Today, I review, link to, and excerpt from The Cribsiders‘ “#155: New Kids on the Block: Care of the Well Baby in the Newborn Nursery“.*
*Marshall C, Schamel K, Chiu C, Masur S. “#155: New Kids on the Block: Care of the Well Baby in the Newborn Nursery.” The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ 8th October, 2025..
All that follows is from the above resource.
Summary:
Kim Schamel, medical director of the Newborn Assessment Nursery at Washington University/St. Louis Children’s Hospital, walks us through newborn nursery 101! She gives pointers for the newborn physical exam, counseling strategies for safe sleep, gives us a framework for evaluating neonatal weight loss, and so much more. From the golden hour to the discharge talk and everything in between, she reminds us that when it comes to healthy babies, just feed them, love them, and don’t shake them!
Newborn Nursery Pearls
- Caring for a newborn is a team sport – whether with a partner or other support person – and there are a lot of choices during this time that are neither right nor wrong for babies as long as families feed them, love them, and don’t shake them!
- To help keep a newborn calm during their first physical exam, use the radiant warmer for heat and a gloved finger for baby to suck on – start with heart and lungs in case baby devolves before you get to this part!
- Kaiser Sepsis Calculator* is your best friend in the first 24 hours – it gives you specific criteria for equivocal and ill-appearing and recommends only a blood culture if equivocal as the CBC has limited sensitivity and specificity this early in life (the best piece of data is right in front of you – look at the baby not the number!)
*Kaiser Sepsis Calculator: Google Search Results
**Update to the Neonatal Early-Onset Sepsis Calculator Utilizing a Contemporary Cohort [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Pediatrics. 2024 Oct 1;154(4):e2023065267. doi: 10.1542/peds.2023-065267.
Newborn Nursery Notes
The Golden Hour
This is a transitional time for newborns! The natural environment is on Mom’s chest. Skin to skin has so many benefits – it helps stabilize baby’s blood sugar and temperature and promotes breastfeeding initiation and exclusivity! Babies just ran a marathon – they like to eat a little post-race snack and then will sleep for most of their first day – and it’s important that we prepare families that their newborn won’t eat much for the next 18 hours or so.
The First Exam
A good newborn exam requires a naked baby, ideally under a warmer. Start with heart and lungs while baby is quiet, then work your way down from the top. Soothing strategies for a crying baby include a pacifier or gloved finger (for breastfeeding babies) for sucking, containment (pulling baby’s arms and legs close to their body), and sometimes even picking them up and swaying. For the Ortalani and Barlow, it’s important to get the femur at a 90 degree angle with the bed, push straight down, and then maintain that pressure while abducting; an abnormal exam will have a palpable clunk. Femoral pulses are hard to feel, but sliding (not lifting!) fingers along the femoral region while maintaining minimal pressure can help. Babies’ head shape can also vary greatly; the only “do not miss” is a subgaleal bleed. These occuf under the deep layer of the scalp outside the bone and feel like a Ziploc bag of water; babies can hemorrhage into this potential space.
Checking Blood Sugars
Common indications for blood sugar checks before feeds include maternal diabetes, small size for gestational age, late prematurity, and maternal beta blocker or steroid use. Hypoglycemia typically occurs within the first 12 hours. For infants of diabetic mothers, elevated insulin levels in utero causes hypoglycemia once their continuous infusion of glucose through the umbilical cord ceases. For small or preterm babies, inadequate glycogen stores are a major factor in hypoglycemia development. Although adults have blood sugars typically above 70, a newborn’s may be in the forties. Babies can’t tell time, so they won’t feed on a schedule, thus asking the family to notify the nurse prior to feeds is often effective.
Thermoregulation
Maintaining Euthermia
Babies use brown fat to stay warm and babies born smaller and earlier generally don’t have good stores of this. A hat is important, especially in the first 24 hours, since newborns lose a lot of heat through the head. [Emphasis Added] If babies use too much energy to stay warm, they aren’t able to use energy for things like eating and growing. Dr. Schamel recommends adding layers while trying to avoid bulky blankets as these increase the risk of SIDS; on a practical level, babies should wear whatever an adult is comfortable in plus one more layer.
Fevers
Some cultures greatly prioritize keeping baby warm thus may add many layers which can occasionally lead to an iatrogenic increased temp. In these cases, Dr. Schamel recommends examining the baby and if well-appearing, we can remove the excess layers and re-evaluate in an hour or so to see if this resolves.
Early Onset Sepsis
The Kaiser Sepsis Calculator has taken a lot of the guesswork out of the evaluation for newborn sepsis in the first 24 hours. This accounts for gestational age, length of rupture of membranes, Group B Strep (GBS) status, antibiotic administration for Mom, and highest maternal temperature. The most important part of the evaluation for sepsis in a term or near-term newborn is a blood culture; complete blood counts have low sensitivity and specificity, especially in the first few hours of life. The most valuable piece of evidence is the baby – look at the baby, not the number. When it comes to “equivocal”, the calculator actually gives clear parameters (listed below)! Finally, only cefazolin, penicillin, and ampicillin constitute adequate prophylaxis as we have studied their pharmacodynamics; for antibiotics to work, they must cross the placenta and ultimately reach the amniotic fluid. In terms of discharge, Dr. Schamel does not necessarily recommend that babies in this category be observed for 48 hours, but rather discourages discharging a baby with persistent physiologic abnormalities. She reminds us that in some situations, tachypnea might be attributable to other conditions like methamphetamine exposure, but other dangerous pathologies should be ruled out before discharging a baby with an elevated respiratory rate.
Feeding
Exclusively breastfed babies will lose an average of 7% of birth weight and babies delivered via c-section lose more weight than those delivered vaginally. Babies are “water-logged” with a continuous infusion of fluid through the umbilical cord, thus we expect weight loss after birth. Once babies lose more than about 8%, Dr. Schamel recommends evaluating the baby’s feeding. After losing more than 10%, she recommends looking more closely and considering supplementation. The Neonatal Early Weight Loss Tool (NEWT) shows weight loss trends by mode of delivery, hour of life and type of feeding and can help providers make decisions about supplementation and discharge. Most babies should stay near their weight loss curve – a baby crossing percentiles in weight loss is cause for further evaluation.
When exploring a baby’s excessive weight loss, evaluate the quality of milk transfer if breastfed (look for observable swallowing) and voiding and stooling patterns (meconium passage ideally in the first 24 hours but can take up to 48 hours, and one wet diaper for each day of life e.g. two wet diapers on day of life two, three on day three). It’s also important to determine whether Mom’s milk is “in” – if she’s entered phase II of lactogenesis. This typically takes about 72 hours in a first time Mom who has delivered vaginally; a c-section may add another day. The length of time to lactogenesis phase II is not an indicator of future milk supply. It’s important to remember that the priority is feeding baby and the second priority is protecting the milk supply. Pumped maternal milk is best, followed by donor breastmilk, then formula. Other causes of inadequate intake include late prematurity as they have less stamina and a weaker suck than a term infant. Neuromuscular differences like Down Syndrome and associated hypotonia or craniofacial differences like cleft lip and palate can also present feeding challenges. Finally, Moms who desire to exclusively pump may face challenges as the first two to three days of life yield only small volumes of colostrum. Dr. Schamel counsels families that any supplementation* is only a temporary bridge.
*Supplementary Feeding Of The Newborn Infant: Google Search
**Breastfeeding and Supplementation Guide from Iowa Health Care: “This is a temporary guide for your baby. Use this with a lactation consultant.” Last reviewed
June 2025
***ABM Clinical Protocol #3: Supplementary Feedings in the Healthy
Term Breastfed Neonate, Revised 2017 [PDF]. BREASTFEEDING MEDICINE
Volume 12, Number 3, 2017.
****Academy Of Breast Feeding Protocols. “ABM publishes protocols to facilitate best practices in breastfeeding medicine. These protocols serve as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to an individual patient’s needs.”
For more information on newborn feeding, check out Cribsiders Episode #14 (Infant Nutrition: Digestible Pearls with Dr. Joan Meek, MD)
Discharge Preparation
Safe Sleep
When we find a baby in an unsafe sleep environment, Dr. Schamel reminds us to model safe sleep and not shame. Parenting a newborn is exhausting and Dr. Schamel recommends helping moms find support whether that’s a partner or other family member to help keep baby safe when Mom needs rest. Supporting the couplet is critical; healthy Mom, healthy baby.
Discharge Screenings
The critical congenital heart disease (CCHD) screen checks the saturations in baby’s hand (pre-ductal) and foot (post-ductal). Screening is ideally done after the first 24 hours to reduce the false positive rate and increase specificity as transitional circulation can affect the oxygen saturation. Oxygen saturation should be greater than or equal to 95% in both locations and a new algorithm with recommendations was published in 2025.
There are two types of hearing screens, which can be performed any time, but waiting until closer to discharge decreases the likelihood of a false positive screen due to retained fluid in the middle ear and residual vernix. The otoacoustic emissions (OAE) is quicker and technically easier and evaluates the ear canal to the middle ear. An auditory brainstem response (ABR) evaluates everything between the middle ear and the brain and evaluates for both sensorineural and conductive hearing loss. Babies at high risk of sensorineural hearing loss should receive an ABR before discharge and any baby who fails the OAE should undergo an ABR as an outpatient. Most babies who do not pass the hearing screen go on to pass outpatient.
The newborn screen should also be performed after 24 hours, ideally between 48 and 72 hours, to avoid the false positive result from the physiologic TSH surge. This screen is important as it tests for diseases that don’t show symptoms until injury has already occurred.
Babies are also screened for hyperbilirubinemia – we have a whole episode on this topic (#45: Neonatal Hyperbilirubinemia – There Future’s So Bright, They Gotta Wear Shades!)
Discharge Criteria
Dr. Schamel says babies need to pass the test of life to go home – they need to eat, pee, poop, keep appropriate vitals, and secure follow-up. The most important piece of discharge is good follow-up! She typically recommends more than 24 hours in the hospital, especially for first-time parents, due to second night syndrome (google it!). Babies are typically exhausted for their first night of life, which can be falsely reassuring for parents, but by the second night, babies often decide it’s “party time.” It’s important that families experience the reality of the newborn period, ideally in a hospital setting where there is ample support.
The Discharge Talk
Dr. Schamel emphasizes several critical safety elements in her discharge talk. She reminds families (again) about the ABC’s of safe sleep (alone, on your back, in a crib) – not in a swing, a boppy, a car seat or a dock-a-tot. Baby MUST be in a rear-facing car seat every single time. She also makes sure families understand what a sick baby looks like: temperature over 100.4, unconsolable irritability, or excessive lethargy (in Dr. Schamel’s opinion, a baby can sleep through one feed, but cannot sleep through two). From a feeding perspective, she counsels families to seek care for vomiting that is green or bloody or for frank diarrhea. She also walks families through normal voiding and stooling patterns. Typically, nurses discuss things like bathing and cord care.
In the words of Dr. Schamel, babies are “miserable, gaseous little malcontents.” We need to prepare families that for the first several months, babies can be pretty fussy and caregivers may think it’s the formula or their breastmilk. She encourages us to empower new Moms to find a support person. Dr. Schamel also reminds us that a lot of raising babies isn’t necessarily right or wrong, it’s just parenting choices. Just feed them, love them, and don’t shake them.
