Almost every newborn emergency comes down to warmth, air, sugar and infection.
A newborn has just made the largest physiological transition of their life — fluid-filled lungs must aerate within minutes, a circulation designed around a placenta must reroute itself, and a body with almost no reserve must maintain its own temperature and glucose. Most babies manage it unaided. The ones who do not usually need something simple done quickly.
That is the shape of this chapter. The interventions that matter most in the first days are unglamorous: keep the baby warm, get air into the lungs, check the glucose, and treat suspected infection early. Getting those right prevents most of what goes wrong.
🩺 Where this lives: Hypothermia is treated as a footnote and behaves as a killer. A newborn has a large surface area relative to mass, minimal subcutaneous fat, and cannot shiver. A wet baby in a cool delivery room loses heat fast, and cold babies become hypoglycaemic, acidotic and unresponsive to resuscitation. Drying and wrapping is not preparation for the real treatment — in many deliveries it is the treatment, and it costs nothing.
💡 A note on numbers. This chapter gives no doses or bilirubin thresholds. Neonatal dosing is weight- and age-specific, and phototherapy and exchange thresholds are read off gestation-specific charts rather than remembered. Learn the principles here; take every number from the chart or your local protocol.
Resuscitation at birth
The single most important idea in newborn resuscitation is that it is a respiratory problem. An adult in cardiac arrest usually has a primary cardiac cause; a newborn almost never does. The heart stops because it is hypoxic, so restoring oxygenation restores the heart — which is why inflation breaths come before compressions, and why "the chest is not moving" is the first thing to check when a baby is not responding.
THE COMMONEST REASON RESUSCITATION IS NOT WORKING
The airway is not open, or the chest is not moving.
Before escalating, check:
HEAD POSITION — neutral, not extended. A newborn's
large occiput flexes the neck when supine, closing
the airway. A shoulder roll helps.
SEAL — is the mask covering nose and mouth without
pressing on the eyes?
INFLATION — are you seeing chest movement with each
breath? If not, nothing downstream will help.
OBSTRUCTION — consider secretions.
APGAR SCORE describes the baby at 1 and 5 minutes and is
useful for documentation and communication. It does NOT
guide resuscitation — you act on tone, breathing and
heart rate as you find them, not on a score you stop to
calculate.
Temperature, glucose and feeding
🔍 The three that quietly cause most trouble
TemperatureDry immediately, remove wet linen, skin-to-skin contact with the mother where possible, hat, warm room. Preterm babies lose heat faster still. Hypothermia worsens hypoglycaemia, acidosis and outcome.
GlucoseNewborn glycogen stores are small and demand is high. At-risk babies — preterm, small or large for gestational age, infants of diabetic mothers, unwell or poorly feeding babies — need glucose monitoring. Hypoglycaemia is a frequent and treatable cause of jitteriness, poor feeding and seizures.
FeedingEarly and frequent breastfeeding supports temperature, glucose and bonding, and colostrum matters. A baby who will not feed is not being difficult — poor feeding is one of the most reliable early signs of serious illness.
Jaundice
💡 Exam angle: the timing rule is asked constantly and is genuinely useful. Jaundice in the first 24 hours is always pathological and usually haemolytic — check blood group, direct antiglobulin test and haemoglobin urgently. Jaundice persisting beyond 14 days (or 21 in preterm babies) needs a split bilirubin, because a raised conjugated fraction points to biliary atresia, where the outcome of surgery depends heavily on how early it happens.
WHY THE CONJUGATED FRACTION MATTERS SO MUCH
UNCONJUGATED bilirubin is fat-soluble. At high levels it
crosses into the brain and deposits in the basal ganglia,
causing KERNICTERUS — permanent choreoathetoid cerebral
palsy, deafness and gaze abnormality. This is what
phototherapy and exchange transfusion exist to prevent.
CONJUGATED bilirubin does not cause kernicterus, but a
raised conjugated fraction is NEVER normal. It means
cholestasis, and the diagnosis you cannot afford to miss
is BILIARY ATRESIA.
So the two fractions carry entirely different messages:
high unconjugated → risk to the BRAIN, treat the level
high conjugated → risk to the LIVER, find the cause
PALE STOOLS and DARK URINE in a prolonged jaundice are the
bedside signs that should trigger urgent referral.
Neonatal sepsis
Newborns cannot localise infection or mount a convincing inflammatory response, so the presentation is a collection of vague signs — poor feeding, lethargy, temperature instability in either direction, grunting, apnoea. That is precisely why the threshold to investigate and treat is deliberately low. In a newborn, "treat now and stop later if cultures are negative" is the safe strategy, which is the opposite of the stewardship instinct that applies elsewhere.
Prematurity and low birth weight
WHAT PREMATURITY ACTUALLY MEANS CLINICALLY
Every system is unfinished, and the problems follow from
which system is least ready:
LUNGS surfactant deficiency → respiratory distress
syndrome. Antenatal steroids given to the
mother accelerate lung maturity and are one of
the highest-value interventions in obstetrics.
TEMPERATURE almost no fat, very high surface area
GLUCOSE minimal stores
BRAIN fragile vessels → intraventricular haemorrhage
GUT risk of necrotising enterocolitis; breast milk
is protective
IMMUNITY immature → high infection risk
EYES retinopathy of prematurity, related to oxygen
exposure — which is why oxygen is targeted
rather than given freely
SMALL FOR GESTATIONAL AGE is not the same as PRETERM. A
growth-restricted term baby has mature organs but poor
reserve; a preterm baby of the same weight has immature
organs. They fail in different ways.
The newborn examination
Clinical reasoning: four presentations
🔍 Case 1 — the baby who will not pink up
PresentationA term baby is floppy and apnoeic at birth. Heart rate 50. The team has given several inflation breaths and is preparing to start chest compressions and draw up adrenaline.
Key questionIs the chest actually moving with those breaths?
ReasoningNewborn bradycardia is almost always hypoxic. Compressions and drugs cannot help a baby whose lungs are not being aerated, and the commonest reason for a failed resuscitation is an unopened airway or an ineffective mask seal.
AnswerBefore escalating: reposition the head to neutral, check the seal, confirm visible chest movement, consider secretions. Escalate only once ventilation is demonstrably effective. Also dry and cover the baby — warmth is part of the resuscitation.
🔍 Case 2 — jaundice on day one
PresentationA baby is visibly jaundiced at 14 hours of age. The mother is blood group O, rhesus negative. The midwife plans to review in the morning.
TrapTreating early jaundice as an accelerated version of the physiological kind.
ReasoningJaundice within 24 hours is always pathological and usually haemolytic. This maternal blood group raises the possibility of both rhesus and ABO incompatibility.
AnswerUrgent bilirubin, blood group, direct antiglobulin test and full blood count, plotted against the gestation-specific chart, with phototherapy or exchange per protocol. This is not a morning review.
🔍 Case 3 — still yellow at three weeks
PresentationA breastfed baby is still jaundiced at 21 days. Feeding and weight gain are good. The parents mention that the stools have become pale and the urine looks dark. Breast milk jaundice is suggested.
Key cluesPale stools and dark urine — features of cholestasis, not of breast milk jaundice.
ReasoningBreast milk jaundice is a real and benign entity, but it is unconjugated. Pale stools and dark urine indicate a conjugated hyperbilirubinaemia, and biliary atresia must be excluded urgently because surgical outcomes depend on early intervention.
AnswerSplit bilirubin immediately and refer urgently if the conjugated fraction is raised. Never attribute prolonged jaundice to breast milk without checking the split.
🔍 Case 4 — the baby who stopped feeding
PresentationA 5-day-old is brought in because he "isn't feeding as well". He is sleepy, temperature 35.9°C, no fever, no focal signs. Membranes had ruptured 22 hours before delivery.
The distractorNo fever, no localising signs, and a vague complaint.
ReasoningPoor feeding, lethargy and a low temperature are classic non-specific signs of neonatal sepsis, and prolonged rupture of membranes is a recognised risk factor. Newborns often do not mount a fever.
AnswerFull septic screen and immediate empirical antibiotics — do not wait for results. Check glucose, keep the baby warm, and admit. Treating on suspicion is correct here even though most such babies turn out not to be septic.
Commonly confused
Confusion
The distinction
Why it matters
Newborn vs adult arrest
Newborn arrest is hypoxic, not cardiac
Inflation breaths precede compressions.
Escalating vs fixing the airway
Most failed resuscitations have a chest that is not moving
Drugs cannot help an unventilated baby.
Jaundice under 24h vs after
Under 24 hours is always pathological
Usually haemolytic and needs urgent work-up.
Unconjugated vs conjugated
Brain risk versus liver disease
Different urgency and different investigations.
Breast milk jaundice vs cholestasis
Pale stools and dark urine mean conjugated
Biliary atresia outcomes depend on early surgery.
No fever vs no sepsis
Newborns may be hypothermic instead
Temperature instability in either direction counts.
Preterm vs small for gestational age
Immature organs versus poor reserve
They fail in different ways.
Rapid revision
MUST-KNOW FACTS
1. Newborn arrest is almost always HYPOXIC, not cardiac.
2. Resuscitation order: warmth, assess, open airway, INFLATION BREATHS.
3. Compressions only if the heart rate stays low despite effective ventilation.
4. If the baby is not responding, check the chest is MOVING.
5. Head in NEUTRAL position — a large occiput flexes the neck.
6. Apgar documents; it does not guide resuscitation.
7. Dry, wrap and keep warm — hypothermia worsens everything.
8. Check GLUCOSE in at-risk and unwell babies.
9. Poor feeding is a red flag, not a feeding problem.
10. Jaundice UNDER 24 HOURS is always pathological — think haemolysis.
11. Day 2–14 jaundice is usually physiological but still measured.
12. Jaundice beyond 14 days is PROLONGED — split the bilirubin.
13. Conjugated bilirubin is NEVER normal.
14. Pale stools + dark urine = biliary atresia until excluded.
15. Unconjugated bilirubin causes KERNICTERUS — permanent brain injury.
16. Plot bilirubin on a gestation-specific chart; never eyeball it.
17. Neonatal sepsis signs are non-specific — and fever may be ABSENT.
18. Risk factors: prolonged rupture of membranes, maternal fever, prematurity.
19. Treat suspected neonatal sepsis IMMEDIATELY after cultures.
20. Antenatal steroids accelerate fetal lung maturity in threatened preterm birth.
21. Preterm risks: RDS, hypothermia, hypoglycaemia, IVH, NEC, infection, ROP.
22. Breast milk protects against necrotising enterocolitis.
23. Oxygen is targeted, not given freely — retinopathy of prematurity.
24. Newborn check: red reflex, femoral pulses, hips, testes, palate, spine.
25. Absent femoral pulses suggest coarctation; absent red reflex needs urgent referral.
26. Give VITAMIN K to prevent haemorrhagic disease of the newborn.
💡 Exam angle: the reliable threads are (a) air before compressions, (b) jaundice under 24 hours being pathological, (c) splitting the bilirubin in prolonged jaundice, (d) poor feeding and hypothermia as sepsis, and (e) the newborn check items and what each screens for. Notice how many of the answers are cheap and immediate — warmth, a repositioned head, a glucose stick, an early antibiotic. Neonatal medicine rewards doing simple things fast.
Syllabus points
Why newborn arrest is respiratory, not cardiac
The resuscitation sequence and inflation breaths
Why a resuscitation fails: the airway and the seal
Temperature, glucose and feeding
Jaundice classified by timing of onset
Unconjugated bilirubin and kernicterus
Conjugated bilirubin and biliary atresia
Neonatal sepsis and its non-specific signs
Prematurity: which system is least ready
Preterm versus small for gestational age
The newborn examination and what it screens for
Create a free account to tick topics off, take notes as you read, watch the video lessons and get a day-by-day study plan built around your exam date.