What components should be included in a comprehensive history for a neonate?

Comprehensive Neonatal History Taking

A thorough neonatal history must systematically cover perinatal events, maternal health, feeding patterns, family history, and social determinants of health to identify risk factors affecting morbidity and mortality.

Perinatal and Birth History

The foundation of neonatal assessment begins with detailed perinatal information:

• Gestational age at birth, birth weight, and any complications during pregnancy or delivery should be documented, as these factors influence later blood pressure and developmental outcomes 1, 2, 3.
• Maternal pregnancy complications including hypertension, infections, and substance use must be elicited, as maternal hypoxia and narcotic drug use during pregnancy cause fetal hypoxia and respiratory dysfunction 1, 4.
• Delivery method, complications during labor, and any birth trauma require documentation, as proper identification of obstetrical anomalies reduces birth trauma 4.
• Umbilical catheter placement and any neonatal ICU procedures should be recorded, as these are pertinent to later complications 1.
• Newborn metabolic screening results, hearing screening completion, and critical congenital heart disease screening must be verified at early visits 2, 5, 6.

Maternal Health and Laboratory Results

Maternal health directly impacts neonatal outcomes:

• Review maternal laboratory results including syphilis, hepatitis B surface antigen (HBsAg), and HIV status to identify transmission risks 5.
• For infants born to HBsAg-positive mothers, verify proper administration of hepatitis B vaccine and hepatitis B immune globulin 2.
• Screen for maternal postpartum depression using validated screening tools through the infant's first 6 months, as this affects infant care quality 5, 6.
• Maternal immunization status and any suspicious vaginal discharge during pregnancy should be documented, as these relate to neonatal infection risk 4.

Feeding and Nutritional History

Feeding assessment is critical for identifying failure to thrive and nutritional deficiencies:

• Document feeding frequency (should be 8-12 times per 24 hours), duration, and method (breast vs. bottle) 5.
• Directly observe breastfeeding technique, assessing position, latch, and swallowing adequacy at early visits 5.
• For bottle-fed infants, verify coordination of sucking, swallowing, and breathing 5.
• Inquire about vitamin D and iron supplementation, as many infants benefit from these 6.
• Ask about appetite, vomiting, diarrhea, constipation, gagging, and gastroesophageal reflux 1.
• For high-risk neonates, obtain a measured 3-day diet record or 24-hour diet recall to assess energy and micronutrient intake 1.

Growth and Development Assessment

Tracking growth trends identifies critical problems:

• Weight assessment compared to birth weight is essential at the 2-week visit, with weight loss >7-10% being concerning 5.
• Measure length and head circumference, plotting on appropriate growth charts (corrected for gestational age in premature infants) 2, 5.
• For premature infants, correct developmental milestones for gestational age for at least 24 months, and extend correction through 36 months for growth in extremely/very preterm infants 2.
• Ask specific developmental questions: "Is there anything your child is not doing that you think he or she should be able to do?" and "Is there anything your child used to be able to do that he or she can no longer do?" 2.
• By 2 months, infants should lift head and chest in prone position and demonstrate social smiling with eye contact 2.

Family and Genetic History

Family history reveals inherited risks:

• Obtain psychiatric and medical disorder history in both parents, as these may be transmitted genetically or experientially 1, 3.
• Document Rh and ABO blood groupings to identify risk for hemolytic disease of the newborn 4.
• Assess parental knowledge of child development and identify specific knowledge deficits 1.
• Inquire about family structure, parental relationship status, and social support systems 3.
• Document developmental histories of each parent, including their experiences in family of origin, as parenting strategies are influenced by how they were raised 1.

Medication and Substance Exposure History

Drug exposure affects neonatal outcomes:

• Screen for neonatal opioid withdrawal syndrome in at-risk infants 6.
• Document any maternal medications during pregnancy, particularly those affecting blood pressure or causing hypoxia 1, 4.
• Inquire about exposure to tobacco smoke in the home environment 3.
• Ask about over-the-counter medications, supplements, and recreational drug use that may affect the infant 1.

Social Determinants of Health and Safety

Social factors profoundly impact outcomes:

• Screen for untreated parental substance use, history of child abuse or neglect, parental mental illness, lack of social support, housing instability, domestic violence history, and barriers to follow-up care 5.
• Assess housing conditions, access to firearms, and environmental safety factors 3.
• Verify safe sleep practices: back to sleep on firm surface, avoid co-sleeping 1, 5.
• Confirm appropriate use of rear-facing car safety seats 5.
• Assess water safety awareness and avoidance of infant walkers 6.

Stooling, Voiding, and Hydration

Elimination patterns indicate adequate intake:

• Document stooling frequency and consistency 6.
• Assess urinary stream in males and voiding frequency 2.
• Evaluate hydration status through skin turgor, mucous membranes, fontanelle fullness, and activity level 5.

Sleep Patterns and Behavior

Sleep history identifies risk factors:

• Inquire about normal infant sleep patterns and duration 6.
• Assess for Brief Resolved Unexplained Events (BRUE) risk factors in infants with concerning history 2.
• Note that premature infants <32 weeks gestation or <45 weeks postconceptional age are higher-risk for BRUE 2.
• Document maternal fatigue levels, particularly during nighttime and early morning hours when risks are elevated 1.

Unresolved Medical Problems

For high-risk neonates requiring ongoing care:

• Review active problem list and identify unresolved medical issues such as bronchopulmonary dysplasia or feeding dysfunction 1.
• Document any required equipment, supplies, and home-care personnel needs 1.
• Ensure coordination with neonatologists or subspecialists for complex conditions 1.
• Verify enrollment in neurodevelopmental follow-up clinics for high-risk infants 1.

Establishing Medical Home

Continuity of care prevents adverse outcomes:

• Verify the plan for ongoing health care maintenance and method for obtaining emergency services 5.
• Ensure parents know how to reach the medical home and have emergency contact information 5.
• Schedule the next preventive care visit (typically 2-month well-child visit) 5.