Scoring: Each criterion scored –1 to 5. Total score mapped to gestational age (score 35 ≈ 38 weeks). Accurate to ±2 weeks. Perform within 12 hrs of birth.
Ambiguous genitalia — senior review urgently; do not assign sex casually
Hips, Spine & Neurology
Barlow test — adduct & push posteriorly (dislocates hip if unstable)
Ortolani test — abduct & lift anteriorly (reduces dislocated hip — clunk)
Sacral dimple — benign if <2.5 cm from anus, no tuft of hair; deeper = spinal dysraphism
Tone — assess by ventral suspension, pull-to-sit; hypotonia = investigate
Moro, rooting, grasp, stepping reflexes
🌡 Neonatal Heat Loss — 4 Mechanisms
1. Evaporation Most significant at birth
Amniotic fluid evaporates from wet skin. Dry the baby immediately and vigorously within first 30 seconds. Replace wet towels with dry ones.
2. Radiation
Heat lost to cooler surrounding objects (walls, windows) without contact. Keep baby away from cold surfaces and outside walls.
3. Conduction
Direct contact with cold surfaces. Pre-warm resuscitaire, scales, and surfaces. Never place on cold metal.
4. Convection
Air currents carry heat away. Close windows, doors, avoid fans near baby. Wrap promptly after drying.
❄ Hypothermia — Risk Factors & Prevention
Highest Risk Groups
Premature / Low birth weight — thin skin, reduced brown fat, large surface area to weight ratio
Wet / not dried immediately at birth
IUGR infants
Sick or compromised newborn
Cold delivery room (<25°C)
Prolonged resuscitation
Prevention Protocol
Delivery room temperature ≥25°C (WHO recommendation)
Pre-warm radiant warmer before birth
Dry immediately, replace wet towels
Hat essential — up to 25% heat loss from head
Skin-to-skin / kangaroo care — strong evidence base
Plastic wrap/bag for <28 weeks without drying (just place in bag head out)
Temperature Monitoring
Axillary route preferred in term neonates. Hold thermometer for minimum 3 minutes. Normal: 36.5–37.5°C.
Avoid rectal temperature — risk of rectal perforation in neonates. Not recommended as routine.
Hypothermia Classification
Category
Temp (°C)
Action
Mild
36.0–36.4
Skin-to-skin, warm wrap, reassess 1hr
Moderate
32.0–35.9
Incubator/radiant warmer, warm feeds
Severe
<32.0
Slow rewarming (0.5°C/hr), warm IV fluids, senior alert
Rapid rewarming causes vasodilation and hypotension. Always rewarm gradually.
☀ Hyperthermia — Fever vs Overheating
Feature
Overheating (Environmental)
Fever (Infection)
Cause
Too many layers, direct sunlight, hot room, over-bundling
Sepsis, meningitis, UTI, viral
Baby appearance
Flushed, sweaty, settled when undressed
Unwell, lethargic, poor feeding, irritable
Action
Remove layers, check room temp, reassess
Full sepsis evaluation — FBC, CRP, blood culture, LP if indicated
Temp threshold (action)
≥38.0°C in neonate <28 days = always investigate for sepsis
GCC Context: High ambient temperatures in GCC countries can cause overheating in cars, outdoors, and poorly ventilated rooms. Educate parents: never leave baby in a car.
🥈 Breastfeeding Initiation — The Golden Hour
Skin-to-skin contact within first 60 minutes of birth — facilitates first latch, releases oxytocin, promotes bonding
Support early latch — delay routine procedures (weighing, vitamin K) until after first feed if possible
Colostrum — produced from approximately 16 weeks gestation; present from birth; 5–7 mL per feed in first 3 days (reassure parents this is normal and sufficient)
Transitional milk Day 3–5; mature milk by approximately Day 14
LATCH Score Assessment Tool
Letter
Criterion
0
1
2
L
Latch
Unable to latch
Repeated attempts needed
Latches independently
A
Audible swallow
None
With stimulation
Spontaneous
T
Type of nipple
Inverted
Flat
Everted/protruding
C
Comfort (mother)
Severe pain
Mild discomfort
No pain
H
Hold (positioning)
Full nurse assist
Minimal assist
Independent
Score ≤7 = breastfeeding support needed. Document at each feed in early days.
Correct Latch Technique
Baby's mouth wide open (>120°), chin touching breast
Lower areola mostly in mouth (asymmetric latch normal)
Nose near but not pressing into breast; able to breathe
No pain for mother (initial latch sensation acceptable; ongoing pain = incorrect latch)
Visible jaw movement and audible swallowing
🕚 Feeding Frequency & Volume Guide
Day of Life
Expected Volume/Feed
Frequency
Notes
Day 1–3 (Colostrum)
5–7 mL
8–12 feeds/24 hrs
Stomach capacity = cherry-sized; reassure parents volume is sufficient
Day 3–4
30–60 mL
8–12 feeds/24 hrs
Transitional milk coming in, volumes increase
Day 7
45–90 mL
8–10 feeds/24 hrs
Demand feeding; minimum 8 feeds per 24 hrs
Week 2–4
60–120 mL
8 feeds/24 hrs
~150 mL/kg/day total; weight gain 20–30 g/day expected
Weight Monitoring: Normal weight loss up to 10% of birth weight by Day 3–4. Regain birth weight by Day 10–14. Loss >10% or failure to regain = feeding review and supplementation consideration.
🍼 Formula Feeding & Bottle Technique
Formula Types
Standard cow's milk-based — for healthy term infants
Hypoallergenic (eHF/AAF) — confirmed CMPA; requires prescription in some GCC countries
Allow pauses — tip bottle down every 20–30 seconds
Baby controls pace — watch for feeding cues (stops sucking, turns away)
Discard unused formula within 1 hour of preparation
Never microwave — hot spots cause burns
📢 Feeding & Jaundice Connection
Inadequate feeding increases bilirubin: Insufficient milk intake reduces gut motility, decreasing bilirubin excretion and increasing enterohepatic circulation. Ensure minimum 8 feeds/24 hrs. If breastfed infant is jaundiced and poorly fed, optimise breastfeeding first before phototherapy assessment.
Breast milk jaundice (benign) — persists beyond 2 weeks; caused by factor in breast milk inhibiting bilirubin conjugation. Continue breastfeeding. Only interrupt if bilirubin approaching exchange threshold (rare).
Breastfeeding during phototherapy: Do NOT stop breastfeeding. Encourage 8–12 feeds/day. Supplement with expressed breast milk if weight loss >10% or signs of dehydration. Avoid routine IV fluids unless clinically indicated.
⚠ Kernicterus — Emergency Warning Signs
URGENT — Call senior immediately if any of the following:
Lethargy / extreme difficulty waking for feeds
High-pitched, abnormal cry
Opisthotonos — backward arching of neck and body (retrocollis)
Upward deviation of eyes (setting sun sign)
Seizures in jaundiced neonate
Hypotonia followed by hypertonia
Acute bilirubin encephalopathy (ABE) is preventable. Early recognition and treatment prevents permanent neurological damage (hearing loss, cerebral palsy, dental enamel hypoplasia).
Enter the infant's details to check phototherapy and exchange transfusion thresholds. Based on NICE NG98 (2020) thresholds — confirm with local protocol for clinical decisions.
📅 Newborn Bloodspot Screening (Heel Prick Test)
Timing & Conditions Screened
Performed at Day 5 of life (Day 5 = day of birth is Day 0)
Timing critical: Too early = false negative for hypothyroidism (TSH peaks after 24–48 hrs). Repeat if taken before Day 5, if premature (<32 weeks), or if blood transfused.
Heel Prick Technique
Warm heel for 3–5 minutes (warm cloth or warm water — not hot) to improve blood flow
Cleanse with 70% alcohol — allow to dry
Lancet to outer lateral heel (avoid posterior heel — calcaneum at risk in small infants)
Wipe away first drop of blood (discard — may be diluted)
Allow blood to drop onto circle — do not press or smear
Each circle must be fully saturated — visible on both sides of card
Air dry card horizontally for minimum 30 minutes
Do not heat, fold, contaminate, or refrigerate wet card
Label card correctly: full name, DOB, time of birth, GA, feeding status, mother's name, NHS/hospital number.
🔊 Newborn Hearing Screening
OAE (Otoacoustic Emissions)
Tests outer hair cell function in cochlea
Quick, non-invasive, used for initial screen
Refer if fail — does not detect auditory neuropathy
Perform when baby settled/sleeping
AABR (Automated Auditory Brainstem Response)
Tests entire auditory pathway to brainstem
Used for NICU graduates and OAE failures
More sensitive — detects auditory neuropathy spectrum disorder
Perform before hospital discharge if possible
Target: All babies screened before hospital discharge, or by Day 21 if born at home. Bilateral pass = complete. Unilateral or bilateral refer = audiology follow-up within 4 weeks.
💉 Vitamin K, Hepatitis B & BCG
Intervention
Dose/Route
Timing
Purpose / Notes
Vitamin K (Phytomenadione)
1 mg IM (preferred) or oral × 3 doses (2mg at birth, 1 week, 1 month)
Within first few hours of birth
Prevents Haemorrhagic Disease of the Newborn (HDN/VKDB). IM most reliable — single dose. Oral requires compliance.
Hepatitis B vaccine
0.5 mL IM — anterolateral thigh
Within 24 hrs of birth (ideally within 12 hrs)
Mandatory in GCC national immunisation programmes. HBsAg+ mother = also give HBIG within 12 hrs.
BCG (Bacille Calmette-Guérin)
0.05 mL intradermal — left deltoid (neonates)
At birth or before 28 days
Given at birth in all GCC countries. Intradermal technique — bevel up, 10–15° angle, pale raised bleb 7 mm confirms correct placement. Do not rub after.
📋 Newborn Examination Checklist
Use this checklist for initial newborn examination documentation. Progress saved locally.
🏙 GCC Neonatal Units — Key Centres
Corniche Hospital — Abu Dhabi, UAE
One of the world's largest maternity hospitals. Over 9,000 births per year. Level III NICU. Internationally accredited. Major referral centre for complex neonatal cases in the UAE.
Hamad Women's Hospital — Doha, Qatar
Largest single-site delivery globally — over 18,000 births per year. State-of-the-art NICU. JCI accredited. Serves Qatar's diverse expatriate and national population.
KFCH & Major Saudi Centres
King Faisal Specialist Hospital, King Abdulaziz Medical City, and King Salman Hospital provide tertiary neonatal care. Saudi MOH hospitals provide Level II/III NICU across regions.
Bahrain — Sickle Cell Screening Pioneer
Bahrain was among the earliest GCC countries to implement universal neonatal sickle cell screening — a model for the region. National genetic screening programmes now expanded across all GCC states.
🧬 Consanguinity & Genetic Conditions
Cultural Context: First-cousin marriage is a longstanding cultural norm in many GCC Arab families. This increases the prevalence of autosomal recessive conditions significantly — GCC neonatal bloodspot screening panels are expanded specifically to address this elevated risk.
Key Autosomal Recessive Conditions with Higher Prevalence in GCC
Normal at birth (fetal Hb protective); present after 6 months
Beta-Thalassaemia
High carrier rate in Gulf Arabs, Omanis
Screened via Hb electrophoresis on bloodspot
G6PD Deficiency
Very high prevalence — Arab, South Asian, African populations
Severe neonatal jaundice — see below
Congenital Hypothyroidism
Higher rate linked to iodine deficiency & consanguinity
Screened Day 5; jaundice, poor feeding, lethargy
PKU & Organic Acidurias
Elevated in consanguineous populations
Normal at birth; metabolic crisis if undetected
🟥 G6PD Deficiency & Neonatal Jaundice in GCC
High Risk Alert: G6PD deficiency is very common in GCC populations (Arab, South Asian, African origin). Affected neonates are at risk of severe haemolytic jaundice that can progress rapidly to exchange transfusion level or kernicterus if unrecognised.
Triggers to Counsel Parents About
Fava beans (broad beans) — breastfeeding mother consuming fava beans can trigger haemolysis in G6PD-deficient infant via breast milk
Certain medications — sulfonamides, nitrofurantoin, dapsone (in mother if breastfeeding)
Naphthalene (mothballs) — still used in some GCC households — toxic to G6PD-deficient neonates
Henna applied to newborn — traditional practice in some GCC families; contains lawsone which can cause haemolysis in G6PD deficiency
Nursing Action: Screen for G6PD in all jaundiced male neonates, especially those of Arab, South Asian, or African descent. Results take 24–48 hrs — do not wait; treat jaundice on bilirubin level.
🌟 Cultural Practices at Birth in GCC
Practice
Description
Nursing Consideration
Adhan (call to prayer)
Father or elder recites adhan in baby's right ear, iqama in left ear
Facilitate if family requests, immediately after birth assessment. Requires brief moment of access.
Tahnik
Small amount of dates or honey rubbed on baby's gums/palate by respected elder
Inform family: honey should not be used in neonates <12 months (botulism risk). Dates rubbed externally acceptable. Discuss diplomatically.
Naming ceremony
Often on Day 7 (Aqiqah — animal sacrifice, shaving of head, naming)
Provide education materials. Ensure baby is stable for discharge if family travelling.
Male circumcision
Timing varies — within first 7 days (Sunnah) or delayed weeks/months
Ensure baby stable. Vitamin K given before procedure. Parental consent documented.
Traditional swaddling
Tight swaddling common in some GCC families
Teach hip-healthy swaddling (hips should flex and abduct freely) — reduces DDH risk.
🌥 Birth During Ramadan
Breastfeeding & Ramadan: Fasting during Ramadan is common in GCC Muslim mothers. Maternal dehydration and reduced caloric intake during the day can significantly reduce breast milk supply and alter milk composition. Islam generally exempts breastfeeding and pregnant women from fasting obligations, but many mothers fast regardless.
Nursing Education Points
Encourage generous fluid and food intake at Suhoor (pre-dawn meal) — fluid front-loading before the fast begins
50 days (private sector); broader for public sector
Labour Law protects against dismissal during maternity
Kuwait
70 days (public sector); 30 days (private sector, extendable)
More generous public sector provision
Bahrain
60 days (public); 45 days (private)
Social insurance funded component
Oman
50 days (public); 50 days (private)
Recent Labour Law updates improved coverage
Note: Figures are indicative. Policies change — verify current local Labour Law and employer policies. Paternity leave is limited across GCC but growing.