Comprehensive Newborn Evaluation
A healthy term newborn requires systematic vital sign monitoring, completion of at least 2 successful feedings with documented technique, maternal and infant laboratory screening (including maternal syphilis, hepatitis B, HIV status, and infant blood type/Coombs if indicated), newborn metabolic screening, hearing screening, and pulse oximetry screening before discharge. 1
Primary Assessment and Vital Signs
The infant's vital signs must be documented as stable for 12 hours preceding discharge, with specific normal ranges 1:
- Axillary temperature: 36.5°C to 37.4°C (97.7–99.3°F) measured in an open crib with appropriate clothing
- Respiratory rate: Below 60 breaths per minute without signs of respiratory distress (tachypnea, nasal flaring, grunting, retractions, cyanosis)
- Heart rate:
- Awake: 100-190 beats per minute
- Sleeping: As low as 70 beats per minute is acceptable if without circulatory compromise and responding appropriately to activity
- Sustained rates near or above the upper range require further evaluation
Laboratory Tests and Maternal Screening
Mandatory maternal laboratory results that must be reviewed 1:
- Maternal syphilis status
- Hepatitis B surface antigen
- HIV status
- Umbilical cord or newborn blood type and direct Coombs test (if clinically indicated)
Newborn Screening Requirements
All newborns must complete the following screenings per hospital protocol and state regulations 1, 2:
- Metabolic screening: Should be performed ideally between 24-48 hours after birth 2
- Hearing screening
- Pulse oximetry screening
Critical caveat: If metabolic screening was performed before 24 hours of milk feeding, a system for repeating the test during follow-up must be in place per local or state policy 1. This is essential because early screening can miss certain metabolic conditions.
Feeding Assessment
The infant must complete at least 2 successful feedings with documented competency 1:
- For breastfeeding: A knowledgeable caregiver must directly observe and document successful latch, swallowing, and infant satiety
- For bottle-feeding: Document that the newborn coordinates sucking, swallowing, and breathing while feeding
Physical Examination Elements
While the guidelines focus primarily on discharge criteria, comprehensive physical examination should include 3:
- Red reflex assessment: Must be symmetric in both eyes without opacities, white spots, or dark spots; abnormal findings or family history of eye disorders warrant ophthalmology consultation
- Cranial examination: Assess for craniosynostosis (premature suture fusion)
- Ear position: Low-set ears warrant evaluation for genetic conditions; renal ultrasonography indicated only if accompanied by other malformations or significant family history
- Neck range of motion: Full assessment to detect torticollis, which can lead to plagiocephaly
- Cardiovascular auscultation: Benign murmurs common in first hours of life
- Respiratory assessment: Close observation for distress signs
Maternal Immunization Requirements
If the mother has not been previously vaccinated, she must receive 1:
- Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine immediately after birth
- Influenza vaccination if delivering during flu season and not previously immunized
Close contacts should also be encouraged to receive Tdap if not previously vaccinated.
Follow-Up Planning
Before discharge, the following must be established 1:
- Identified medical home for continuing care
- First visit scheduled (or instructions provided for scheduling)
- Emergency contact instructions provided
- For discharge before 48 hours: Mandatory appointment within 48 hours of discharge; if this cannot be ensured, discharge should be deferred
The follow-up visit must assess weight, hydration, jaundice, feeding patterns, stool/urine patterns, review outstanding laboratory results, perform indicated screenings (such as serum bilirubin), and screen for maternal postpartum depression 1.
Social Risk Factor Assessment
Discharge should be delayed until resolved or a safety plan is established if any of these risk factors are present 1:
- Untreated parental substance use or positive toxicology
- History of child abuse or neglect by anticipated caregivers
- Parental mental illness
- Lack of social support (especially single, first-time mothers)
- No fixed home
- History of domestic violence during pregnancy
- Adolescent mother with other risk factors
- Barriers to follow-up care (transportation, communication, language)
Parental Education Documentation
Document that training and information has been provided on 1:
- Breastfeeding benefits and technique
- Expected urination and stooling frequency
- Umbilical cord, skin, and genital care
- Temperature assessment with thermometer
- Signs of illness and jaundice
- Infant safety: car seat use, supine sleep positioning, avoidance of co-sleeping
The use of standardized predischarge checklists facilitates uniform implementation of these requirements across all care settings 1.