Newborn danger signs that mean you should go to hospital today

Go to hospital the same day if your newborn is not feeding well, has a fit, breathes 60 or more times a minute, pulls in the chest deeply, has a temperature of 37.5 degrees C or more or below 35.5 degrees C, or moves only when stimulated. These signs can be the only clue to a serious infection.

What are the danger signs in a newborn baby?

WHO lists these danger signs in newborns, and a large study of young infants used almost the same list. Any one of them means your baby should be seen by a doctor today:^1,2

• Not feeding well
• A fit (convulsion), now or earlier
• Fast breathing, 60 or more breaths a minute
• Severe chest indrawing (the lower chest sucks in with each breath)
• No movement on their own
• Temperature of 37.5 degrees C or more
• Temperature below 35.5 degrees C
• Any yellow colour in the first 24 hours, or yellow palms and soles at any age

These signs come from a large study in young infants in several countries. Having any one of them picked up most babies with serious illness.²

Why are danger signs in newborns easy to miss?

Because sick newborns rarely look dramatically ill at first. A baby with a bloodstream infection may just feed a little less, sleep a little more, or feel a little cool.

Older children with infection often have high fever and stop playing. Newborns are different. By the time the signs are obvious, the illness can be advanced. This is why India's home-based newborn care programme trains ASHAs to look for these signs during their visits. Dr Dutta would like every parent and grandparent to know them too.

When is poor feeding a danger sign?

A baby who was feeding well and now refuses feeds, sucks weakly, or falls asleep after a few sucks needs a doctor today. In the large study of young infants, a history of difficulty feeding was one of the strongest signs of serious illness.²

Compare with your baby's own pattern. A newborn who goes much longer than usual without wanting to feed, or cannot attach at all, is telling you something. Do not wait for the next feed to "see if it improves".

How do I know if my newborn is having a seizure?

Seizures in newborns are often subtle and do not look like fits in older children. Some show no visible signs at all and are seen only on a brain wave test (EEG).³

Watch for:

• Repeated lip smacking, chewing or tongue movements
• Cycling or pedalling movements of the legs
• Rhythmic jerking of one arm or leg
• Eyes turning to one side, or a fixed stare
• Pauses in breathing with colour change

Normal newborns can be jittery, especially when cold or crying. Jitters stop when you gently hold the limb. Movements that carry on when you hold the limb need urgent care. If you can, take a short phone video. It helps the doctor a lot.

How do I count my newborn's breathing?

Count breaths for one full minute while your baby is calm or asleep, watching the tummy rise. Sixty or more breaths a minute is fast breathing in a newborn.¹

Newborns breathe unevenly, with short pauses and bursts. So counting for only 15 seconds and multiplying by 4 can mislead you. If the count is 60 or more, wait a few minutes and count again. If it is still high, go to hospital. Fast breathing can be a sign of pneumonia, infection or a heart problem.

What do chest indrawing and grunting mean?

Severe chest indrawing means the lower chest wall sucks in deeply with each breath. Grunting is a short noise at the end of each breath out. Both are signs of breathing difficulty.²

Mild indrawing can be normal because a newborn's chest wall is soft. Deep, obvious indrawing is not. Other signs of struggling to breathe include flaring of the nostrils, nodding of the head with each breath, and a blue colour around the lips. A baby with any of these needs to be seen at once.

What temperature is a fever in a newborn?

In a young baby, a temperature of 37.5 degrees C or more is a danger sign.² For babies aged 8 to 60 days, a temperature of 38 degrees C or more needs a doctor's assessment, even if the baby looks well.⁴ In the first week of life, any fever is even more urgent.

Use a digital thermometer in the armpit and hold it for the full time. Feeling the forehead is not reliable. Do not give paracetamol before the doctor sees your baby unless advised, because it can hide the fever and delay diagnosis.

Is a low temperature dangerous in a newborn?

Yes. A temperature below 35.5 degrees C is a danger sign.¹ Sick newborns, especially premature ones, often become cold rather than hot.

In a large study from Nepal, the risk of death rose by about 80 percent for every 1 degree drop in a newborn's temperature.⁵ The risk was highest in premature babies.⁵ If your baby feels cold, warm them skin-to-skin against your chest with a cap and a blanket over both of you, and recheck the temperature. If it stays low, or the baby seems unwell, go to hospital.

What if my baby feels hot because of overdressing in summer?

Overdressing can raise a baby's temperature, especially in a Kolkata summer. Take off the extra layers, wait 15 to 20 minutes in a cool room, then measure again.

If the temperature is still 37.5 degrees C or more, or your baby seems unwell, go to hospital.² Grandparents often wrap babies in many layers out of care. WHO's general advice is 1 or 2 more layers of clothing than an adult is wearing.¹ In hot, humid weather, use the lower end: one light cotton layer more than the adults in the room.

What does it mean if my baby moves only when stimulated?

It means the baby may be seriously ill. A healthy newborn moves their arms and legs on their own when awake, and wakes for feeds.

In the large study of young infants, a baby who moved only when stimulated was much more likely to be seriously ill.² A baby who is floppy like a cloth doll, very hard to wake, or does not move at all needs emergency care. Do not wait to see if they "sleep it off".

Is green vomit in a newborn an emergency?

Yes. Green (bile-stained) vomit in a newborn should be treated as a possible blocked bowel until proven otherwise. Go to hospital straight away.

In a study of newborns with green vomit, more than a third had a surgical cause, such as a twisted or blocked bowel.⁶ Many others turned out to be fine, but only tests can tell the difference.⁶ Watch also for a swollen, tight tummy, blood in the stool, or vomiting everything. Milky spit-ups after feeds are common and are a different thing.

When is jaundice a danger sign?

Yellow skin in the first 24 hours after birth, or yellow palms and soles at any age, are danger signs.¹ Both need a bilirubin test the same day.

Mild yellow colour on the face and chest from day 2 or 3 is common and often harmless. But only a measurement tells you how high the level is. A yellow baby who is also very sleepy, feeding poorly, or has a high-pitched cry needs emergency care. Jaundice beyond 2 weeks, or pale stools, also needs a check.

What do skin and cord infections look like in a newborn?

Redness spreading from the cord onto the tummy, pus from the cord, many pus-filled spots on the skin, or a large boil can all be signs of infection. In a newborn, these can spread to the blood quickly.

Other warning signs on the skin are:

• Blue colour of the lips, tongue or face
• Very pale or mottled (blotchy, marbled) skin
• Bruises or tiny red spots that do not fade when pressed
• Swelling, redness or warmth over a joint or limb that the baby does not move

What are the signs of dehydration in a newborn?

A dehydrated baby passes much less urine, has a dry mouth, and may have a sunken soft spot on the head or sunken eyes. In the first week, fewer wet nappies than expected is often the earliest sign.

Dehydration in breastfed newborns is usually from too little milk, not illness. In an Indian study, babies admitted with dehydration often also had fever, jaundice and lethargy.⁷ Diarrhoea or vomiting can cause dehydration fast in young babies. Keep breastfeeding and go to hospital if you see these signs.

Why are newborns so vulnerable to infection?

A newborn's immune system is new. Their infection-fighting cells are fewer and slower, and they have not yet built their own antibodies. Infection can spread from the skin, cord or urine to the blood and brain within hours.

Infection is common in Indian newborns. In a study of babies admitted to newborn intensive care units in Delhi hospitals, about 14 percent developed sepsis (a serious bloodstream infection), most within the first 3 days.⁸ Many of the germs resisted common antibiotics.⁸ Premature babies, small babies, and babies whose mothers had fever or early rupture of the waters are at higher risk.

Does acting early really make a difference?

Yes, a very large difference. Early treatment with the right antibiotics, warmth and feeding support works well.

In the Gadchiroli field trial in Maharashtra, trained village health workers found and treated sick newborns early at home. Newborn deaths fell from 62 to 25 per 1000 births over the years of the programme.⁹ Deaths from sepsis fell by 90 percent.⁹ The home visits by ASHAs that Indian families receive today follow the same idea.

What should I do on the way to hospital?

Go to the nearest hospital that has a paediatrician or a neonatal unit. On the way:

• Keep your baby warm, ideally skin-to-skin on the mother's or father's chest, with a cap and a cloth over both of you
• Keep breastfeeding if your baby is able to feed
• Do not give any medicine, ghutti, water or home remedy before the baby is seen
• Take the discharge summary, vaccination card and any recent test results

Many families hesitate because a senior relative says the baby is fine. Please do not wait. No good paediatrician will be annoyed that you came.

When should I take my newborn to hospital today?

Take your baby to hospital the same day if you notice any of these:

• Poor feeding or refusing feeds¹
• A fit, or strange repeated movements
• Breathing 60 or more times a minute, deep chest indrawing, or grunting²
• Temperature of 37.5 degrees C or more, or below 35.5 degrees C²
• Moving only when stimulated, or floppy
• Yellow skin in the first 24 hours, or yellow palms and soles
• Green vomit, a swollen tummy, or blood in the stool
• Blue lips, very pale or mottled skin
• Spreading redness or pus around the cord
• Very few wet nappies, or a sunken soft spot

And if you simply feel something is wrong and cannot explain why, go anyway. A mother's instinct is often right.