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Overview of the routine management of the healthy newborn infant

Author Lori A Sielski, MD Section Editor Leonard E Weisman, MD Deputy Editor Melanie S Kim, MD

Literature review current through: Oct 2012. | This topic last updated: feb 6, 2012.

INTRODUCTION After birth, most newborn infants require only routine care to make a successful transition to extrauterine life. The major components of routine care for the term (gestational age 37 weeks) and late preterm (gestational age between 34 to 36 6/7 weeks) neonate are: Delivery room and transitional care, including early bonding Newborn assessment including a comprehensive review of the maternal history and a complete physical examination Prophylaxis care to prevent serious disorders Family education Discharge evaluation DELIVERY ROOM CARE After delivery, immediate neonatal care includes drying the infant, clearing the airway of secretions, and providing warmth. During this initial care, a delivery room assessment of the neonate's clinical status is quickly performed by addressing these questions: Is the infant full-term? Is the infant breathing or crying? Does the infant have good muscle tone? If yes is the answer to all the questions, the infant does not require further intervention and should be given to the mother. Healthy term or late preterm infants should remain with the mother to promote infant-maternal bonding by skin-to-skin contact and early initiation of breastfeeding. If the answer to any of the questions is no, then the infant requires further evaluation and intervention. Oxygen administration Positive pressure ventilation Chest compressions Use of resuscitative medications (eg, epinephrine) Apgar score Evaluation is generally based upon the assignment of an Apgar score at one and five minutes of age. The following signs are given values of 0, 1, or 2 and added to compute the Apgar score. Scores may be determined using the Apgar score calculator. Heart rate Respiratory effort Muscle tone Reflex irritability Color About 90 percent of all neonates have Apgar scores of 7 to 10, and generally require no further intervention. They usually have all of the following characteristics

and can be admitted to the level 1 newborn nursery for routine care: Term or late preterm gestation Spontaneous breathing or crying Good muscle tone Pink color Infants with lower scores may require further evaluation and intervention including one percent of all neonates who require extensive resuscitative measures at birth. The care of these infants is discussed in greater detail separately. Transitional period The transitional period between intrauterine and extrauterine life is during the first four to six hours of life after delivery. Physiological changes that occur during the transitional period include decreased pulmonary vascular resistance with increased blood flow to the lungs, lung expansion with clearance of alveolar fluid and improved oxygenation, and closure of the ductus arteriosus. During this period of time, the clinical status of the infant should be assessed every 30 to 60 minutes to ensure further interventions and/or evaluations beyond routine care are no longer required for successful transition to extrauterine life. The following clinical parameters are monitored beginning in the delivery room and continuing in either the nursery or mother's room: Temperature The normal axillary temperature should be between 36.5 to 37.5C (97.7 to 99.5F) for an infant in an open crib. Initial hyperthermia may be reflective of maternal fever or the intrauterine environment. Persistent hyperthermia or hypothermia may be indicative of sepsis. Hypothermia may contribute to metabolic disorders such as hypoglycemia or acidosis. Respiratory rate The normal respiratory rate is 40 to 60 breaths per minute, which should be counted over a full minute. Tachypnea may be a sign of respiratory or cardiac disease. Apnea may be secondary to exposure to maternal medications (eg, magnesium sulfate and anesthesia), a sign of neurologic impairment, or sepsis. Heart rate The normal heart rate is 120 to 160 beats per minute but may decrease to 85 to 90 per minute in some term infants during sleep. Heart rates that are too high or low may be indicative of underlying cardiac disease.

Color Central cyanosis (lips, tongue, and central trunk) may be indicative of respiratory or cardiac disease. Tone Hypotonia may be secondary to exposure to maternal medications or fever, be indicative of an underlying syndrome (Downs syndrome), sepsis, or neurologic impairment.

ROUTINE CARE A newborn should have a thorough evaluation performed within 24 hours of birth to identify any abnormality that would alter the normal newborn course or identify a medical condition that should be addressed (eg, anomalies, birth injuries, jaundice, cardiopulmonary disorders, or increased risk of sepsis). The assessment of the newborn infant including review of the maternal, family, and prenatal history and a complete examination is discussed in detail separately. The assessment and management for neonatal sepsis are also presented. In addition to the assessment of the newborn, the following routine procedures and ongoing evaluations are performed after birth to prevent serious disorders. Prophylactic eye care to prevent neonatal gonococcal ophthalmia Administration of vitamin K1 to prevent Vitamin K deficient bleeding (VKDB) Hepatitis B vaccination Umbilical cord care to prevent infection Monitoring for hyperbilirubinemia and hypoglycemia In the United States, universal newborn screening for hearing loss, metabolic and genetic disorders, and congenitally acquired infectious disorders are routinely performed in all neonates. Eye care In the neonate, the risk of contracting gonococcal conjunctivitis is markedly reduced by prophylactic administration of ophthalmic antibiotic agents shortly after birth. Ocular prophylaxis is safe, easy to administer, and an inexpensive method to prevent sight-threatening gonococcal ophthalmia. In the United States, the majority of states require prophylaxis against gonococcal ophthalmia neonatorum. The following are regimens recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC): 0.5 percent erythromycin ointment (1 cm ribbon in each eye) 1 percent tetracycline ointment (1 cm ribbon in each eye) Erythromycin ophthalmic ointment causes less chemical conjunctivitis than does silver nitrate solution. However, silver nitrate is more effective as a prophylaxis for penicillinase-producing Neisseria gonorrhoeae than erythromycin and should

be used in areas where that organism is prevalent. One percent silver nitrate solution and 1 percent tetracycline are not commercially available in the United States. Povidone-iodine solution (2.5 percent) also may prevent ocular gonococcal infection with less toxicity and at lower cost than other agents, although further confirmatory studies are needed. This preparation also is not commercially available in the United States. In 2009, there was a shortage of 0.5 percent erythromycin ophthalmic ointment in the United States. As of December 2009, according to the Food and Drug Administration, erythromycin ophthalmic ointment is available in sufficient quantities to meet the historical demand for this product. However, it remains important for institutions to limit their orders to meet their immediate clinical needs until increased production rates produce sufficient amounts to restore inventory supplies. If erythromycin ophthalmic ointment is not available, the Centers of Disease Control (CDC) recommends the following: If 0.5 percent erythromycin ophthalmic ointment is not available, an acceptable alternative is 1 percent azithromycin ophthalmic solution (AzaSite). The recommended dose is 1 to 2 drops placed in the conjunctival sac of each eye, taking care to not touch the applicator tip to the infant. Because this is a solution, it is important to assure that the drops are placed properly, and a two person administration approach should be considered. If neither 0.5 percent erythromycin ophthalmic ointment or 1 percent azithromycin ophthalmic solution is available, other alternatives include: 0.3 percent gentamicin ophthalmic ointment (Gentak) 0.3 percent tobramycin ophthalmic ointment (Tobrex) If none of these are available, a fluoroquinolone ophthalmic ointment (0.3 percent Ciprofloxacin ophthalmic ointment) can be used, but this is a less suitable alternative given data on possible gonococcal antimicrobial resistance. Of note, there have been adverse reports associated with 0.3 percent gentamicin ophthalmic ointment of lid swelling and dermatitis, appearing a few days after ointment application. Most cases have been mild and have not required additional treatment. Some cases were much more severe with eyelid discharge, blistering, erythema, and swelling, which have prompted some clinicians to suggest that gentamicin ophthalmic ointment not be used as an alternative for

neonatal ocular prophylaxis. If gentamicin ointment is used, excess ointment from the eyelids should be removed by delivery room staff to prevent and reduce the severity of this complication. Since there are no efficacy data for any of the above suggested alternatives, providers should be alert to the possibility of failure of prophylaxis. At the first postnatal visit within 48 to 72 hours after discharge, the infant should be examined closely for ophthalmia neonatorum. Infants with ophthalmia neonatorum should be tested for Neisseria gonorrhoeae infection and should be reported to the local health department and CDC as a prophylaxis failure. The CDC has also recommended that hospitals: Routinely review their supply of 0.5 percent ophthalmic ointment. Reserve 0.5 percent ophthalmic ointment for only neonatal prophylaxis. If there are severely low supplies (ie, depletion within the week), contact their wholesale distributor or call Bausch and Lomb customer service, 1-800-323-0000. If supplies are not available, contact the FDA drug shortage email account. Ocular infections in newborns caused by Chlamydia trachomatis are common in the United States. The agents also used for gonococcal prophylaxis are not effective in preventing neonatal chlamydial conjunctivitis. Povidone-iodine appears to be significantly more effective against C. trachomatis than silver nitrate or erythromycin. Technique After wiping each eyelid with sterile cotton gauze, the prophylactic agent is placed in each of the lower conjunctival sacs. The agent should be spread by gentle massage of the eyelids, and excess solution or ointment can be wiped away after one minute. The eyes should not be irrigated after the application because doing so may reduce efficacy. Eye prophylaxis should be performed shortly after birth within the first hour of life in all infants, regardless of whether they are delivered vaginally or by cesarean section. If prophylaxis is delayed, a monitoring system should be established to ensure that all infants receive prophylaxis. The efficacy of longer delays is not known. The principal side effect is chemical (noninfectious) conjunctivitis. This condition typically appears within the first 24 hours of age and resolves by 48 hours. It is most often seen after application of silver nitrate. Vitamin K Prophylactic vitamin K1 is given to newborns shortly after birth to prevent vitamin K deficient bleeding (VKDB), previously referred to as hemorrhagic disease of the newborn. In a systematic review of trials that compared either oral or intramuscular administration of vitamin K to placebo,

vitamin K1 oxide improved biochemical indices of coagulation status during the first week after birth. In the single trial of intramuscular vitamin K, vitamin K compared to placebo was more effective in preventing VKDB. Vitamin K1 can be given either orally or intramuscularly. However, currently used oral regimens are less effective than a single intramuscular dose of vitamin K in preventing late-onset VKDB (defined as bleeding disorder due to vitamin K deficiency in infants between two weeks and two months of age). This was illustrated in a review of surveillance data from four countries that used oral vitamin K prophylaxis in a variety of different regimens. The rate of late-onset VKDB was 1.2 to 1.8 per 100,000 births for oral prophylaxis versus no reported cases of late VKDB in infants who received vitamin K intramuscularly. Several small studies suggested that intramuscular preparations of vitamin K may increase the risk of childhood cancer, however, subsequent studies have failed to show an association between vitamin K and childhood cancer. The American Academy of Pediatrics (AAP) concluded that intramuscular prophylaxis of vitamin K is superior to oral administration because it prevents both early (within the first week of life) and late VKDB, and the risk of cancer from intramuscular vitamin K is unproven. Based upon these conclusions, the AAP recommends vitamin K1 be given to all newborns as a single intramuscular dose of 0.5 to 1 mg. An oral suspension of vitamin K is not available in the United States. Oral prophylaxis with vitamin K1 (2 mg per dose) is generally given at the first feeding and then at one, four, and eight weeks. Small daily oral doses of vitamin K may approach the efficacy level of parenteral administration, but further studies are needed for confirmation. In some countries, oral administration of vitamin K has been advocated because it is easier to administer and is less costly. Efforts continue to develop an oral regimen that is equally effective as the single intramuscular dose of vitamin K. Infants who are premature, receiving antibiotics, or have liver disease or diarrhea, should receive intramuscular prophylaxis because they may have decreased absorption of the oral preparation. Preterm infants The above AAP recommendation to administer intramuscular vitamin K to newborns is based upon evidence obtained in full term infants. The optimal dosing in preterm infants is unknown. In one small controlled trial of infants less than 32 weeks gestation, intramuscular prophylaxis of 0.2 mg provided adequate vitamin K supplementation as demonstrated by normal undercarboxylated

prothrombin concentrations and no evidence of clinical bleeding. A larger intramuscular dose of 0.5 mg resulted in higher vitamin K1 and vitamin K1 2,3epoxide concentrations, suggesting that an excess of vitamin K1 was administered. Further studies with a larger number of patients are required to determine whether the lower intramuscular vitamin K dose of 0.2 mg is sufficient in preterm infants. Umbilical cord The postpartum care of the umbilical cord in reducing the risk of infection (omphalitis) is dependent on the quality of the care at delivery and postnatally. If there is an increased risk for omphalitis especially in a clinical setting of low resources, the use of antiseptic agents (eg, triple dye, alcohol, silver sulfadiazine, and chlorhexidine) for cord care is an excellent and inexpensive option that reduces neonatal morbidity and mortality. However, in developed countries where aseptic care is routine in the clamping and cutting of the umbilical cord, additional topical care beyond dry-cord care is not needed to prevent omphalitis. Hepatitis B vaccination Universal vaccination of newborns regardless of maternal hepatitis B virus surface antigen (HBsAg) status is recommended. Infants of HBsAg-positive mothers should receive hepatitis B immunoglobulin (HBIG) in addition to hepatitis B vaccine (HBV) shortly after birth, preferably within 12 hours of age.

intervention in the first year of life. This report has been endorsed by the American Heart Association, American Academy of Pediatrics, and the American College of Cardiology Foundation. The implementation of a screening program has been challenging because of the costs to train personnel needed to perform testing and establish diagnostic services needed to perform and interpret high-quality echocardiography in a timely manner for infants with positive test results. However, a small number of states require mandatory pulse oximetry screening. Feeding Infants should be fed early and frequently to avoid hypoglycemia. The frequency, duration, and volume of feeds will be dependent upon whether the infant is breastfed or receives formula. Each feeding should be recorded, and if the infant is fed formula, the volume of feeding should also be recorded. Breastfeeding is recommended because of its increased benefits for both the infant and mother compared to formula feeding, except when medically contraindicated, such as in infants with mothers with human immunodeficiency viral (HIV) infection or in some cases of maternal drug abuse. Breastfed infants should be fed as soon as possible after delivery, preferably in the delivery room. They should receive 8 to 12 feeds per day during the newborn hospitalization. Rooming-in, skin-to-skin contact, frequent demand feedings in the early postpartum period, and lactation support increase the rate of successful breastfeeding. Infants who are fed formula should be offered standard 20 cal/oz iron containing formula. They are fed on demand, but the duration between feedings should not exceed four hours. The volume of feedings should be at least 0.5 to 1 oz per feed during the first few days of life. Weight loss Weight loss is normal after delivery particularly in the breastfed infant. However, weight loss beyond 7 percent requires medical attention and should be evaluated with a complete feeding assessment. Normal infants stop losing weight by five days of age and typically regain their birth weight by 10 to 14 days. The expected weight loss is up to 7 percent. Greater weight loss in the breastfed infant should prompt ongoing lactation assessments and interventions. Glucose screening Although neonatal hypoglycemia may contribute to brain injury, healthy asymptomatic term infants born after an uncomplicated pregnancy and delivery are at a low risk for significant hypoglycemia. As a result, blood

Newborn screening
Hearing loss Universal screening for hearing loss is recommended to detect infants with hearing loss. It is legally mandated in most of the United States. Metabolic and genetic disorders In addition, screening for disorders that are threatening to life or long-term health in asymptomatic newborns is recommended so that interventions can be initiated to prevent or reduce morbidity and mortality. Universal screening of newborns for metabolic and genetic disorders, and congenitally acquired infections including phenylketonuria, congenital hypothyroidism, galactosemia, toxoplasmosis, and hemoglobinopathies occurs throughout the entire United States. Critical congenital heart disease In 2011, a report from the United States Health and Human Services Secretarys Advisory Committee on Heritable Disorders in Newborns and Children recommended routine pulse oximetry newborn screening to detect infants with critical congenital heart disease (CHD), defined as CHD requiring surgery or catheter based

glucose measurement is not routinely performed in these neonates. Monitoring of glucose concentration in the normal nursery is performed in the following infants who are at risk for significant hypoglycemia. Premature infants Infants who are large or small for gestational age Infants of diabetic mothers Infants whose mothers were treated with beta adrenergic or oral hypoglycemic agents Infants who require intensive care Infants with polycythemia Infants with symptoms consistent with hypoglycemia such as jitteriness, tremors, hypotonia, irritability, lethargy, stupor, apnea, poor feeding, hypothermia or seizures Newborn circumcision Hyperbilirubinemia Hyperbilirubinemia with a total serum bilirubin level greater than 25 mg/L (428 micromol/L) is associated with an increased risk for bilirubin-induced neurologic dysfunction (BIND). As a result, during the birth hospitalization, infants should be routinely assessed every 8 to 12 hours and at discharge for the presence of jaundice. In patients who present with jaundice within the first 24 hours of life or who have jaundice in excess for their age, bilirubin measurement should be performed either by transcutaneous bilirubin or total serum bilirubin measurement. Because visual assessment is not as reliable as measurement of total serum bilirubin, most birthing centers include routine bilirubin testing either by transcutaneous bilirubin or total serum bilirubin measurement. The most reliable predictor for subsequent development of significant hyperbilirubinemia combines a predischarge bilirubin screen with an assessment of risk factors. Education The parents or primary care giver should receive training and demonstrate competence or understanding of the following infant care tasks. The importance and benefits of breastfeeding. Positioning the infant and determining adequate latch-on and swallowing, if breastfeeding. Appropriate frequency of urination, and defecation and appearance of urine and stool. Cord, skin, and genital care. Recognition of the signs of common neonatal illnesses, particularly hyperbilirubinemia and sepsis. Proper infant safety, including supine sleeping position, and installation and use of car safety seat.

LENGTH OF HOSPITAL STAY The optimal length of stay varies for each mother-infant pair and should be long enough to permit detection of early neonatal problems and to ensure that the family is able and prepared to care for the infant at home. Factors involved in this decision include the health of the mother, the health and stability of the infant, the ability and confidence of the mother to care for the infant, the adequacy of support systems at home, and access to appropriate follow-up care. All efforts should be made to keep the infant-mother dyad together to promote maternal-infant bonding. Discharge criteria Decision for discharge is made jointly with the family, and the obstetric and neonatal care providers and is based upon the perception that the infant-mother dyad are ready for discharge. Factors associated with a need for increased hospital stay include first time mother, chronic maternal illness, in-hospital neonatal illness, breastfeeding, mothers with inadequate prenatal care and poor social support, and black non-Hispanic maternal ethnicity. The American Academy of Pediatrics Committee on Fetus and Newborn issued the following recommended minimum criteria and conditions that should be met before discharge of the newborn: No neonatal abnormality requiring continued hospitalization was detected during the hospital course and physical examination at discharge. The infant's vital signs are within normal ranges and are stable for at least 12 hours before discharge (respiratory rate <60 per min; heart rate between 100 and 160 beats per minute; axillary temperature 36.5 to 37.4C [97.7 to 99.3F]). The infant has urinated and passed at least one stool spontaneously. Almost all term infants will have urinated and passed at least one stool by the first 24 hours of life. The infant has completed at least two successful feedings and is able to coordinate sucking, swallowing, and breathing while feeding. If the infant was circumcised, there is no evidence of excessive bleeding at the circumcision site for at least two hours. If the infant was jaundiced, the clinical significance has been determined and appropriate plans for management and follow-up have been instituted. The infant has been screened and monitored for sepsis based upon maternal risk factors and guidelines for the prevention of perinatal group B streptococcal disease.

The mother has received training and demonstrated competency in the care of her infant as described above. Family members or other support persons, including health care professionals, are available to the mother and her infant after discharge. Maternal test results were reviewed including maternal syphilis, hepatitis B surface antigen status, and, in some states, HIV screening. When clinically indicated, test results for cord or infant blood-type, and neonatal direct Coombs test results were obtained and reviewed. Initial hepatitis B vaccine is administered. Hepatitis B immunoglobulin also is given to infants with mothers who are hepatitis B virus surface antigen positive. Hearing and metabolic screening has been completed. Family, environmental, and social risk factors have been assessed and addressed (eg, substance abuse, child abuse or neglect, domestic violence, mental illness, lack of social support, lack of reliable income). Barriers to follow-up care are assessed and addressed (eg, transportation, telephone communication). A medical home for continuing infant care has been identified and timely communication of pertinent birth hospitalization information has been sent to the care providers of the medical home. If the infant is discharged before 48 hours after delivery, a follow-up appointment should occur at the medical home by a licensed health care professional no later than 72 hours after discharge and within 48 hours if there are identified risk factors. If an appropriately timed follow-up appointment can not be ensured than discharge should be deferred until an appointment can be made. These criteria are generally not achieved before the infant is 48 hours of age. Consideration of discharge before 48 hours of age should be limited to singleton infants who are born between 38 and 42 weeks of gestation, are appropriate weight for gestational age, and who meet the above criteria. Discharge legislation In the United States, because of concerns that early discharge could adversely affect maternal and infant health outcomes, both state and federal governments (Newborns' and Mothers' Health Protection Act [NMHPA]) passed postpartum discharge laws in the late 1990s to prevent extremely short length of hospital stay (LOHS). In general, these laws require insurance plans to cover postpartum stays of up to 48 hours for infants born by vaginal

deliveries and up to 96 hours for cesarean deliveries. The impact of legislation ensuring insurance coverage for a minimum of 48 hours has increased the LOHS of newborn infants and their mothers and appears to have decreased neonatal readmission rates and emergency room visits. FOLLOW-UP VISIT A follow-up visit can take place in the home or clinical setting as long as the health care professional is competent in assessing newborns and communicates the results of the evaluation to the infant's physician. The follow-up visit includes: Assess the general health of the neonate Weigh the infant, assess for signs of dehydration and extent of jaundice, identify new problems, review feeding pattern including stool and urine output Assess the quality of mother-infant interaction Assess infant behavior Reinforce maternal and family education in infant care for feeding, supine sleeping position, child safety seats, and the benefits of breastfeeding (if appropriate) Review results of outstanding laboratory tests including the newborn screen Perform any necessary tests such as bilirubin check in an infant with clinically significant jaundice Verify the plan for health care maintenance and the medical home Assess parental well-being including any indications of post-partum depression in the mother READMISSIONS Despite enactment of the Newborns' and Mothers' Health Protection Act, potentially preventable readmissions of newborns continue to occur. This was illustrated in an analysis of 2540 newborns readmitted in the first 10 days of life who were identified from clinical discharge records collected by the Pennsylvania Health Care Cost Containment Council (PHC4). The following findings were noted: Mean time to readmission was 111 hours since birth and 62 hours since nursery discharge Jaundice was the most common diagnosis occurring in 92 percent of the infants. The remaining infants were readmitted for dehydration, feeding problems, and/or associated electrolyte abnormalities. Multivariate analysis demonstrated that infants were more likely to be readmitted with first-time compared to experienced mothers, mothers of Asian or Pacific Islander

ancestry compared to other races, older mothers greater than 30 years of age compared to younger mothers, or mothers with diabetes or pregnancy-induced hypertension. In addition, nursery length of stay less than <72 hours and prematurity also increased the risk of readmission. These results identified several predictors of newborn readmission that appear to be associated with early discharge, inexperienced parenting, difficulty establishing infant feeding, and in Asian and Pacific Islander infants, who have an increased risk of hyperbilirubinemia. These findings may be useful in providing additional support for at-risk families and anticipatory care, thereby decreasing the need for readmission. SUMMARY AND RECOMMENDATIONS Most newborn infants make a successful transition to extrauterine life and require only routine care immediately after birth. Immediately after an uncomplicated delivery, routine delivery care includes drying the infant, clearing the airway of secretions, and providing warmth. About 90 percent of infants will not require further intervention in the delivery room, and these infants should be given to their mothers for skin-to-skin contact. During the transitional period (first four to six hours of life), optimal routine care, which begins in the delivery room, includes promoting early bonding with skin-to-skin contact and early initiation of breastfeeding, and monitoring the clinical status of the infant every 30 to 60 minutes to determine whether further intervention is required. Routine care includes a thorough evaluation performed within 24 hours of birth to identify any abnormality that would alter the normal newborn course or identify a medical condition that should be addressed during the first days of life. The assessment includes a review of the maternal, family, and prenatal history and a complete examination. We recommend that all neonates are treated with an ophthalmic antibiotic agents shortly after birth to prevent gonococcal conjunctivitis (Grade 1A). In our practice we use 0.5 percenterythromycin ointment (1 cm ribbon in each eye). Alternative medications, which are not available in the United States, include 1 percent silver nitrate solution, 1 percent tetracycline ointment, and 2.5 percent povidone-iodine solution. We recommend that all neonates receive prophylactic administration of vitamin K1

oxide to prevent Vitamin K deficient bleeding (VKDB) (Grade 1A). We recommend intramuscular versus oral preparations of vitamin K because of the superiority of the intramuscular route for prevention of both early and late VKDB (Grade 1C). We recommend hepatitis B vaccination (HBV) of all newborns regardless of maternal hepatitis B virus surface antigen (HBsAg) status to prevent HB infection (Grade 1B). We recommend that infants of HBsAg-positive mothers receive both hepatitis B immunoglobulin (HBIB) and HBV shortly after birth (table 2) (Grade 1A). In the United States, universal newborn screening for hearing loss and disorders that are threatening to life or long-term health is implemented in all fifty states. Routine care includes assessing infants for hyperbilirubinemia and hypoglycemia, which may result in significant morbidity. Minimum criteria and conditions established by the American Academy of Pediatrics should be met prior to discharge. These include normal and stable vital signs for at least 12 hours before discharge, evidence of urination and defecation, completion of two successful feedings, no physical abnormalities requiring continued care, no evidence of excessive bleeding (especially in infants who are circumcised), and successful training of the family to provide ongoing care at home. In the United States, legislation requires insurance plans to cover postpartum stays up to 48 hours for infants born by vaginal deliveries and up to 96 hours for cesarean deliveries with complications. At discharge, a medical home should be identified and an appropriately timed followup visit should be made. Infants who are discharged before 48 hours after delivery should be assessed within 48 hours, and no later than 72 hours after discharge. The follow-up visit should be include assessment of the general health of the infant, the infantmother interaction, parent's well-being, and infant behavior, verification of ongoing health care, and parental education.