creation date: 2026-09-25 12:45
tags: Assessments
Newborn History
Background
The newborn history is used for consults. Note, depth of questions may not be as necessary for an infant with prior chart history.
For the physical exam, see newborn exam.
History
Feeding
A complete history of feeding should ascertain amount of BM/EBM/formula used.
Breastfeeding:
- Duration of feed
- Latching well
- How many feeds per day
Expressed breast milk:
- Amount pumped
- Amount taken by baby
- Bottle and nipple used
Formula:
- Amount taken up
- Bottle and nipple used
Associated findings should also be asked:
- Apnea
- Arching
- Spit-up
- Projectile vomiting
- Diaphoresis
- Cyanosis
Voiding / Stooling
Inquire about:
- Number of wet diapers in 24 hours
- Number of stools in 24 hours
- Colour of the stools
- Presence of blood/mucous in stool
Birth History
Maternal / Prenatal History
Note the following:
- GTPAL
- Natural conception (NC) vs. IVF
- Serologies
- HIV
- Syphilis
- Serology
- Rubella
- Hepatitis B
- GBS status - and if positive, whether adequate prophylaxis was given
- Prenatal complications
For prenatal complications, it is important to list them as it can be easy to forget:
- Infections
- GDM
- GHTN, preeclampsia
- Alcohol, smoking, or recreational drug use
Delivery and Birth
Note the following:
- Gestational age
- Hospital of birth
- C section or spontaneous vaginal delivery
- If C-section, emergent or scheduled
- Complications
For complications, list them:
- Meconium in uterus
- Fever
- Infection
- Resuscitation for baby
- Oxygen therapy for baby
- NICU stay
- Hypoglycemia
- Jaundice
Medical History
Past Medical History
Inquire about any diagnoses the neonate may have received.
Medications
Inquire about current medications, including vitamin D.
Immunizations
Inquire about vitamin K shot and erythromycin eye drops.
If they are above the age of 2 months, inquire about vaccinations.
Developmental History
Confirm baby is alert and active. If they are older, inquire about developmental milestones.