Clinical Judgment: Musculoskeletal, Neurologic, and Psychosocial
Neurologic
Hypoxic-ischemic encephalopathy (HIE) evolves through stages; abnormal tone, feeding difficulty, altered consciousness, and seizures after a sentinel event or fetal acidosis are the clues. Therapeutic hypothermia at about 33.5°C for 72 hours improves outcomes when started within 6 hours of birth in eligible infants - know the entry criteria (gestational age, birth weight, cord or early blood gas, exam, amplitude-integrated EEG). Neonatal seizures are often subtle or electrographic only, so EEG matters. Intraventricular hemorrhage is graded I–IV; grade III with venous infarction and grade IV carry the worst prognosis. Cluster care, midline head position, and stable blood pressure reduce risk.
Musculoskeletal
Clavicle fracture is the most common birth injury. Erb palsy affects the upper roots (C5–C7), with the arm internally rotated and the grasp intact. Cephalohematoma respects suture lines; subgaleal hemorrhage does not and can exsanguinate - an emergency. Screen for developmental dysplasia of the hip with Ortolani and Barlow maneuvers in breech and female infants.
Psychosocial
Developmental care - dim lights, protected sleep, clustered care, kangaroo care - is an intervention, not a courtesy. Parents of NICU infants carry high rates of depression, anxiety, and post-traumatic stress; screen and refer. Include families on rounds and in care planning.
Traps and rule of thumb
Dismissing a subgaleal bleed as a bruise, or expecting every neonatal seizure to be tonic-clonic. Rule of thumb: encephalopathy plus acidosis after a sentinel event means call the cooling team before 6 hours - every hour counts.