This chapter will describe the care of hospital-born low-risk newborn infants between birth and discharge home. Routine care usually begins with an initial assessment of the infant in the newborn nursery.
The goals of postnatal neonatal care for low-risk newborns are to
ensure transition to extra-uterine life,
prevent or treat neonatal conditions arising from maternal or infant medical and social risk factors, and
ensure a successful transition to home care.
The infant should be examined by the primary provider within the first 24 hours after birth. Generally, immediately after birth, healthy infants will remain with their mothers for a period of transition, skin-to-skin contact, breastfeeding, and bonding. This time together helps maintain the infant’s body temperature and facilitates successful breastfeeding. Guidelines suggest that the newborn’s condition should be evaluated after birth every 30 minutes until it has been stable for 2 hours. Thereafter, observations can be less frequent if the infant appears well. Nursing staff, medical staff, or a midwife in the postpartum area should perform a full assessment of the infant to identify potential problems.
In the first few hours after birth, the infant’s body temperature should be measured on a regular basis. Skin temperature is usually lower than central body or core temperature, but it is still a reliable indicator of optimal temperature. Rectal temperature is a good indicator of core temperature, but insertion of a rectal temperature probe carries with it a risk of large bowel perforation. Measurement of axillary temperature is the preferred and safe alternative, and the normal range is 36.5°C to 37.4°C.
At delivery, the skin is wet and covered with amniotic fluid; the infant is usually exposed to low ambient temperature in the delivery room and frequently is kept unclothed to allow adequate initial observation. Therefore, heat is lost by evaporation, radiation, and convection. If measures are not taken to prevent heat loss in the newborn, body temperature can fall precipitously. Drying the infant immediately after birth, wrapping the infant in a warm, dry towel, and placing a knit cap on the head all help to reduce heat loss. Delivery room assessments and resuscitation should be performed under a radiant warmer, ideally with a servo-controlled feedback device that attaches to the infant’s skin. Infants may also be placed in an incubator for observation in a neutral thermal environment of 31°C to 34°C at 50% humidity. In this range of ambient temperature and humidity, heat loss, metabolic demands, and oxygen consumption are lowest.
The nursery should be free of drafts at a temperature of 24°C to 26°C to assure a proper thermal environment for the healthy term infant. An infant who is hypothermic soon after birth should be warmed in an incubator or beneath a radiant warmer at a moderate rate to avoid the adverse consequences of cold stress and of excessive application of external heat. When an infant is in an incubator, both the infant’s temperature and the ambient temperature inside the incubator should be monitored and recorded. When an infant achieves a stable normal temperature, care can be provided in an open crib with adequate clothing and a blanket to prevent cooling. Temperature instability may be an important indicator of illness and, in particular, of infection.
The majority of life-threatening cardiopulmonary conditions appear during the first 6 hours after birth. The newborn’s heart rate, blood pressure, respiratory rate, quality of respirations, oxygenation, and color of skin and mucous membranes should be monitored and recorded frequently during this time.
In the first 10 minutes after birth, the average heart rate is 160 beats per minute (bpm) but may vary from 120 to 180 bpm. Thereafter, the average is 120 to 130 bpm (range 90–175 bpm). A consistently low or high heart rate suggests a pathologic condition. Tachycardia may be a sign of low intravascular volume, cardiovascular or respiratory disease, drug withdrawal, pain, or hyperthyroidism. Rates greater than 200 bpm should prompt consideration of tachydysrhythmias such as supraventricular tachycardia. Bradycardia is often seen after perinatal asphyxia and also may be an ominous sign in association with apnea, airway obstruction, or infection. An irregular rhythm is occasionally encountered during auscultations, most frequently due to premature atrial contractions. These are typically benign and resolve within 48 hours. More than 6 ectopic beats per minute should be evaluated with a 12-lead electrocardiogram and referral to a cardiologist if a conductive defect is suspected.
Normal newborns breathe approximately 40 times per minute. This rate is variable between 30 and 60 breaths per minute. Breathing may not be regular. Periodic breathing, characterized by brief respiratory pauses, is considered to be normal. These are usually 5 seconds or less in duration but occasionally last as long as 10 to 15 seconds. A prolonged respiratory pause of longer than 20 seconds is abnormal and is considered to be apnea, especially if it results in bradycardia. These episodes require investigation. It is a nonspecific sign; it may be caused by such diverse conditions as infection, cardiac disease, hypoglycemia, polycythemia, and intracranial hemorrhage.
Tachypnea (respiratory rate > 60 breaths/min) in the newborn is also a nonspecific sign. Tachypnea is very common during the first few hours of transition, and in the first 24 hours. Tachypnea is most often due to retained fetal lung fluid (transient tachypnea of the newborn). In addition to the causes noted above for apnea, tachypnea may also be caused by disorders such as respiratory distress syndrome, meconium aspiration, pneumonia, and pneumothorax.
The normal range of blood pressure measured with a properly fitting limb cuff in term infants within 12 hours after birth is 65 to 95 mm Hg systolic and 30 to 60 mm Hg diastolic, with a mean blood pressure ranging from 40 to 55 mm Hg. An abnormal gradient of upper extremity to lower extremity blood pressures and absent or weak femoral pulses may be signs of coarctation of the aorta.
Oxygenation is best assessed with a pulse oximeter. After 10 minutes of life, the oxygen saturation should be in the 90s. Pulse oximeter probes should be attached to the right hand to assess preductal oxygenation. Oxygen saturation measured on other extremities may be affected by right-to-left shunting across the ductus arteriosus in the newborn.
Feeding can be initiated once the infant has been initially assessed and vital signs are stable. If the mother has chosen to breastfeed, this should occur in the first hour after delivery. Careful observation during the first 1 or 2 feeds may yield valuable information regarding coordination of suck and swallow, possible presence of gastrointestinal obstruction, and the potential for aspiration of gastric contents.
Choanal and esophageal atresia should be excluded if the infant experiences difficulty breathing during feeding or if the infant regurgitates during or after each feeding. A soft catheter can be passed orally into the stomach to assure patency of the esophagus; however, an H-type tracheoesophageal fistula will not be recognized this way and needs to be ruled out by other methods. Inability to pass a catheter nasally can reveal choanal atresia.
Newborns commonly regurgitate a small amount of milk with some feedings. Recurrent vomiting, or larger amounts or bile-stained emesis, may reflect intestinal obstruction that requires immediate diagnostic evaluation. During the first day, infants who have large amounts of mucus or swallowed blood in the stomach may repeatedly regurgitate small amounts of material or have difficulty in feeding. If vomiting persists, further assessment, including abdominal radiography, should be pursued.
All mothers should be encouraged to breastfeed, unless there are clear contraindications. Exclusive breastfeeding for 3 to 6 months may help prevent allergic conditions from occurring in infancy and early childhood. In infants who are breastfed, feeding behavior, frequency of feeding, stool characteristics, and initiation of maternal milk production should be noted and recorded. If there are any concerns regarding nutritional intake, the change in weight before and after breastfeeding can be measured. In babies who are fed milk formula, nutritional intake can be judged by the volume of formula ingested.
Approximately 70% of normal newborn infants excrete meconium during the first hours, and 95% of infants pass at least 1 stool within 24 hours. An infant who does not pass meconium in the first 24 hours should be evaluated. Passage of meconium may be delayed in infants with distal intestinal obstruction, as in meconium plug syndrome, or in infants with aganglionic colon (Hirschsprung disease). Other causes of abnormal gastrointestinal motility and delayed stool excretion are premature birth, sepsis, hypothyroidism, and various drugs, including narcotics.
Infants with high gastrointestinal obstruction usually present with vomiting but may not have abdominal distension or abnormal stool frequency during the first 24 hours after birth. Infants with lower intestinal obstruction are less likely to exhibit vomiting early but often exhibit abdominal distension and absent stools. Plain films of the abdomen are simple and effective in the initial evaluation of abdominal distention.
The color and consistency of stools change from green-black and viscous on the first day to green-yellow and paste-like by the third or fourth postnatal day. Normal stools are not watery, but those of breastfed infants are often softer and less formed than are the stools of formula-fed infants. During the first week, the normal frequency of stool output varies from 1 to 10 per day, usually averaging 3 to 5 stools daily. Delayed or infrequent stool passage increases the risk of hyperbilirubinemia during the first week.
Stools that are dark red and tarlike in consistency are indicative of old blood, usually maternal in origin, which was swallowed at the time of delivery. This can be distinguished from the infant’s blood by a test that differentiates between adult and fetal hemoglobin (the Apt test for alkali resistance of fetal hemoglobin). Small streaks of bright red blood in the stools often reflect the presence of a rectal fissure. If no fissure is found, or if there are large quantities of blood in the stools, further evaluation is indicated. Diarrhea is a common sign of systemic or gastrointestinal infection, feeding intolerance, or drug withdrawal.
Newborn babies very frequently urinate shortly after birth in the labor and delivery setting and virtually all normal infants have voided at least once within 24 hours. An absence of urine output may be of prerenal origin (severe hypovolemia and hypotension, myocardial failure, dehydration); or it may reflect renal anomalies, such as absent kidneys, acute tubular necrosis from ischemia, or renal vein thrombosis; or it may signal obstruction to urinary outflow, possibly from posterior urethral valves or from a blocked urethra.
An infant who does not pass urine in the first 24 hours should be examined for genital abnormalities and for a distended bladder. The prenatal records should be reviewed for the presence or absence of oligohydramnios. The delivery summary should be reviewed for documentation of possible void at the time of delivery. The infant may also be challenged with a supplemental feeding. If no urine is excreted, a straight catheter may be passed to detect presence of urine in the bladder. If the bladder remains dry, initial work up would include blood urea nitrogen, creatinine, and renal and bladder ultrasound.
Neonatal urine is normally yellow or light brown. Urate crystals, which vary from brick red to tan in color, are a common source of diaper stain in the newborn period and are often misinterpreted as blood. True hematuria is pathologic and requires urgent evaluation. During the first week of life, female infants may experience estrogen withdrawal and have vaginal bleeding which may complicate the clinical picture. Such bleeding should be brief (1 day) and occurs in tiny amounts.
The newborn infant should be weighed in the hospital at birth, and daily thereafter, upon discharge from hospital. At postnatal follow-up examinations, hospital staff should determine whether the infant is small, appropriate, or large for gestational age. A maturational assessment such as the Ballard score may be useful for preterm infants. Infants who are small or large for gestational age may be at risk for postnatal complications, such as hypoglycemia or polycythemia.
The normal newborn loses approximately 5% to 10% of the birth weight during the first few days after birth and usually begins to regain weight by the second half of the first week. Weight loss beyond 7% should prompt an evaluation of feeding effectiveness. Weight loss of more than 10% in a term infant is considered abnormal.
Infant length is best measured with the infant supine, using a calibrated length board. In practice, a less accurate method using a measuring tape is common. It should be secured at the top of the head. The infant’s knees should be held together and pressed gently to straighten the legs. Then the measuring tape is used to calculate the distance from the top of the infant’s head to the infant’s heels. Body length does not change measurably during this newborn period.
Occipital-frontal head circumference should be measured by placing a measuring tape above the eyebrows and the ears and wrapping it around the largest part of the occiput. The circumference may decrease by up to 1 cm as tissue edema abates during the week after birth. In some infants, head circumference may increase by up to 1 cm as the cranial molding that occurred during labor resolves. Rapid expansion of the head size in the first week may be a sign of ventricular enlargement and merits evaluation by cranial imaging studies. Infants who were delivered with instrumentation (vacuum or forceps) may be at increased risk for cephalohematoma, subgaleal hemorrhage, and intracranial hemorrhage and should have serial examinations and serial measurement of occipital-frontal head circumference.
Prevention of Neonatal Ophthalmia
Ophthalmia neonatorum is defined as conjunctivitis occurring in the first month of life. Several organisms can infect the eyes of the newborn, including Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex virus, or other bacterial microbes like skin, respiratory, vaginal, and gastrointestinal tract pathogens. Neisseria gonorrhoeae infects the eyes in 1% of the cases but can penetrate the intact corneal epithelium and cause microbial keratitis, ulceration, and perforation. To prevent gonococcal ophthalmia, all newborn infants should have 2 drops of a solution of 1% silver nitrate or a 1- to 2-cm ribbon of ophthalmic antimicrobial ointment, containing either 1% tetracycline or 0.5% erythromycin, placed in each eye within 1 hour after birth. The solution or ointment should reach all parts of the conjunctival sac and should be dispensed from a single-use container. The eyes should not be rinsed after treatment because doing so decreases effectiveness.
It is important to note that neither silver nitrate nor erythromycin ointment is effective treatment for an already established case of gonococcal ophthalmia and systemic antimicrobial therapy is required. Typical side effects of eye prophylaxis include chemical conjunctivitis, especially with silver nitrate prophylaxis.
Prevention of Hemorrhagic Disease of the Newborn: Vitamin K
Hemorrhagic disease of the newborn has become a rare entity because of vitamin K prophylaxis. Vitamin K is necessary for synthesis of factors II (prothrombin), VII, IX, and X, and yet vitamin K is undetectable in cord blood. Lactobacillus, the primary gut flora in breastfed babies, does not synthesize vitamin K, and breast milk contains only small amounts of vitamin K (1–9 mcg/L versus 53–66 mcg/L in formula).
All newborns should receive a single dose of vitamin K (1 mg, intramuscularly) during the first few hours after birth to prevent the development of hemorrhagic disease of the newborn. Classically, vitamin K deficiency can cause gastrointestinal, intracranial, or generalized bleeding between 2 and 7 days after birth (0.25–1.7% incidence). However, the early form of the disease may present in the first 24 hours, and the late form may present anywhere between 2 weeks and 6 months of age. The late form of hemorrhagic disease occurs mainly in babies who are exclusively breastfed but may also be associated with cystic fibrosis, celiac disease, chronic diarrhea, α1 antitrypsin deficiency, or hepatitis.
For infants of parents who refuse the intramuscular injection, a 2-mg oral dose of vitamin K maintains normal coagulation status in the first few days, but the effect may be transient and the dose should be repeated. The recommended timing of additional dosing varies. Some recommend an additional dose of 2 mg at 6 to 8 weeks of age, while others recommend weekly dosing while breastfeeding. The intramuscular form of vitamin K can be given safely orally.
It is now public policy in the United States to immunize all infants against hepatitis B infection. In infants born to mothers who are negative for hepatitis B surface antigen, the first dose of recombinant vaccine should be administered before 2 months of age. Infants who receive the first dose in the delivery hospital are more likely to complete the 3-dose series. Delivery hospital protocols that encourage vaccination in the first 12 hours of life also protect the infant against maternal hepatitis B surface antigen conversion that may have occurred during the pregnancy. If the vaccine is given prior to discharge in the nursery, an immunization record should be filled out and given to the parents. Due to the effective vaccination policy, the incidence of acute hepatitis B virus infection among US children younger than 19 years decreased by 98% between 1990 and 2010.
Infants born to mothers who are positive for hepatitis B surface antigen or to mothers of unknown hepatitis status need special management. Proper prophylaxis can prevent transmission in approximately 95% of exposed newborns that complete the 3-dose vaccine series. If the mother is positive for hepatitis B surface antigen, the infant should be bathed soon after birth to remove infectious bloody material, and the skin should be swabbed carefully with disinfectant before any drug injection or blood drawing. In addition, the infant should receive hepatitis B immune globulin (0.5 mL) intramuscularly at 1 site and recombinant hepatitis vaccine concurrently in another site within the first 12 hours after birth. Infants whose mothers are positive for hepatitis B surface antigen should be immunized on an accelerated schedule, with the second dose at 1 month and the third at 6 months after birth.
If the mother is of unknown hepatitis B status at the time of delivery, her blood should be sent for immediate testing, and the infant should receive the vaccine within 12 hours as described above for the infant whose mother is positive for hepatitis B surface antigen. If the mother is proven to be positive for hepatitis B surface antigen, the infant should then receive hepatitis B immune globulin as soon as possible and no later than 7 days postnatally. If the mother is hepatitis B surface antigen negative, the regular schedule of immunizations should be followed.
Umbilical cords tend to dry quickly, naturally, and without any additional care. This simple observation has called into question the various methods of care previously thought necessary to prevent infection. Cord care is best accomplished by leaving the umbilicus exposed to air and keeping it clean and dry. Topical application of antiseptic agents such as triple dye, chlorhexidine, or alcohol to the cord has no advantage over dry umbilical cord care. Regardless, parental education regarding the signs and symptoms of omphalitis is imperative.
Routine monitoring of blood glucose concentration is only recommended for symptomatic infants and infants at risk for hypoglycemia. At-risk infants should be fed by 1 hour of age and have a screening blood glucose test 30 minutes after feeding. In at-risk or symptomatic newborns, blood sugar should be measured with a rapid bedside screening method within 2 to 3 hours of life, before breastfeeding, and whenever clinical signs of hypoglycemia are noted. Hospital protocols specifying serial glucose measurements, early feedings, and transfer criteria should be developed for infants at risk for hypoglycemia.
Risk factors for neonatal hypoglycemia include being infants of diabetic mothers (IDM); small or large for gestational age (SGA or LGA) infants; preterm or postmature infants; or intrapartum asphyxia, polycythemia, hypothermia, or stress related to clinical conditions such as infection. Clinical signs of hypoglycemia include changes in level of consciousness, apnea or cyanosis, poor feeding, hypothermia, hypotonia, tremor, and seizures. Blood glucose measurement of below 40 mg/dL by the screening technique should be evaluated using a specific assay for serum or plasma glucose, and treatment for hypoglycemia should be initiated while the result is pending. Hypoglycemia may also occur in a variety of neonatal conditions.
Hypoglycemia is defined as a blood glucose concentration low enough to cause signs and symptoms of impaired brain function. Most healthy term infants have a serum or plasma glucose concentration higher than 40 mg/dL on the first day of life and over 45 to 50 mg/dL thereafter. However, there is a physiologic dip in blood glucose concentrations during the first 2 hours of life, and at this time, blood glucose levels as low as 30 mg/dL may be tolerated in an otherwise healthy term infant who is able to feed appropriately. A steady state rate of glucose production has been measured in normal infants by 3 to 4 hours of life. It is important to note that individual infants exposed to high glucose levels in utero may become symptomatic at “normal” glucose concentrations above 40 mg/dL.
Hospital nurseries should define operational thresholds, or levels at which nurses and physicians should consider intervention, and have clear protocols for treatment of hypoglycemia, using guidelines from the American Academy of Pediatrics and the Pediatric Endocrine Society for detection and treatment of neonatal hypoglycemia.
Screening for Critical Congenital Heart Disease
Critical congenital heart disease (CCHD) is a group of heart conditions that are present at birth, and can be cyanotic or acyanotic. In the United States, the frequency of these lesions is 18 per 10,000 deliveries. The most common lesions presenting in the early neonatal period are coarctation of the aorta, double outlet right ventricle, d-transposition of the great arteries, Ebstein anomaly, hypoplastic left heart syndrome, interrupted aortic arch, total anomalous venous return, tetralogy of Fallot, tricuspid atresia, and truncus arteriosus. Many of these conditions are life threatening and generally require intervention soon after birth. CCHD commonly presents within hours or a few days of life. Clinical signs and symptoms can include a heart murmur, reduced pulses, tachypnea, hypotension, hypoxemia, or cyanosis. If untreated, CCHD can lead to shock, coma, and death. CCHD affects the flow of blood into, out of, or through the heart. Sometimes the defect is in the heart itself, while other times it affects the valves that regulate the blood flow within the heart. Newborn screening for CCHD includes a thorough physical examination including auscultation of the heart and palpation of peripheral pulses, and includes pre and post ductal oxygen saturation screening. This should be done after 24 hours of life or just prior to discharge from hospital if within 24 hours of birth.
In infants at risk, hematocrit/hemoglobin can be measured to exclude possible anemia or polycythemia. Anemia may result from hemolysis or blood loss, or other conditions such as suspected subgaleal hemorrhage that may require measurement of serial hematocrits. Suspected fetomaternal hemorrhage can be detected by performing a Kleihauer-Betke acid elution test on maternal blood. Polycythemia is more common than anemia and is often associated with delayed cord clamping at birth, when the infant is held below the level of the uterus or placenta for a prolonged time (more than 1 minute) (placental-to-infant transfusion), postmaturity, severe intrauterine growth restriction, large size for gestational age, monozygotic twins, or infants born to diabetic or hypertensive mothers.
Isoimmunization and Hyperbilirubinemia
It is the standard of care to obtain a mother’s blood type and Rh during pregnancy in order to avoid Rh sensitization and isoimmune hemolytic disease. Some centers obtain the mother’s blood type and Rh upon admission to labor and delivery in order to avoid transcription errors of prenatal laboratory results. If a mother’s Rh status is negative, her infant’s blood type and Rh should be determined and a direct Coombs test should be performed. Blood type and direct Coombs test also should be performed if the mother has a positive antibody titer.
Risk factors for hyperbilirubinemia include predischarge total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) in the high-risk or high intermediate risk zone, lower gestational age (late preterm gestation 34 0/7 to 36 6/7 weeks), exclusive breastfeeding, especially if nursing is not going well and weight loss is excessive, jaundice observed in the first 24 hours of life, isoimmune or other hemolytic disease (eg, G6PD deficiency), history of a sibling who was jaundiced or required phototherapy in the newborn period, East Asian race, polycythemia, cephalohematoma, or bruising.
Guidelines from the American Academy of Pediatrics recommend predischarge bilirubin measurement and/or assessment of clinical risk factors to evaluate the risk of subsequent severe hyperbilirubinemia. Some hospitals have implemented the guideline by obtaining a predischarge total serum or transcutaneous bilirubin and determining risk based on an hour-specific nomogram. The American Academy of Pediatrics and the Centers for Disease Control and Prevention have developed toolkits to assist birthing centers in following the guidelines for management of hyperbilirubinemia. (See Chapter 55 for further information.)
Metabolic Diseases and Hemoglobinopathies
Inborn errors of metabolism are rare but potentially serious, even lethal if untreated. Advances in laboratory technology such as tandem mass spectrometry (MS/MS) have increased the number of genetic conditions that can be diagnosed at birth through neonatal screening programs. Newborn screening policies and availability of tests greatly vary around the world. In the United States, in 2005, the American Academy of Pediatrics endorsed the report from the American College of Medical Genetics, which recommended that all states should screen newborn infants for a core panel of 29 treatable conditions and an additional 25 conditions that may be detected by screening. Newborn screening blood specimens are collected on a test paper between 24 and 48 hours after birth. If the initial testing is obtained before 24 hours of life, in most states it is recommended that a second sample should be obtained. Some states also mandate or recommend that an additional newborn screening blood specimen be collected on all infants at 10 to 14 days of age.
Newborn nurseries should have protocols in place to ensure that initial testing is performed on all infants at the proper time, that conditions affecting results are noted (eg, blood transfusion), that results are followed up in a timely manner, and that infants with positive results are referred for diagnostic testing and treatment. Hospitals should perform regular audits of live births as well as outborn transfers, and certify that each infant was tested or retested at the appropriate time, review all abnormal test results, and document referral for appropriate evaluation and treatment.
Screening newborn infants for deafness and auditory abnormalities is recommended by the American Academy of Pediatrics so that infants with sensorineural or conductive hearing loss can be diagnosed by 3 months of age and early intervention initiated by 6 months of age. Hearing screening should be completed prior to discharge from the hospital, and hospital programs must ensure that tracking, follow-up, identification, intervention, and evaluation can be carried out when necessary. According to the recommendations of the American Academy of Pediatrics Task Force on Improving the Effectiveness of Newborn Hearing Screening, Diagnosis, and Intervention, and the Joint Committee on Infant Hearing, all infants should be screened by 1 month of age.
Currently, there are 2 methods of automated testing: the auditory brain stem response and the otoacoustic emissions test. Both of these tests can be performed by nursery personnel trained in their use. Infants who fail these screening tests in 1 or both ears should be referred, not later than 3 months of age, for formal diagnostic studies at an audiology center that is capable of testing young infants. The prevalence of newborn hearing loss is 1 to 2 per 1000 live births, and the incidence in normal newborns is 1 per 1000. The referral rate for diagnostic testing after failed hearing screening should be less than 4%.
Exposure to Toxic Substances
Infants who have been exposed in utero to drugs of abuse should be identified in the neonatal period so that they can be monitored carefully for signs of neonatal abstinence syndrome. Every nursery should have a protocol that defines specific criteria based on maternal risk factors and on infant symptoms to determine those patients for whom a urine or meconium sample should be sent for detection of illicit drugs. Common maternal risk factors include history of drug use; limited prenatal care; history of hepatitis B, HIV, syphilis, gonorrhea, or prostitution; and unexplained placental abruption. Clinical suspicion is increased when these risk factors are accompanied by preterm labor.
Infant risk factors include unexplained neurologic complications, unexplained intrauterine growth retardation, and evidence of drug signs of withdrawal. The signs and symptoms of neonatal abstinence syndrome include neuroexcitability or central nervous system dysfunction; metabolic, vasomotor, and respiratory disturbances; and gastrointestinal dysfunction. The onset of symptoms depends on the drug, the time and extent of the last exposure, as well as the metabolism and excretion of the drug and its metabolites. Abstinence scores should be obtained regularly in exposed infants and may be used to guide therapy, which may be with morphine, methadone, or phenobarbital. Abstinence scores may also be elevated in infants who have been exposed to stimulants, as these infants may have higher levels of excitability and may appear to be irritable or hungry. This usually represents drug effect rather than withdrawal.
Toxicology testing may be performed on the infant’s urine, meconium, or umbilical cord. Urine testing is the most readily available, although collection with a urine bag can be difficult. The first void contains the highest concentration of drug or metabolites, but generally detects drug use in only the prior 72 hours. As such, negative urine toxicology results are common even with known drug use. Chronic use of certain drugs (marijuana, barbiturates, or phencyclidine) may allow detection up to 30 days after last use. Meconium screening may allow detection of drugs used a month or more before birth when collected in the first 2 days of life. Meconium is easier to collect than urine, but delayed passage of stool will also delay drug detection. Regardless of method used, positive results should ideally be confirmed by a second test. Umbilical cord testing for substances of abuse is increasingly being used in many hospitals. Its main advantage is that it obviates the need to wait to collect urine or meconium and thus every eligible baby can have a sample sent to the lab with a more rapid turnaround.
A physician or other allied health professional should order the screening, document the indication, and inform the infant’s mother. Mothers with a history of drug use should also receive a social services evaluation, the focus of which should be the health and well-being of the mother, infant, and family. Such infants are not candidates for early discharge, and arrangements should be made for appropriate care and follow-up evaluation. Issues for long-term follow-up include increased risk of sudden infant death syndrome, high-risk social situations, and abnormal cognitive and behavioral development.
Renal Pelviectasis and Hydronephrosis
Approximately 1% of infants will have urinary dilatation detected in utero by ultrasound. Most children with this diagnosis will have a benign course, but some will suffer renal deterioration due to infection or obstruction. Of all cases with dilatation, the order of significant uropathy is approximately 20%. Currently, there is no consensus regarding subsequent evaluation once mild antenatal renal pelviectasis is noted. Most agree that a newborn infant with mild unilateral pelviectasis or hydronephrosis (< 7 mm of dilatation) does not require further evaluation. Those with greater than 7 mm of dilatation should have a renal ultrasound. The use of prophylactic antibiotics during this period is controversial but still widely practiced. Infants with a positive ultrasound should be placed on prophylactic antibiotics and a repeat renal ultrasound obtained at 1 month of age. A negative study at this time would warrant no further workup, while persistent findings should trigger referral to a specialist. Whether or not to perform a voiding cystourethrogram if the first renal ultrasound is negative is also controversial. Approximately 25% of infants with vesicoureteral reflux on complete evaluation (ultrasound plus voiding cystourethrogram) have a negative ultrasound. Grades 1, 2, and 3 vesicoureteral reflux also often have normal ultrasounds, as the findings of hydronephrosis with vesicoureteral reflux are often transient.
Newborns with more serious prenatal diagnoses, such as fetally diagnosed severe bilateral hydronephrosis, bilateral hydroureteronephrosis, multicystic dysplastic kidney, or male fetal hydronephrosis with prenatal history of oligohydramnios, should be evaluated with a consult from a pediatric urologist, a same-day renal/bladder ultrasound, a chemistry panel at 12 hours of life, and a voiding cystourethrogram based on the recommendations of the consulting specialist. These infants also require antibiotic prophylaxis.
Developmental Dysplasia of the Hip
Hip instability occurs in approximately 1% of newborns, while the incidence of dislocation is only 1 to 1.5 per 1000. All newborns should be screened for developmental dysplasia of the hip (DDH) through physical examination (the Ortolani and Barlow maneuvers) and review of risk factors. Developmental dysplasia of the hip is more common in girls and with breech presentation and in those with a positive family history, and more commonly involves the left hip. Infants with a positive Ortolani or Barlow sign at the time of newborn examination should receive a consultation by a pediatric orthopedist, and those with equivocal examinations at birth should have a follow-up hip examination at 2 weeks of age, followed by a referral to a pediatric orthopedist if the examination remains positive.
Routine radiologic screening is not recommended for newborn infants with negative examinations. However, infants with 1 risk factor present should be reexamined at 2 weeks of age and then according to the periodicity schedule. Radiologic screening (ultrasound at 6 weeks or plain radiographs at 4 months) is recommended for female infants who were carried in the breech position, as these represent the 2 greatest risk factors for DDH.
Acute infections acquired during the perinatal period are common. Sepsis and pneumonia commonly coexist, and spread of the infection to the central nervous system can lead to long-term disability or death. Prolonged rupture of membranes (> 18 hours), fetal tachycardia, maternal fever, premature delivery, maternal chorioamnionitis, and birth depression are major risk factors in the perinatal period.
Signs and symptoms of neonatal sepsis include abnormal body temperature, poor feeding, abdominal distension, lethargy, hypoglycemia or glucose intolerance, hypotension, cyanosis, respiratory distress, petechiae, apnea, and irritability or seizures. Sepsis is often associated with poor peripheral perfusion, pallor or cyanosis, and mottled skin. Umbilical erythema, sometimes accompanied by a generalized rash, is indicative of serious infection and merits prompt evaluation and treatment with antibiotics. Jaundice in the first 24 hours after birth also may indicate the presence of infection.
Serious neonatal infections may present with either low or high white blood cell counts (< 5000/mm3 or > 30,000/mm3 of blood) with a high percentage of immature cells (bands, myelocytes, metamyelocytes). However, healthy newborns often have high white blood cell and absolute band counts because of the demargination that occurs during the stress of delivery. C-reactive protein has a good negative predictive value for sepsis when at least 2 values are obtained 24 hours apart and are both negative (< 1 mg/dL). Conversely, C-reactive protein has positive predictive value for sepsis only when elevated above 6 mg/dL.
The subtleties of presentation and potential gravity of neonatal sepsis are cause for a high index of suspicion and low threshold for conducting a careful diagnostic evaluation. The presence of multiple risk factors should prompt diagnostic tests for infection and immediate antibiotic treatment. Conditions associated with a modest risk of sepsis (eg, prolonged rupture of membranes) may warrant screening laboratory studies, including a white blood cell count and C-reactive protein, and careful clinical observation. Blood culture should also be considered during this period of observation.
Any infant with signs or symptoms of sepsis, regardless of laboratory values, should undergo a complete sepsis evaluation, including white blood cell count, blood culture, and cerebrospinal fluid culture, and should be started on empiric antibiotics immediately.
Group B Streptococcal Infection
Intrapartum antibiotic prophylaxis is recommended for group B Streptococcus–positive mothers in order to minimize the risk of infection to the newborn. One dose of antibiotics (penicillin, ampicillin, or cefazolin) received 4 hours prior to delivery is considered adequate to achieve effective antibacterial levels in the fetus and amniotic fluid.
Infants of group B Streptococcus–positive mothers who have received adequate intrapartum antibiotic prophylaxis can simply be observed for 48 hours. Gestational age at birth of less than 37 weeks or prolonged rupture of membranes (greater than 18 hours) warrant diagnostic evaluation, as well as 48 hours’ observation. Infants born to mothers whose group B streptococcal status is unknown should be observed and evaluated for sepsis according the general principles discussed here. The Centers for Disease Control and Prevention recommends that infants born to mothers with chorioamnionitis, infants with premature prolonged rupture of membranes, and infants with a sibling who had group B streptococcal sepsis should receive a full diagnostic evaluation and empiric antibiotic therapy. Above all, clinical signs and symptoms of systemic illness warrant prompt evaluation and treatment.
Circumcision, or removal of the penile foreskin to near the coronal sulcus, is frequently performed to prevent late inflammatory diseases of the penis (eg, balanoposthitis) and stenotic or constrictual foreskin problems (phimosis and paraphimosis). Many times circumcision is done for personal, religious, or cultural reasons.
Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks of the procedure and benefits justify access to this procedure for families who choose it, though the policy statement of the American Academy of Pediatrics states that the potential medical benefits are not sufficient to warrant its recommendation as a routine procedure. Circumcision is associated with decreased risk of penile cancer, urinary tract infection, and sexually transmitted diseases, including human papillomavirus, syphilis, gonorrhea, and human immunodeficiency virus (HIV). The complication rate of circumcision is less than 1%, and complications typically involve bleeding and infection at the surgical site.
Circumcision is contraindicated in infants with a family history of bleeding disorder (hemophilia) and infants with structural abnormalities of the penis, including hypospadias, epispadias, chordee, or ambiguous genitalia. Other relative contraindications include prematurity, small or concealed penis, curvature or penile torsion, large hydroceles, and clinical instability or illness.
Circumcision is performed by either a surgical clamp technique (eg, Gomco or Mogen) or use of a PlastiBell circumcision device. With the former procedures, the diaper adhesion to the surgical site is prevented postoperatively by petrolatum gauze dressing or petrolatum applied to the diaper or penis. With the PlastiBell device, the underlying tissue is normally healed by the time the ring falls off. Circumcision should be performed using local anesthesia, most commonly with local dorsal penile nerve block or penile ring block. Use of topical anesthetic cream (mixture of lidocaine and prilocaine) is recommended if local injection of anesthetic is not available.
Parents of infants who remain uncircumcised should receive instruction soon after delivery and at subsequent physician office visits regarding proper hygiene. Parents should be discouraged from forcibly retracting the foreskin of the uncircumcised penis, until such time as the foreskin becomes naturally softened and detached from adhesions.
Ankyloglossia, or tongue-tie, is a condition in which the sublingual frenulum extends out toward the tip of the tongue. Ankyloglossia occurs in rates ranging from 0.1% to 10.7%, but definitive incidence and prevalence is unknown due to an absence of standard diagnostic criteria. When ankyloglossia is present, 25% to 80% incidence of breastfeeding difficulties is reported, including failure to thrive, maternal nipple damage, maternal breast pain, poor milk supply, maternal breast engorgement, and refusing the breast. Ineffective latch is hypothesized to underlie these problems. A small body of evidence suggests that frenulotomy may be associated with improvements in breastfeeding as reported by mothers, and potentially in nipple pain. However, the strength of evidence is low to insufficient.
Complications of frenulotomy are rare but include bleeding, infection, and salivary gland injury.
BREASTFEEDING AND LACTATION SUPPORT
Neonatal nutrition is ideally provided through breastfeeding. Initiation of breastfeeding should start shortly after birth and effectiveness should be continuously monitored until discharge home. There are very few contraindications of breastfeeding. The numerous benefits of breastfeeding and management approaches to encourage and facilitate breastfeeding are discussed elsewhere.
Successful breastfeeding depends on early initiation and support. Newborn infants should breastfeed within the first hour of life unless medically contraindicated. Hospital staff should be trained to recognize breastfeeding difficulties and to help mothers achieve proper position and latch. Regular nursing assessments should include documentation of breastfeeding efficacy using a lactation scoring system. Mothers identified with greater needs should be referred for additional consultation with a lactation specialist.
Hospitals should also consider developing preventive management guidelines for infants at risk for feeding difficulties, which may exacerbate weight loss and hyperbilirubinemia. Mothers of premature infants, late preterm infants, and multiples often require additional lactation consultation, care planning, and close, frequent follow-up. Although use of formula and pacifiers may negatively affect breastfeeding duration, early supplementation (with pumped milk or formula) may be appropriate for certain at-risk groups and in certain clinical situations.
Breastfeeding is contraindicated in maternal conditions that may result in transmission of infection to the infant, such as active pulmonary tuberculosis (until treatment is started and the mother is considered to be noncontagious), herpetic breast lesions, or infection with HIV. Possible effects on the infant of maternal medications and chemical exposures also should be considered, as many drugs and other chemicals can pass from mother to infant in breast milk.
BIRTH PLANS AND REFUSAL OF ROUTINE CARE
Birth plans play an important role in the relationships parents have with their newborn children and with their care providers. Preferences regarding childbirth, feeding, and routine care (such as location; length of stay; administration of prophylactic erythromycin, vitamin K, and hepatitis B vaccine; or circumcision) should be discussed prenatally with the obstetrician or midwife.
Care providers should make every effort to discuss the birth plan by presenting the family evidence- based standard of care guidelines, and to address contingency plans in case of emergency (neonatal resuscitation, transfers to higher level of care, transports). Hospitals should ensure that policies are in place to obtain waivers of liability from parents when required by law.
LATE-PRETERM AND EARLY-TERM DELIVERIES
Newborn nurseries frequently have admissions of infants whose gestational age falls in the category of late-preterm (34 0/7 to 36 6/7 weeks of gestation) or early term (37 0/7 to 38 6/7 weeks of gestation). Currently, in the United States, 6.8% of all deliveries occur in the late preterm period, and 24.8% occur in the early term period. Delivery can be indicated medically at such an early gestational age due to placental/uterine, fetal, maternal, or obstetric issues.
Mortality and morbidity are higher in these infants than in term newborns and there should be a low threshold for transfer to the neonatal intensive care unit. These preterm infants require increased observation, particularly with respect to symptoms of respiratory distress, dysregulation of body temperature and blood sugar control, inconsistencies in feeding ability/performance, hyperbilirubinemia, or meeting criteria for discharge from hospital. Administration of antenatal betamethasone for women at risk for late preterm delivery significantly reduces the rate of neonatal respiratory complications, although this intervention is associated with a higher risk of neonatal hypoglycemia.
Timing of discharge for late preterm infants depends on the infant’s competency in thermoregulation and feeding, stable weight, absence of medical illness and social risk factors, and the readiness of the family to provide a safe environment post discharge. Early medical follow up should be scheduled for 24 to 48 hours post discharge.
PREPARATION FOR DISCHARGE
The time that a newborn infant spends in the hospital nursery provides an important opportunity for maternal education as well as for critical infant evaluation. Although in the United States, legislation has guaranteed a 48-hour stay for vaginal deliveries and a 72-hour stay for delivery via Cesarean section, the needs of each mother–infant dyad dictate the amount of preparation deemed to be sufficient. Before the infant is discharged from the hospital, the mother should receive sufficient practical instruction to ensure appropriate home management of feeding, bathing, and general care of the infant, including recognition of well-being and illness.
The adequacy of the home situation should be evaluated, as well as the presence of particular stresses, such as domestic violence, isolation, depression, and homelessness. Social services and public health nurse referrals may be very helpful in ensuring a safe and nurturing environment for the baby after discharge. Additional anticipatory counseling should be done to promote infant safety and to prevent exposure to potential infections and toxins.
The discharge examination of the infant should be done, if possible, in the parents’ presence to allow ample opportunity to express their concerns and ask questions about the findings they may think are abnormal. Plans for subsequent well-baby care of the infant should be established and instructions given for communicating concerns to the appropriate medical provider.
Term, healthy infants who are discharged within 48 hours after birth should be seen again in 2 to 3 days. Infants with risk factors such as prematurity, weight loss, poor feeding, or early jaundice may require earlier and more frequent follow-up visits. The hospital staff should document the location and date of the infant’s anticipated follow-up, ensure parental understanding of the time interval and any significant clinical conditions, and facilitate the transfer of information to the provider who will assume care of the infant.
Car Seat Selection and Testing
Every hospital should have policies to ensure that each newborn is transported home properly restrained safely in a car seat. The policies should ensure that parents are informed about the importance and proper use of car seats, that hospital staff are trained to assess infant car seat needs, that all infants less than 37 weeks’ gestation have a period of observation in a car seat prior discharge from hospital, that all printed materials are reviewed periodically for accuracy, and that provisions are made for parents to obtain free or low-cost seats when needed.
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