Newborn Care and Health Guidelines Quiz

Newborn Standards of Care

• Newborn (Neonatal) period: first 28 days of extrauterine life
• Healthy People 2020 objectives
• Major focus of many public health efforts:
  • increasing breastfeeding rates for optimal nutrition
  • obtaining recommended universal screening panel (RUSP) for state-mandated diseases
  • reducing proportion of children with metabolic disorder requiring special education services
  • increasing percentage of healthy full-term newborns placed to sleep on their backs to prevent infant mortality
• Guide to Clinical Preventive Services and Advisory Committee on Heritable Disorders in Newborns and Children recommend:
  • Prenatal screening
  • Promoting breastfeeding
  • Screening neonates for sickle hemoglobinopathies
  • Screening for congenital hypothyroidism
  • Screening for phenylketonuria (PKU) for all newborns before discharge from the nursery
  • Topical ocular prophylaxis of all newborns
  • Screening for developmental hip dysplasia

Anatomy and Physiology

• Intra-to-extrauterine transition
  • placenta (responsible for metabolic functions, blood supply to baby)
  • Umbilical vessels- clamped and severed and newborn begins to breathe
  • Foramen ovale closes 6 mo-1 yr after birth/ductus arteriosus- within a few days after birth
  • Pulmonary vascular pressure- drops, allowing blood to flow to lungs for oxygenation
  • Gastrointestinal tract- absorbs nutrients and expels waste after first feed
  • Renal system- excretes waste and maintains chemical balance
  • Liver- metabolizes and excretes toxins
  • Immunologic system- immature until vaccines are given
• Vital signs: First period (after delivery)- SNS changes (tachycardia, rapid respirations, grunting, flaring, retractions, falling body temp, hypertonus, alertness). PNS changes (bowel sounds initiation, oral mucus production). Second period- oral mucus production more evident, HR more labile, newborn becomes more responsive to endogenous and exogenous stimuli, and meconium is passed.

Assessment

• History: Past maternal, past obstetric, family history (three generation pedigree), obstetric history (current maternal health, maternal age, prenatal care, medications, infections, alcohol/drug use, heavy metal exposure, hypertension, glucose intolerance, labor duration, anesthesia, delivery route, polyhydramnios, oligohydramnios), social history (emotional stressors, unplanned pregnancy, financial, emotional support, educational background, anticipated involvement of partner)
• Physical examination:
  • APGAR- indicated how well the resuscitation efforts succeeded. Determines long-term health outcomes (Activity, Pulse, Grimace, Appearance, Respiration). Scores 0-2 for each.
  • Gestational Age- based on physical exam. Done within 2 hours of birth to confirm maternal gestational dates. 90th percentile (LGA), < 10th percentile (SGA). Between 10-90th percentile (AGA)
  • Temperature- heat loss rate in newborn is 4x that of an adult. Can fall in cool, drafty environment. Towel dry newborn after birth, skin-to-skin contact, use a radiant warmer, warp in a warm blanket, cover head when being held by parents
  • Lungs- Further expulsion of amniotic fluid and high pulmonary vascular resistance ensure with newborn's first breaths. Careful bulb suctioning. With C section, more intervention required to help with respiratory efforts. Newborn lung sounds are bronchovesicular or bronchial sounds. Fine crackles during first few hours of life are normal
  • Umbilical cord- has two arteries and one vein.
  • After Stabilization- after initial assessment in OR, physical assessment is done (gestational age, age in hours, stage of transition)
  • Screening- done before discharge (maternal syphilis/hepatitis B/HIV, newborn blood type, Coombs test, Hearing screening by 1 month old, CHD and bilirubin screening tests, Administer first Hep B dose)

Management Strategies

• Initial Care:
  • Establishing Feeding: follow up in 2-3 days to ensure nutrition
  • Prophylaxis for ophthalmia neonatorum with ointment and vitamin K IM
  • Anticipatory Guidance Before Discharge
  • Physical Care:
    • Umbilical cord- leave cord to air dry, place diaper below cord until it separates. Separation occurs at 10-14 days, slight blood discharge will be seen for 1-2 days. Avoid bellybands/coins to cover the navel. Foul smelling discharge warrants evaluation for sepsis. Apply silver nitrate for a granuloma
    • Circumcision- decision rests with parents, AAP states no evidence for routine circumcision, but benefits are greater than risks. Lowers chances for UTIs, keeps glans penis cleaner, penile cancer reduction, phimosis, balanitis, adhesions, and urethral meatus occlusion reduction. Gentle cleaning around gential area, don't force foreskin back, cleanse penis daily with cotton swabs dipped in tap water with petroleum jelly for first 2-3 days
    • Bathing, Oils, and Powders- do not require dial baths. Mild cleansing agents are gentle enough. Avoid oils and powders. Use Keri, Eucerin Aveeno or Cetaphil for lotion. Diapers- Frequent changing and proper cleaning

Early Discharge and Follow Up

• Guidelines for Early Discharge of Normal, Healthy Newborns:
  • Stable vital signs, rectal temp 97.7-99.3 F (36.5-37.4°C) in an open crib, heart rate 100-190 bpm, respiratory rate less than 60 breaths/min, urine and stool passage, two successful feedings, baseline bilirubin, evaluation and monitoring for sepsis based on maternal risk factors, newborn laboratory data
• Guidelines for 48- to 72-Hour Follow-Up Visit: Review delivery and discharge summaries, assess newborn's general health, weight, hydration, jaundice, identify new problems, review feeding, stooling, urination, lactation consult if needed, assess bonding, reinforce maternal and family education, review outstanding laboratory data, neonatal screens or other tests if indicated, develop health care maintenance plan, emergency care, preventive care, immunizations, periodic screenings, evaluate mother for postpartum depression, referrals to WIC program eligibility.

Common Neonatal Skin Conditions

• Provide a table comparing significant maternal or newborn history, rash descriptions, diagnoses and management/treatments.

Head, Face, and Eye Conditions

• Caput Succedaneum- diffuse, superficial swelling of soft tissue on scalp, usually crosses suture lines, originates from trauma, swelling in parietal scalp regions. Differential Diagnosis- cephalohematoma, subgaleal hemorrhage. Management- no treatment, resolves over first few days of birth.
  • Cephalohematoma- deep collection of blood in subperiosteal area of scalp, doesn't cross suture lines, results from trauma in a difficult delivery. Clinical Findings- swelling in parietal area, no cross-suture lines, primigravida history or traumatic delivery, rarely associated with skull fracture, coagulopathy, or intercranial hemorrhage. Differential Diagnosis- caput succedaneum, subgaleal hemorrhage, cranial meningocele. Management- no treatment, resolves within few weeks to months
  • Craniotabes- thinning bone of the scalp seen in premature. Clinical Findings- ping-pong ball effect when pressing parietal bone. Management- no treatment, resolves spontaneously.

Head, Face, and Eye Conditions: Jaundice

• Jaundice- accumulation of bilirubin in skin. Clinical findings- when bilirubin exceeds 5-7 mg/dL, a cephalocaudal pattern. Physiologic jaundice- rise in bilirubin, from 1-3 mg/dL to 5-6 mg/dL on third day, declining to normal adult level of <1.3-1.5 by 10-12 days. Pathologic jaundice- occurs too early, persists too long, too high bilirubin levels (within 24 hours, lasting longer than 10-14 days, risk factors include hemolytic disease/anemia, inborn errors of metabolism, premature [GA 35-36 weeks])
  • Physical exam- assess for jaundice within first 24 hours of life and throughout neonatal period. Face usually affected first, then shoulders, chest, and abdomen.

Sudden Unexpected Infant Death

• SIDS- sudden death in infancy, explained or unexplained, often during sleep. Non-Hispanic black and American Indian/Alaska Native infants have more than twice the risk of SIDS than their white peers. Ninety percent of SIDS occurs prior to 6 months of age with a peak between 1 and 4 months. "BRUE" events (brief episodes occurring in infants less than a year). Three main pathophysiologic mechanisms contribute to SIDS: Decreased arousal, asphyxia and re-breathing, thermal stress. Possible causes: respiratory obstruction, restrictive clothing, and hyperthermia. Factors associated with SIDS include previous BRUE, poverty, lack of prenatal care, low birth weight, small for gestational age (SGA), preterm birth, young maternal age, high parity, maternal smoking and drug use, and co-sleeping.
• Clinical Findings: Bed sharing, maternal cigarette smoking, drug/alcohol use, limited prenatal care, bottle-feeding, low educational attainment, unmarried, multiparity, maternal age < 20 years old, short interval pregnancies, anemia, newborn-premature, low birth weight, twins/multiple births, APGAR, recent URT infection

Measures that Aid in Preventing Sudden Unexplained Infant Death

• Breastfeeding is recommended
• Infants should be immunized (reduces risk by 50%)
• Place infants on their backs to sleep until at least 6 months old.
• Use a firm mattress, do not use bumper pads
• Avoid overheating, alcohol and drugs, cigarette smoking, bed sharing and co-sleeping, and have stuffed animals in infant's bed.
• Separate but proximate caregiver-sleeping environments.
• Consider pacifier use.

Discussion Questions

• How to assess a newborn with a focus on SIDS prevention
• Prepare a presentation on umbilical cord care and circumcision for parents.
• Explain the process and importance of 1 and 5 minute APGAR scores to expecting mothers.

Test your knowledge about the Healthy People 2020 objectives for newborn care, recommended screenings for neonates, and best practices to promote infant health. This quiz covers essential aspects of newborn management, including cord care, circumcision guidelines, and more.