Neonatal care covers the first 28 days of life, the period in which a large share of deaths in children under five years occurs. Most of these deaths trace back to a list of causes that can be recognised early, treated with simple measures and often prevented such as infection, complications of prematurity and low birth weight, and birth asphyxia.
The outcome in these babies depends heavily on what happens in the first hours and days, and on whether the person at the bedside recognises that the baby is unwell. A systematic approach to newborn health problems therefore begins with routine care, moves to the danger signs, and then to the individual conditions.
Routine care in the first hour
Most babies need only simple support at birth. The baby is dried with a clean towel, observed while being dried, placed skin-to-skin on the mother’s chest and covered to prevent heat loss. Delayed cord clamping is performed according to current guidelines when clinically appropriate, without delaying necessary resuscitation. Breastfeeding should begin as soon as possible, ideally within the first hour, and intramuscular vitamin K should be administered to prevent vitamin K deficiency bleeding.
The cord stump is kept clean and dry, and the birth doses of BCG, oral polio and hepatitis B vaccines are given as per the national immunisation schedule. These steps are common to every set of neonatal care guidelines, and skin-to-skin contact with early breastfeeding is among the most effective ways to keep the baby warm and prevent hypoglycaemia.
Resuscitation should be anticipated at every delivery, because it cannot always be predicted from the maternal history, although pre-eclampsia, multiple pregnancy, preterm labour, prolonged labour and meconium-stained liquor raise the likelihood.
Danger signs, sepsis and prevention
Sick newborns rarely present with a clear focal complaint, so the WHO danger signs are the practical screening tool: poor feeding, convulsions, drowsiness or unconsciousness, movement only on stimulation, a respiratory rate of 60 per minute or more, grunting, severe chest indrawing, central cyanosis, temperature above 38 °C and temperature below 35.5 °C.
Newborn infection symptoms are largely these same signs, with a few additions such as severe jaundice, marked abdominal distension, many or severe skin pustules, redness spreading from the umbilicus to the abdominal wall, pus at the umbilicus, a bulging fontanelle, and painful or swollen joints. Any newborn with a danger sign requires urgent clinical assessment and appropriate referral or admission according to the baby's condition and the applicable neonatal protocol
Blood glucose should be checked promptly in babies with suspected hypoglycaemia, altered consciousness or seizures, and treatment should not be delayed when hypoglycaemia is strongly suspected. Hypothermia is as important as fever in this age group, since small and sick babies often fail to mount a fever and become cold instead.
Neonatal sepsis is classified as early-onset or late-onset, although the time cut-off varies between clinical guidelines. Early-onset infection is commonly associated with organisms acquired from the mother around delivery, while late-onset infection may arise from healthcare-associated or community sources. Blood cultures should be obtained before antibiotics when feasible, provided this does not delay urgent treatment. Lumbar puncture should be considered when meningitis is suspected or indicated by the applicable neonatal sepsis guideline, once the baby's clinical condition permits the procedure.
Empirical antibiotic treatment for suspected neonatal sepsis should follow current national or hospital guidelines, taking into account the likely source of infection, local antimicrobial resistance patterns and the baby's clinical condition. Antibiotics should be reviewed when culture results and clinical progress become available, with treatment narrowed, changed or discontinued when appropriate. The duration of treatment depends on the diagnosis, culture results, clinical response and whether complications such as meningitis are present.
Prevention of neonatal infections begins before delivery and continues throughout newborn care. Hand hygiene, clean delivery practices, appropriate umbilical cord care, aseptic procedures and avoiding unnecessary separation of mother and baby help reduce infection risk. Antibiotic prophylaxis or empirical treatment should be based on recognised maternal and neonatal risk factors and the applicable clinical guideline, rather than being prescribed routinely to all newborns with a risk factor.
Decisions to stop antibiotics should take account of culture results, the baby's clinical progress and the local protocol. In neonatal units, exclusive breastfeeding when appropriate, kangaroo mother care, aseptic injection practices and prompt removal of unnecessary intravenous lines can help reduce infection risk.
Jaundice and other conditions
Jaundice is visible in more than half of normal newborns and in about 80 percent of preterm babies, and most of it is physiological. It is pathological when it appears on the first day of life, lasts beyond 14 days in a term baby or 21 days in a preterm baby, is accompanied by fever, or involves the palms and soles. The causes to look for are sepsis, haemolysis from blood group incompatibility or glucose 6-phosphate dehydrogenase deficiency (G6PD), congenital infection, hypothyroidism and, in a baby with pale stools and dark urine, liver disease such as biliary atresia.
Neonatal jaundice treatment depends on the serum bilirubin plotted against the baby’s age in hours, the gestational age and the neurotoxicity risk factors, which include sepsis, haemolysis and clinical instability. Phototherapy is the main treatment and exchange transfusion is kept for very high levels, so each unit should work from one current threshold chart, such as the 2022 American Academy of Pediatrics (AAP) guideline, adapted to its follow-up facilities.
A baby who remains jaundiced beyond two weeks should be evaluated, with total and direct (conjugated) bilirubin testing guided by feeding type and current clinical guidelines. Breastfed babies who are otherwise well and gaining weight may have prolonged breast milk jaundice. However, pale stools or dark urine require prompt investigation for liver or bile duct disorders, such as biliary atresia. Jaundice accompanied by other signs of illness also warrants urgent evaluation. Breastfeeding should usually continue unless galactosemia is suspected or the treating team advises otherwise.
Among the other common neonatal conditions, convulsions need early attention. The usual causes are hypoxic ischaemic encephalopathy, central nervous system infection, hypoglycaemia and hypocalcaemia, so management begins with airway and breathing, a glucose check with prompt correction, phenobarbital for persisting fits, and a search for infection.
Conjunctivitis with a lot of pus or swollen eyelids may be gonococcal and is treated as an inpatient condition because of the risk of blindness, and the mother and her partner need treatment as well.
Preterm and low birth weight babies
Babies of 35 to 36 weeks, or weighing 2.0 to 2.5 kg, can usually breastfeed and keep themselves warm, although their mothers need support for breastfeeding . Babies under 35 weeks or under 2.0 kg should be managed in a special care unit, because the risks of hypothermia, feeding problems, apnoea, respiratory distress syndrome and necrotizing enterocolitis rise as the baby gets smaller.
Premature baby care rests on four things: warmth, feeding, respiratory support and infection control. Kangaroo mother care is the preferred way of keeping a stable small baby warm and, according to current WHO advice, should begin as soon as possible after birth, without an initial period in an incubator. Temperature should be checked regularly and maintained within the normal axillary range of 36.5–37.5 °C, using an appropriate thermometer so that hypothermia is not missed.
Low birth weight baby care also depends on the mother’s own milk. Babies who can suckle are breastfed, and the others receive expressed milk by cup and spoon or by gastric tube, with donor milk if the mother’s milk is not available and safe milk-banking facilities exist, and formula only as a last option. In babies under 1.5 kg, feeds are started in small volumes of 2 to 4 ml every one to two hours and increased by 1 to 2 ml per feed each day as tolerated, with blood glucose checked every six hours until feeding is established. Vitamin D at 400 IU is added once full feeds are accepted, and iron is started at about two weeks of age.
Neonatal complications and management in these babies follow a predictable pattern. Respiratory distress syndrome, which comes from surfactant deficiency, appears within hours of birth with tachypnoea, grunting, recession and cyanosis. Antenatal corticosteroids given to mothers at risk of preterm delivery reduce its incidence, and the baby is supported with minimal handling, oxygen titrated to avoid eye damage from excess oxygen, continuous positive airway pressure with antibiotics started when infection is suspected, in accordance with the applicable neonatal protocol.
Apnoea of prematurity is commonly treated with caffeine citrate, which is the preferred first-line medication. Aminophylline may be considered as an alternative under the applicable neonatal protocol when caffeine is unavailable or unsuitable.
Necrotizing enterocolitis (NEC) presents with abdominal distension, feed intolerance, bile-stained aspirates or blood in the stool. In such cases of NEC, feeds are stopped, the stomach is decompressed, intravenous fluids and antibiotics are started, and a surgeon is called if the abdominal X-ray shows free gas.
A low birth weight baby can go home when there are no danger signs, weight is increasing on breastfeeding alone, temperature is maintained between 36 and 37 °C in an open cot, and the mother is confident. Weekly weighing continues until the baby reaches 3 kg. Counselling on exclusive breastfeeding, warmth and the danger signs for seeking care covers the points that matter most for the common health problems in newborn babies after discharge.
Wish to upskill in newborn care?
Newborn units depend on doctors who are comfortable with resuscitation, sepsis, respiratory support and the nutrition of small babies. Doctors who want structured training can look at fellowship programmes in paediatrics, neonatology or critical care offered by MediCOLL Learning.
These recognised fellowships provide an additional qualification on top of the MBBS or a postgraduate degree such as MD. It helps to strengthen the existing knowledge and skills and follow a combination approach of online classes with in person clinical training in a multispecialty hospital under the guidance of experts. This format helps to continue learning while practicing especially for working professionals.
Frequently Asked Questions
Q. What are the most common neonatal problems?
The most common problems are infection and sepsis, jaundice, prematurity with its complications (respiratory distress syndrome, apnoea, feeding problems and necrotizing enterocolitis), low birth weight, hypothermia, hypoglycaemia and birth asphyxia. Infection, prematurity and birth asphyxia are the main drivers of serious illness and death in this age group.
Q. When should a newborn be referred to a special care unit?
Any baby with a danger sign should be admitted, and so should a baby born before 35 weeks or weighing less than 2.0 kg. Jaundice on the first day, jaundice involving the palms and soles, a need for oxygen, and feed intolerance with abdominal distension are further reasons for referral.
Q. Is jaundice in a newborn always abnormal?
No. More than half of normal newborns have some jaundice, and in most it settles without treatment. It becomes a concern when it starts on the first day, lasts beyond 14 days in a term baby or 21 days in a preterm baby, comes with fever, or reaches the palms and soles.
Q. How can MBBS graduates or postgraduates like MD enhance their skills in newborn care?
Medical professionals can either follow a long-term route, such as a postgraduate degree in paediatrics followed by neonatology training, or pursue a short-term course such as a fellowship. A fellowship is a structured training programme for doctors who wish to gain knowledge and skills in a chosen field of interest, and it provides an additional qualification alongside the existing degree.
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