NURSERY CARE OF THE WELL NEWBORN

I. ADMISSION TO THE NEWBORN NURSERYII. TRANSITIONAL CARE

III. ROUTINE CAREIV. ROUTINE MEDICATIONS

V. SCREENINGVI. ROUTINE ASSESSMENTS

VII. FAMILY AND SOCIAL ISSUESVIII. FEEDINGS.

IX. NEWBORN CIRCUMCISION X. DISCHARGE PREPARATION

XI. FOLLOW UP

I. ADMISSION TO THE NEWBORN NURSERY

Healthy newborns should with their mother

immediate initiation of breast- feeding and early bonding.

Avoid separation of mother and infant.

A. Criteria for admission is a well-appearing infant of at least 35 weeks gestational age,

B. Impeccable security in the nursery : - protect the safety of families - prevent the abduction of newborns.

ex : - identification bands - transport of infants between areas should not occur if identification banding has not been done.

A. The transitional period : first 4 to 6 hours after birth.

- the infant's pulmonary vascular resistance ↓, - blood flow to the lungs is greatly increased

- overall oxygenation and perfusion improve, and the ductus arteriosus begins to constrict or close.

B. Interruption of normal transitioning, usually due to complications occurring in the peripartum period, will cause signs of distress in the newborn.

II. TRANSITIONAL CARE

C. Common signs of disordered transitioning are (i) respiratory distress, (ii) poor perfusion with cyanosis or pallor, or (iii) need for supplemental oxygen.

D. Transitional care of the newborn can take place in the mother's room or in the nursery.1. Evaluated for problems that may disqualify

their admission to the normal nursery, such as gross malformations and disorders of transition.

2. Evaluated every 30 to 60 minutes during this period : heart rate, respiratory rate, and axillaris temperature; assessment of color and tone; and signs of withdrawal from maternal medications.

3. When disordered transitioning is suspected, a hemodynamic ally stable infant can be observed closely in the nursery setting for a brief period of time. Infants with persistent signs of disordered transitioning require transfer to a higher level of care.

III. ROUTINE CARE

A. Healthy newborns should be with their mothers all or nearly all the time.

When possible, physical assessments, administration of medications, and bathing should occur in the mother's room.

Nursing ratio of 1:6-81. Assessment of gestational age ( new Ballard score).2. The infant's weight, frontal-occipital circumference

(FOC), and length arc-recorded.

B. The infant's temperature is stabilized with one of three possible modalities:1. Open radiant warmer on servo control.2. Incubator on servo control.3. Skin-to-skin contact with the mother.

C. Universal precautions should be used with all patient contact.

D. The first bath : non medicated soap and warm tap water (note: axillary temperature >36,5°C )

E. umbilical cord care . Keeping the cord dry promotes earlier detachment of the umbilical stump.

IV. ROUTINE MEDICATIONS

A. Prophylaxis against gonococcal ophthalmia neonatorum within 1 hour of birth, Prophylaxis is administered as single ribbon tetracycline ointment 1% of bilaterally in the conjunctiva sac

B. A single, intramuscular dose of 0.5 to 1 mg of vitamin K 1 oxide (phytonadione) before 6 hours prevent vitamin K deficient bleeding (VKDB).

C. The first dose of preservative-free hepatitis B vaccine

Hepatitis B vaccine is administered by 12 hours of age when the maternal Hep BsAg is positive or unknown. Infants of Hep BsAg positive mothers also require hepatitis B immune globulin

A. Prenatal screening test results should be reviewed and documented on the infant's chart at the time of delivery.

Maternal prenatal screening tests typically include the following:1. Blood type, Rh, antibody screen.2. Hemoglobin or hematocrit.3. Rubella antibody.

V. SCREENING

4. Hepatitis B surface antigen.5. Serologic test for syphilis (Venereal Disease

Research Laboratory [VDRL] or rapid plasmin regain [RPR]).

6. Human immunodeficiency virus (HIV).7. Gonorrhea and Chlamydia cultures.8. Serum a-fetoprotein/triple panel.9. Glucose tolerance test.10.Group B streptococcus (GBS) culture.

B. Cord blood is saved up to 14-21 days, depending on blood bank policy.1. A blood type and direct Coombs should be

performed on any infant born to a mother who is Rh-negative, has a positive antibody screen, or who has had a previous infant with Coombs positive hemolytic anemia.

2. A blood type and direct Coombs should be obtained on any infant if jaundice is noted within the first 24 hours of age or there is unexplained hyperbilirubinemia (see Chap. 18).

C. Newborn metabolic screen1. Some states universally screen for four core

metabolic conditions : congenital hypothyroidism, phenylketonuria, galactosemia, and hemoglobinopathies.

2. Newborn screening programs vary considerably among states.

3. Routine collection of the specimen is between 24 and 72 hours of life. In some states, a second screen is routinely performed at 2 weeks of age.

D. Group B streptococcal disease1. In several countries : All newborns should be

screened for the risk of perinatally acquired GBS disease as outlined by the Centers for Disease Control.

2. Penicillin is the preferred intrapartum chemotherapeutic agent. Intravenous administration to the mother at >4 hours or earlier before delivery provides adequate neonatal prophylaxis.

3. Newborns should be managed according to the management algorithm

E. Glucose screening1. Infants should be fed early and frequently to

prevent hypoglycemia.2. Infants of diabetic mothers ,SGA and LGA infants

should be screened for hypoglycemia in the immediate neonatal period .

F. Bilirubin screening1. Before discharge, all newborns should be

screened for the risk of subsequent, significant hyperbilirubinemia.

2. Provide parents with verbal and written information about newborn jaundice.

G. Routine hearing screen for congenital hearing loss is mandated in most states .

Verbal and written documentation of the hearing screen results should be provided to the parents with referral information if needed.

VI. ROUTINE ASSESSMENTS

A. The infant's physician should perform a complete physical examination within 24 hours of birth.

B. Vital signs, including respiratory rate, heart rate, and axillary temperature are recorded every 8 to 12 hours.

C. Each urine and stool output is recorded in the baby's chart. The first urination should occur by 30 hours of life. The first passage of me conium is expected by 48 hours of life. Delayed urination or stooling is cause for concern and must be investigated.

D. Daily weights are recorded in the infant's chart. Weight loss in excess of 7% is cause for concern and must be investigated. Excessive weight loss is usually due to insufficient caloric intake. If caloric intake is thought to be adequate, organic etiologies should be considered, that is, metabolic disorders, infection, or hypothyroidism.

Thank you

A. Sibling visitation is encouraged and is an important element of family-focused care. However, siblings with fever, signs of acute respiratory or gastrointestinal illness, or a history of recent exposure to communicable diseases, such as chicken pox, are discouraged from visiting.

VII. FAMILY AND SOCIAL ISSUES

B. Social service involvement is helpful in circumstances such as teenage mothers; lack of, or limited, prenatal care; history of domestic violence; maternal substance abuse; history of previous involvement with Child Protective Services, or similar agency.

VIII. FEEDINGS.The frequency, duration, and volume of each feed will depend on whether the infant is breast-feeding or bottle-feeding.A. The breast-fed infant should feed as soon as possible

after delivery, preferably in the delivery room and feed 8 to 12 times/day.

Consultation with a lactation specialist during the postpartum hospitalization is strongly recommended for all breast-feeding mothers

A. The American Academy of Pediatrics (AAP) states that scientific evidence exists that demonstrates potential medical benefits of newborn male circumcision; how ever, these data are not sufficient to recommend routine neonatal circumcision. Potential benefits are decreased incidence of : - urinary tract infection ,

- development of squamous cell carcinoma - acquiring sexually transmitted diseases particularly HIV infection.

IX. NEWBORN CIRCUMCISION

B. Informed consent is obtained before performing the procedure. The potential risks and benefits of the procedure are explained to the parents.1. The overall complication rate for newborn

circumcision is approximately 0.5%.2. The most common complication is bleeding

(~0.1%) followed by infection. A family history of bleeding disorders, such as hemophilia or von Will brand disease, needs to be explored with the parents when consent is obtained. Appropriate testing to exclude a bleeding disorder must be done before the procedure if the family history is positive.

3. The parents should understand newborn circumcision is an elective procedure; the decision to have their son circumcised is voluntary and not medically necessary.

4. Contraindications to circumcision in the newborn period include the following:a. Sick or unstable clinical status.b. Diagnosis of a congenital bleeding disorder.

Circumcision can be performed if the infant receives appropriate medical therapy before the procedure (i.e., infusion of factor VIII, or IX).

c. Inconspicuous or "buried" penis.d. Anomalies of the penis, including hypospadias,

ambiguity, chordae, or micropenis.e. Circumcision should be delayed in infants with

bilateral cryptorchidism.C. Adequate analgesia must be provided for neonatal

circumcision. Acceptable meth ods of analgesia are dorsal penile nerve block, subcutaneous ring block, and eutectic mixture of local anesthetics (EMLA ccream): 2.5% prilocaine and 2.5% lidocaine.

D. In addition to analgesia, other methods of comfort are provided to the infant during circumcision.1. Twenty-four percent sucrose on a pacifier, per

nursery protocol, should be given to all infants as an adjunct to analgesia.

2. The infant's upper extremities should be swaddled, and the infant placed on a padded circumcision board with restraints on the lower extremities only.

3. Administration of acetaminophen before the procedure is not an effective adjunct to analgesia.

E. Circumcision in the newborn can be performed using one of three different methods:1. Gomco clamp.2. Mogen clamp.3. Plastibell device.

F. Oral or written instructions explaining post circumcision care should be given to all parents

A. Parental education on routine newborn care should be initiated at birth and continued until discharge. Written information in addition to verbal instruction may be helpful and in some cases it is mandated. A review of the following newborn issues should be done at discharge:1. Observation for neonatal jaundice.2. Routine cord and skin care.3. Routine postcircumcision care (when indicated).

X. DISCHARGE PREPARATION

4. Back to sleep positioning.5. Subtle signs of infant illness including fever,

irritability, lethargy, or a poor feeding pattern.

6. Adequacy of oral intake, particularly for breast-fed infants. appropriate installation and use of an infant car seat.

7. Smoke detectors.8. Lowering of hot water temperature. 9. Avoidance of second-hand smoke

B. The discharge examination is reviewed in Chapter 3.C. Discharge readiness

1. Each mother-infant dyad should be evaluated individually to determine the optimal time of discharge.

2. The AAP recommends that minimum discharge criteria be met before any newborn is discharged from the hospital. It is unlikely that fulfillment of these criteria can be accomplished with a postnatal stay of <48 hours.

3. Discharge before 48 hours of age should be limited to infants who are of singleton birth, at least 38 weeks' gestational age, and who have a birth weight that is appropriate for gestational age

Early discharge criteria include the following:

a. Uncomplicated ante partum, intrapartum, and postpartum courses for both mother and infant.

b. Vaginal delivery.c. Normal, stable vital signs in an open crib for at

least 12 hours preceding discharge.d. Passage of first urine and stool.e. Completion of at least two successful feedings.f. Unremarkable physical examination, absence of

abnormalities that would require continued hospitalization.

g. Assessment of risk for hyperbilirubinemia.h. Maternal competence in routine newborn care.i. Assessment of maternal support.j. Assessment of family, environmental, and social

risk factors. k. Review of maternal and infant blood tests.l. Administration of initial hepatitis B vaccine. m. Completion of hearing and metabolic screen per

state regulations. n. No excessive bleeding at the circumcision site for

at least two hours o. Definitive follow-up arrangements for both mother

and infant

XI. FOLLOW-UP

A. For newborns discharged within 48 hours after delivery, outpatient follow-up should be within 48 hours of discharge. If early follow-up cannot be ensured, early discharge should be deferred.

B. For newborns discharged between 48 and 72 hours of age, outpatient follow-up should be within 2 to 3 days of discharge. Timing will depend on the risk for subsequent hyperbilirubinemia, feeding issues, or other concerns.

C. The follow-up visit is designed to perform the following functions:

1. Assess the infant's general state of health including weight, hydration, and degree of jaundice.

2. Identify any new problems.3. Perform screening tests in accordance with state

regulations.4. Review adequacy of oral intake and assess

elimination patterns.5. Assess quality of mother-infant bonding.6. Reinforce parental education.7. Review results of any outstanding laboratory tests.8. Provide anticipatory guidance and health care

maintenance