruises.
  • Erythema toxicum: red macules with yellow-white papules in the first days; eosinophils on smear.
  • Milia, and Epstein pearls on the palate.
  • Acrocyanosis in the first days.
  • Physiologic breast enlargement and pseudomenses (vaginal withdrawal bleeding from maternal estrogen).
  • Caput succedaneum: scalp edema that crosses suture lines and resolves in days.
  • Cephalohematoma: subperiosteal bleed limited by sutures. It resolves in weeks and may worsen jaundice.
• Findings that need attention:
  • subgaleal hemorrhage: a fluctuant swelling that crosses sutures and can cause shock;
  • a single umbilical artery (associated with renal anomalies);
  • an absent red reflex (cataract or retinoblastoma);
  • hip instability (Ortolani and Barlow tests);
  • ambiguous genitalia;
  • central cyanosis;
  • bilious vomiting;
  • delayed passage of meconium (beyond 48 hours).

Essential Intrapartum and Newborn Care (EINC): The 'Unang Yakap' Protocol

Promulgated under Department of Health (DOH) Administrative Order No. 2009-0025, the Essential Intrapartum and Newborn Care (EINC) guideline—popularly designated as Unang Yakap (First Embrace)—establishes an evidence-based bundle of four core sequential, time-critical practices designed to reduce preventable neonatal mortality. Disrupting this sequence increases risks of neonatal hypothermia, sepsis, intraventricular hemorrhage, and breastfeeding failure.

The Four Core Sequential Steps

1. Immediate and Thorough Drying (First 30 Seconds):

   • Using a clean, dry cloth or towel, the clinician immediately dries the infant thoroughly starting with the face, eyes, head, front, back, arms, and legs.
   • Rationale: Prevents rapid evaporative heat loss (the primary mechanism of neonatal hypothermia) and provides tactile stimulation to initiate spontaneous respiration.
   • Critical Practice: The vernix caseosa must not be wiped off, as it serves as a natural protective barrier against microbial invasion and preserves skin hydration.
   • Wet towels must be immediately removed and replaced with a clean, dry cover.

2. Early Skin-to-Skin Contact (Uninterrupted Until the First Full Breastfeed):

   • The unclothed, dried infant is placed prone directly on the mother's bare chest or abdomen.
   • The infant's back is covered with a clean, warm blanket and a knitted cap or bonnet is placed on the head.
   • Rationale: Provides optimal thermal stability (maternal thoracic skin temperature dynamically warms the hypothermic infant), colonizes the neonate with benign maternal skin flora rather than hospital pathogens, stabilizes cardiac rhythm and blood glucose, and promotes maternal-infant bonding through endogenous oxytocin surge.

3. Appropriately Timed Cord Clamping (1 to 3 Minutes):

   • The umbilical cord is clamped and cut only after umbilical arterial pulsations have completely ceased, typically between 1 and 3 minutes post-delivery (or up to 3 minutes in vigorous infants).
   • Two sterile clamps or ties are applied: the first at 2 cm from the umbilical base and the second at 5 cm from the base, with the cord severed between them using sterile scissors.
   • Rationale: Facilitates physiologic placental transfusion, transferring 80 to 100 mL of blood into the neonatal circulation. This increases neonatal blood volume by 30%, elevates hemoglobin and ferritin stores to prevent infant anemia through 6 months of age, and significantly reduces the incidence of intraventricular hemorrhage and necrotizing enterocolitis in preterm neonates.
   • Contraindicated Practice: Milking or stripping the cord toward the infant is avoided due to risks of hyperviscosity and polycythemia.

4. Early Initiation of Breastfeeding within the First Hour:

   • The clinician observes for developmental feeding readiness cues: rooting, mouth opening, licking, moving the head from side to side, and hand-to-mouth movements (typically emerging 20 to 60 minutes after birth).
   • The mother is assisted with latch-on and positioning (chin touching breast, mouth wide open, lower lip turned outward, more areola visible above the upper lip).
   • Rationale: Ensures delivery of colostrum—rich in secretory Immunoglobulin A (sIgA), lactoferrin, and white blood cells—which lines the neonatal gut mucosa to prevent bacterial translocation, provides early calories to prevent hypoglycemia, and accelerates meconium passage to reduce hyperbilirubinemia.

Obsolete and Harmful Practices Prohibited under EINC

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APGAR Score: Objective Assessment of Transition

Devised by Dr. Virginia Apgar in 1952, the APGAR score provides a standardized, rapid evaluation of the neonate's physiologic transition from intrauterine to extrauterine life. It is routinely recorded at 1 minute and 5 minutes after birth. If the 5-minute score is below 7, evaluation continues every 5 minutes up to 20 minutes.

The APGAR Scoring Grid (0 to 10 Points)

Clinical Interpretation and Board Traps

• Score 7 to 10: Reassuring, normal adaptation; routine post-delivery care.
• Score 4 to 6: Moderately abnormal; indicates physiologic depression requiring thermal support, airway clearing, and tactile stimulation or assisted ventilation.
• Score 0 to 3: Severely depressed; mandates immediate advanced neonatal resuscitation.
• Critical Board Exam Rule: Resuscitation must never be delayed to compute the 1-minute APGAR score. Resuscitation steps under the AAP/AHA Neonatal Resuscitation Program (NRP) are governed by immediate real-time assessments of respirations and heart rate, not by waiting for a formal APGAR calculation.

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Neonatal Resuscitation Program (NRP)

Approximately 10% of newborns require some assistance to begin breathing, and 1% require intensive resuscitation. The Neonatal Resuscitation Program (NRP) follows a strict algorithmic timeline structured in 30-second decision-action cycles.

Step 1: Initial Assessment at Delivery

Upon emergence, ask three rapid screening questions:

1. Is the infant term?
2. Does the infant have good muscle tone?
3. Is the infant breathing or crying?

If the answer is YES to all three: the infant stays with the mother for routine EINC care. If the answer is NO to any question: move the infant immediately to a radiant warmer for initial resuscitation steps.

Step 2: Initial Resuscitation Steps (0 to 30 Seconds)

1. Provide Warmth: Position the infant under a preheated radiant warmer; leave unclothed for visualization.
2. Position Airway: Place the head and neck in the neutral or slightly extended 'sniffing' position. Avoid hyperextension or flexion, which obstructs the airway.
3. Clear Secretions (PRN): Suction the mouth first, then the nose ('M before N') with a bulb syringe only if secretions are copious or obstructing the airway.
4. Dry and Stimulate: Dry the infant and discard wet linens. Provide tactile stimulation by gently rubbing the back or flicking the soles of the feet.

Step 3: Positive Pressure Ventilation (PPV) (30 to 60 Seconds)

Reassess respirations and heart rate (auscultate precordium for 6 seconds and multiply by 10):

• Indications for PPV: Apnea, gasping respirations, or heart rate < 100 beats per minute.
• Equipment & Gas Blend: Use a flow-inflating bag, self-inflating bag, or T-piece resuscitator. For infants $\ge 35$ weeks gestation, initiate PPV with room air (21% O2). For preterm infants $< 35$ weeks, initiate with 21% to 30% O2 to prevent oxidative retinal and pulmonary toxicity.
• Rate: 40 to 60 breaths per minute (cadence: Breathe, two, three; Breathe, two, three).
• Peak Inspiratory Pressure: Initial PIP of 20 to 25 cmH2O; target PEEP of 5 cmH2O.

Step 4: Ventilation Corrective Steps (The MR. SOPA Mnemonic)

If heart rate is not increasing and the chest is not moving after 15 seconds of PPV, execute the MR. SOPA algorithm sequentially:

Step 5: Chest Compressions

• Indication: Heart rate remains < 60 beats per minute despite at least 30 seconds of effective PPV that moves the chest (ideally via an alternative airway).
• Technique: Two-thumb encircling-hands technique on the lower third of the sternum (between the xiphoid process and intermammary line). Compress the chest by one-third of its anteroposterior diameter.
• Ratio & Cadence: 3:1 compression-to-ventilation ratio (3 compressions followed by 1 breath). This provides 90 compressions and 30 breaths (120 events) per minute.
• Oxygen Concentration: Increase supplemental oxygen to 100% FiO2 whenever chest compressions are initiated.

Step 6: Epinephrine Administration

• Indication: Heart rate remains < 60 beats per minute despite 60 seconds of coordinated chest compressions and 100% PPV.
• Concentration: 1:10,000 (0.1 mg/mL).
• Route & Dosage:
  • Intravenous/Intraosseous (Preferred): Administer 0.02 mg/kg (equivalent to 0.2 mL/kg of 1:10,000) via an umbilical venous catheter (UVC), followed by a 3 mL normal saline flush.
  • Endotracheal Route (Temporary): 0.05 to 0.10 mg/kg (0.5 to 1.0 mL/kg), while IV/IO access is being secured.
  • Repeat every 3 to 5 minutes if heart rate remains < 60 bpm.
• Volume Expansion: If there is documented acute blood loss (placental abruption, vasa previa) or signs of shock (pallor, weak pulses, poor perfusion), administer Normal Saline (0.9% NaCl) 10 mL/kg IV over 5 to 10 minutes.

Routine newborn care and screening

• Timing: after the first breastfeed and within the first hours:
  • vitamin K 1 mg IM prevents vitamin K deficiency bleeding;
  • eye prophylaxis (erythromycin or tetracycline ointment) prevents gonococcal ophthalmia;
  • hepatitis B vaccine within 24 hours and BCG.
• Bathing is delayed for at least 6 hours.
• Expanded newborn screening (ENBS) under the Newborn Screening Act (RA 9288, 2004):
  • a heel-prick blood spot, ideally collected after 24 hours of life and before discharge;
  • the expanded panel covers 29 disorders: endocrine (congenital hypothyroidism, congenital adrenal hyperplasia), metabolic (PKU, galactosemia, maple syrup urine disease, homocystinuria and other amino acid, organic acid and fatty acid oxidation disorders), G6PD deficiency, hemoglobinopathies, biotinidase deficiency and cystic fibrosis;
  • PhilHealth's newborn care package covers the test;
  • positive screens are recalled urgently for confirmatory testing.
• Universal newborn hearing screening under RA 9709 (2009) uses otoacoustic emissions or automated ABR before 3 months, so that hearing loss is identified and treated by 6 months.
• Kangaroo mother care (continuous skin-to-skin carrying with exclusive breastfeeding) is recommended for stable low-birth-weight infants. It reduces mortality, hypothermia and infection.

Neonatal Hyperbilirubinemia: Physiologic vs. Pathologic Jaundice

Jaundice is visible when total serum bilirubin (TSB) exceeds 5.0 mg/dL (occurring in 60% of term and 80% of preterm infants). Unconjugated bilirubin is lipid-soluble, cross-reactive with neuronal membranes, and neurotoxic; conjugated bilirubin is water-soluble and excreted in bile.

Physiologic vs. Pathologic Jaundice Criteria

Etiologies of Indirect (Unconjugated) Hyperbilirubinemia

1. ABO Incompatibility: Mother is blood group O, infant is blood group A or B. Maternal anti-A or anti-B IgG antibodies cross the placenta. Typically causes mild to moderate hemolysis with spherocytes on peripheral smear; direct Coombs test is positive or weakly positive. Can occur in the first pregnancy.
2. Rh Isoimmunization: Mother is Rh-negative, infant is Rh-positive. Prior sensitization (sensitizing event in an earlier pregnancy) produces maternal anti-D IgG antibodies. Causes severe hemolysis, profound anemia, hepatosplenomegaly, erythroblastosis fetalis, and hydrops fetalis. Direct Coombs test is strongly positive.
3. G6PD Deficiency: X-linked recessive enzymopathy common in the Philippines (screened in the Philippine Newborn Screening Program under RA 9288). Red blood cells are vulnerable to oxidative stress from infections, naphthalene (mothballs), or drugs, producing acute hemolytic crises with Heinz bodies and bite cells.
4. Breastfeeding vs. Breast Milk Jaundice:
   • Breastfeeding (Lactation Failure) Jaundice: Occurs in the first week of life due to inadequate caloric/fluid intake and infrequent feeds, leading to mild dehydration, delayed meconium passage, and increased intestinal reabsorption of bilirubin via enterohepatic circulation. Management: increase feeding frequency to 8 to 12 times per day; do not discontinue breastfeeding.
   • Breast Milk Jaundice: Develops in the second week of life (peaks days 5 to 15, lasts up to 3 months) in thriving, vigorous infants. Caused by high levels of beta-glucuronidase and free fatty acids in breast milk that deconjugate intestinal bilirubin and inhibit hepatic glucuronosyltransferase. Management: continue breastfeeding; reassure parents.

Phototherapy and Exchange Transfusion

• Phototherapy Mechanics: Blue-green light in the 460 to 490 nm wavelength spectrum penetrates neonatal skin and converts lipophilic unconjugated bilirubin into water-soluble structural isomers (lumirubin) via photoisomerization. Lumirubin bypasses hepatic conjugation and is excreted directly into bile and urine. Eyes must be shielded with opaque patches to prevent retinal damage, and gonads must be covered.
• Bronze Baby Syndrome: A dark, grayish-brown skin discoloration occurring when phototherapy is inadvertently applied to infants with conjugated (direct) hyperbilirubinemia, resulting from photo-induced modification of copper porphyrins.
• Exchange Transfusion: Indicated when total serum bilirubin reaches critical thresholds on the Bhutani nomogram or when signs of acute bilirubin encephalopathy appear. Utilizes double-volume exchange ($160-170\text{ mL/kg}$) through an umbilical venous catheter, removing 85% of circulating red blood cells, half the intravascular bilirubin, and circulating maternal antibodies.
• Kernicterus (Chronic Bilirubin Encephalopathy): Unconjugated bilirubin crosses the blood-brain barrier and deposits preferentially in the basal ganglia (globus pallidus), subthalamic nuclei, and auditory brainstem nuclei. Clinical sequelae include choreoathetoid cerebral palsy, upward gaze palsy (Parinaud syndrome), sensorineural hearing loss, and dental enamel hypoplasia.

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Neonatal Respiratory Distress: Differential Diagnosis

Respiratory distress manifests with tachypnea (respiratory rate $> 60\text{ breaths/minute}$), expiratory grunting, subcostal and intercostal retractions, nasal flaring, and central cyanosis.

Comparison of Major Neonatal Pulmonary Conditions

Neonatal hypoglycemia and other metabolic problems

• Neonatal hypoglycemia:
  • At risk: infants of diabetic mothers, preterm, small- or large-for-gestational-age infants, and infants who are sick, cold or stressed.
  • Symptoms: jitteriness, poor feeding, lethargy, apnea, hypothermia and seizures.
  • Thresholds: many units treat a glucose below about 45 mg/dL (2.5 mmol/L) in the first days, or higher in symptomatic infants.
  • Management:
    • early, frequent breastfeeding, and dextrose gel where available;
    • for symptomatic or persistent hypoglycemia, an IV bolus of 10% dextrose 2 mL/kg followed by an infusion;
    • persistent hypoglycemia beyond the first days needs evaluation for hyperinsulinism or endocrine and metabolic disease.
• Hypocalcemia: early, in infants of diabetic mothers, preterm and asphyxiated infants; late, from high-phosphate feeds or hypoparathyroidism (DiGeorge syndrome). It causes jitteriness and seizures.
• Inborn errors of metabolism: suspect them in a previously well neonate who deteriorates after feeding begins, with vomiting, lethargy, seizures, metabolic acidosis, hypoglycemia or hyperammonemia. ENBS finds many before symptoms appear.

Neonatal sepsis

• Presentation: signs are nonspecific: poor feeding, temperature instability (often hypothermia), lethargy, apnea, respiratory distress, jaundice and hypoglycemia.
• Evaluation: blood culture, a CBC with ratio of immature to total neutrophils, CRP, and a lumbar puncture when indicated.
• Prevention: clean delivery, hand hygiene, early breastfeeding and intrapartum GBS prophylaxis.