This post contains The Standard Newborn Evaluation template or checklist from The Newborn Nursery Orientation Manual Updated 2014* from the University of Viriginia Children’s Hospital.
*This link downloads the entire manual to your computer. The manual is an excellent newborn memory aid. I’ve included the Table of Contents:
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Standard Newborn Evaluation
History
1. Date, time and location of birth, referring MD/hospital
2. Birth weight
3. Sex, race
4. Gestational age (EGA)
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by dates (mother’s estimate)
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by pre-natal exam (obstetrician’s estimate) (i.e. serial fundal heights, first fetal heart tone, sonography)
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by post-natal exam – Ballard assessment (estimate)
5. Mother’s age and history of previous pregnancies (Gravid = # pregnancies; Para = # births; AB = # abortions,
spontaneous or therapeutic; living = # children living – summarized, for example, as G3, P2, AB1, L2)
6. Blood types of mother and baby, Coombs test, mother’s antibody screen; ABO & Rh incompatibility
7. Maternal Labs
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VDRL
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Hepatitis B
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HIV
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GC, chlamydia
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Group B strep status
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Amniocentesis-genetic or for lung maturity
8. Complications of pregnancy, labor and delivery
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Maternal illness/infections
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Use of drugs, prescribed and non-prescribed
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Alcohol and smoking
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Duration of labor/premature labor – tocolytic drugs
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Duration of rupture of membranes – evidence of maternal infection/colonization culture results/ antibiotic therapy
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Type of delivery – spontaneous vaginal (SIVA), forceps, C-section
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Characteristics of amniotic fluid – oligohydramnios, polyhydramnios, meconium stained
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Abnormal presentation
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Fetal monitoring
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Anesthesia used
9. APGAR scores at one and five minutes and every five minutes thereafter until score exceeds six
10. Neonatal course to date
11. Social history
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Where mother lives
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Role of father in family
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Other members of the household
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Financial support
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Emotional support
12. Plans for feeding – breast or bottle
13. Plans for well child care and immunizations
Physical Exam
1. Vital signs, measurements
(descriptive terms: T, P, R, BP; Wt, length, head circumference, including percentiles)
2. General appearance
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level of activity (active/lethargic)
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general perfusion and color (pink/blue/mottled/pale/yellow; edematous/dehydrated; well developed)
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nutritional status/state of hydration
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gross abnormalities
3. Skin
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vernix
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capillary hemangiomas (benign): most common on eyelids, forehead, back of neck –
occasionally on trunk or extremities -
mongolian spots (benign)
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cafe-au-lait spots: > 5 suggestive of neurofibromatosis (if all > 1.5 cm in diameter)
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milia: superficial epidermal inclusion cysts – generally on face
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erythema toxicum
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“parchment skin”: seen in post-term babies
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dryness, turgor: assess hydration
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petechiae
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common, benign: usually on face and upper body – occurs 2° intra-thoracic pressure as the chest passes through the birth canal
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uncommon: pathologic as a result of thrombocytopenia; important to note distribution and watch for progression
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“sucking blisters”: hands
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abrasions
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peeling of skin in postmature baby
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jaundice
4. Head
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shape
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molding
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asymmetry: may be normal 2° fetal posture or abnormal 2° structural defect
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appearance
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bruising
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scalp: internal monitor sites, scalp blood sampling sites
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forceps marks
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hair distribution
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palpation
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caput succedaneum: diffuse, generally symmetric scalp edema 2° vertex presentation (usually resolves in first few days); edema crosses sutures
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cephalohematoma: sub-periosteal hemorrhage; feels like boggy edema but is located over one particular bony area; may take months to resolve; never crosses sutures; can indicate linear skull fracture or more occult intracranial bleeding
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sutures: craniotabes is a soft area in parietal bone near the sagittal suture
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palpable fractures
5. Fontanelles
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anterior and posterior
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may suggest increased intracranial pressure if bulging open wide fontanelle extending into frontal area
6. Eyes
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may be hard to assess in first 24 hours due to edema of lids
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reactiveness of pupils (PERRL = Pupils equal, round, reactive to light)
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red reflex exam for retinoblastoma, corneal opacities
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lens
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test for congenital cataracts
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discharge
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conjunctival hemorrhage: common, may be benign; occurs 2° increase in intra-thoracic pressure when the chest passes through the birth canal
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inter-canthal distance: if increased or decreased may suggest a congenital syndrome
7. Ears
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external appearance: shape and position
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low set ears may suggest a congenital syndrome such as Down syndrome
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external canals: check for patency, atresia
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tympanic membranes: canals may be too tortuous to allow visualization
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preauricular sinus and tags: may be associated with renal anomalies/hearing loss
8. Nose
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external appearance: congenital abnormalities, atresia
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flaring of nostrils: may suggest respiratory distress
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patency of nares: congestion/discharge
9. Mouth
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external appearance: cleft lip, shape, etc
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precocious dentition (supernumerary teeth)
10. Palate
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structural abnormalities
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cleft: may lead to feeding problems aspiration etc. in the immediate neonatal period
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high arched: may suggest congenital syndrome
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lesions
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Epstein Pearls: whitish nodules on palate; benign, common; accumulation of epithelial cells
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11. Neck
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tone: increased may indicate neurological disease
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palpitation: masses include thyroid, cystic hygroma, branchial cleft/cysts
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mobility: congenital torticollis (may palpate mass as well)
12. Chest
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appearance
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congenital deformities may cause asymmetry
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retractions: sub-xiphoid or intercostal suggest respiratory distress with increased effort of breathing
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respiratory pattern: rate and rhythm commonly quite variable; > 60 resp/min for sustained time is abnormal
13. Lungs
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auscultation
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rales, wheezes, rhonchi, grunting
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compare air movement on each side and between lung zones
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14. Heart
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cyanosis: central vs acrocyanosis
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precordial activity
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rhythm and rate (RRR = regular rate and rhythm)
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commonly quite variable
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may range from 100-180 in various states of rest/activity
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extra systoles and sinus pauses common
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S1, S2: may be grossly abnormal in valvular heart disease
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murmurs
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murmur = m
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grade I-VI (written e.g. II/VI)
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describe location and quality
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murmurs in first day from a closing ductus are common
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any murmur still present on third day should be evaluated
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gallops
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extra heart sounds very difficult to hear at the rapid heart rate of a newborn
15. Pulses
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palpate in each extremity and compare side to side and UE to LE
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decrease in LE pulse or delay in transmission to LE vs UE may indicate coarctation of the aorta
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pulse graded 0-4+: 0 = Absent, 2+ = Normal, 4+ = Bounding
16. Abdomen
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observation: distended, discolored, scaphoid
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bowel sounds: may not be present early in life
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palpation: for masses, distension etc.
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umbilicus: number of cord vessels
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liver: commonly palpable up to 1 cm below the right costal margin
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spleen: may be just palpable under left costal margin
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kidneys: usually palpable, at least in part, in a very relaxed infant who allows deep palpation; palpable large kidneys suggestive of hydronephrosis
17. Genitalia
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inspection
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examine all structures to ascertain if they are clearly male or female
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particularly check for location of the urethral orifice; may be displaced (hypospadias, epispadias) in what appears to be male infant (may be male or virilized female)
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foreskin is often tight and appears closed
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female genitalia may appear enlarged in proportion to the other body structures 2° the effects of maternal hormones and/or prematurity
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palpation
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palpate for testes in the scrotum or inguinal canal
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scrotal enlargement may be 2° hydrocele which is relatively common – diagnose by transillumination as well as palpation (intermittent, recurrent hydrocele is suggestive of hernia)
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testes may be in canal or not palpable in ELBW infant
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discharge
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females may have a clear mucous discharge or even blood (“pseudomenses”) 2° hormonal stimulation in utero with sudden withdrawal in post-partum
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circumcision
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may look quite edematous and erythematous
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watch for difficulty urinating after procedure
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18. Breasts: may not be visible in ELBW; term infant may have prominent breast tissue, hormonally stimulated
19. Rectum: check for patency (evidence of stooling), fissures (may see bloody stools), placement (may be
anterior)
20. Hernia: check inguinal regions; diastasis recti (midline weakness of the abdominal musculature) is common
and may simulate a ventral hernia
21. Spine
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inspect and palpate for deformity, deviation
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inspect for dermal sinus tracts: may be anywhere along the midline from the nose, over the skull and down the spine to the sacrum
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any dimple should be carefully examined to be sure that the bottom of the pit is visible (traction on the skin helps exam)
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any discoloration or hairy lesion should be evaluated
22. Clavicles: inspect for asymmetry; palpate for fractures (common birth trauma)
23. Extremities
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inspect for deformities – fetal position may cause some apparent abnormalities that are self-correcting
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check joints or observe for range of motion: term infants are normally quite flexed as a general posture
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check palmar creases
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hips – test for congenital dysplasia by:
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observing for differences in leg movement
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check for differences in leg length
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checking for asymmetry of leg skin folds (misleading)
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manipulation of the hips (abduction) with fingers over the greater trochanter and feeling for (or hearing) clicks
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Barlow & Ortoloni maneuvers
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Digits: count them; extra digit buds or skin tags are not uncommon (often familial)
24. Neuro
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degree of alertness
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spontaneous movement
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posture
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tone
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grasp, suck, Moro, root
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DTRs
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response to light, sound
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facial, brachial plexus palsies
25. Cord (Umbilicus)
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check for secure clamping
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count and document the arteries (2, thick-walled) and vein (single, thin walled) in the remnant
26. Voiding
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95% of infants void in the first 24 hours
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98% void in the first 48 hours
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most common reason for “delay” in voiding is missing urination at birth
27. Stools
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90% of infants pass stool in the first 24 hours
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98% stool in the first 48 hours
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prolonged time without stooling suggests meconium ileus (cystic fibrosis), meconium plug, or other congenital defect