Newborn Nursery




Normal Fetal Adaptation at Birth



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Thermoregulation




  • Heat loss: Evaporation, radiation, conduction, convection.
  • Heat production: Mainly through nonshivering thermogenesis (lipolysis of brown adipose tissue).




Gas Exchange




  • From placenta to lungs.
  • Fetal Hb allows fetus to maintain lower arterial oxygen tension (greater affinity for oxygen binding than adult Hb).




Effective Breathing and Pulmonary Inflation




  • From sporadic breathing to continuous breaths.
  • Replacement of fetal lung fluid with air (decreased production and increased absorption).




Circulation




  • In fetus: ↑ PVR, ↓ SVR.
  • At birth: SVR increases with removal of placenta; PVR decreases with replacement of fetal lung fluid with oxygen and endogenous nitric oxide production, causing vasodilation.
  • Mixed circulation persists during this “transition” secondary to ductus arteriosus (closes within 2 wk, but flow decreases within a few hours of birth) and foramen ovale (right-to-left flow reverses soon after birth).




Newborn Exam



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Vital Signs




  • Temperature (36.5°C–37.4°C)
  • Respirations (<60 breaths/min with no signs of respiratory distress)
  • HR (100–160 beats/min)




Head Circumference, Length, Weight, and Assessment of Gestational Age




General Appearance




  • Activity, color, abnormalities




Skin




  • Color, normal rashes (erythema toxicum, pustular melanosis), mongolian spots, abnormalities (nevi, hemangiomas)




Heent



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  • Swelling (caput, cephalohematoma, subgaleal hemorrhage), trauma (forceps marks, scalp electrode marks), scleral hemorrhage, symmetric pupillary response, presence of red reflex, choanal atresia, cleft lip/palate, ear pits/tags, facial symmetry




Neck




  • Clavicles, cysts, webbing, masses




Chest




  • Equal breath sounds, respiratory distress (grunting, retracting)
  • Nipples (supernumerary), sternal abnormalities (ie, pectus excavatum or carinatum)




Heart




  • S1/S2 , rate, murmur, PMI, brachial and femoral pulses




Abdomen




  • Bowel sounds, defects, organomegaly, masses, appearance, cord vessels (two arteries, one vein)




Genitals/Anus




  • Patent anus, ambiguous genitalia, abnormal anatomy (hypospadias, epispadias)
  • Boys: Descended testicles, penile length
  • Girls: Perforate hymen, clitoral length




Extremities




  • Tone, equal movement, perfusion, digits, Barlow and Ortolani maneuvers for hip dysplasia




eFigure 28-1.



New Ballard score for assessment of fetal maturation of newly born infants. (Reproduced with permission from Ballard JL, et al: New Ballard score, expanded to include extremely premature infants. J Pediatr 1991;119:417. New York: McGraw-Hill. Copyright © The McGraw-Hill Companies. All rights reserved.)





eFigure 28-2.



Infant evaluation at birth—Apgar score. (Reproduced with permission from Hay WW Jr, Levin MJ, Sondheimer JM, Deterding RR: Current Diagnosis & Treatment: Pediatrics, 19th ed. New York: McGraw-Hill. Copyright © The McGraw-Hill Companies. All rights reserved.)


aOne minute and 5 minutes after complete birth of the infant (disregarding the cord and the placenta), the following objective signs should be observed and recorded.


bTested after the oropharynx is clear.





Reflex




  • Rooting, grasp, asymmetric tonic neck reflex, Moro reflex




Routine Newborn Care



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Hearing Screen




  • Mandated ABER or OAE testing prior to 3 months.




Bathing




  • Sponge bath until cord stump falls off.




Feeding



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  • Encourage breastfeeding within 1 hr of birth and formula within 3 hr if baby is alert, has no abdominal distension or respiratory distress, and has a good cry.
  • Term babies take 0.5–1 oz q2–4hr initially.
  • Breastfeeding should occur q1-3hr (see Chapter 4).




Eyes




  • 0.5% erythromycin ointment to both eyes within 2 hr after birth for prophylaxis against ophthalmia neonatorum.




Vitamin K




  • 0.5–1 mg IM within 6 hr of life to prevent hemorrhagic disease of the newborn.




Stool




  • Meconium within 48 hr of life.




Urine




  • Void within 30 hr of life.




Umbilical Cord




  • Triple dye, then keep cord clean and dry until stump falls off (average 6–14 DOL).




Nails




  • Keep short with emery board or baby nail clippers.




Sleep




  • Back to sleep to reduce the risk of SIDS.




Newborn Screening



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(Pediatrics 2006;118(3):1304)





  • The process of testing newborn babies for genetic, endocrinologic, metabolic, and hematologic diseases.
  • Tests are performed by heelstick after feeds have been established, usually between 24 and 48 hr of age.
  • Each state determines what screens will be performed. For a state-by-state list, see the U.S. National Newborn Screening & Genetics Resource Center (NNSGRC) website (genes-r-us.uthscsa.edu).
  • Most states now utilize tandem mass spectrometry, which allows for detection of a greater number of inborn errors of metabolism.
  • If an abnormality is noted, the agency performing the test is responsible for contacting the parents, physician, hospital, and/or nursery. Appropriate response varies by disease screened for, but a guide can be found with ACTion sheets at the NNSGRC website (genes-r-us.uthscsa.edu).




Early Discharge Criteria (<48 H of Life) (Institutional Practice; Adapted from Pediatrics 2010;125(2):405)



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  • 37-41 completed weeks’ gestation
  • No findings that require continued hospitalization.
  • Vital signs documented as normal (see “Newborn Exam” above).
  • Infant has urinated regularly and passed at least one stool spontaneously.
  • Infant has completed at least 2 successful, consecutive feeds
  • No significant bleeding at circumcision site
  • Risk of development of hyperbilirubinemia has been assessed and appropriate follow up arranged.
  • Infant has been appropriately screened for sepsis on the basis of maternal risk factors (including GBS status and adequacy of antepartum prophylaxis).
  • Maternal labs have been reviewed and found to be normal/negative (RPR, Hepatitis B surface antigen, HIV and GBS).
  • Infant blood work, such as blood type, Coombs, have been reviewed (as clinically indicated)
  • Initial hepatitis B vaccine administered
  • Newborn metabolic and hearing screens have been completed per state regulations.
  • Mother is able to provide adequate newborn care upon discharge (including feeding, normal urination/stooling patterns, cord, skin, and genital care, able to identify signs of illness, identify jaundice, and understands basic infant safety (eg, car seat safety, supine positioning for sleep)
  • Maternal social and environmental risk factors are assessed (substance abuse, homelessness, abuse or neglect, domestic violence, etc.)
  • A medical home for the infant is established (infants discharged <48 hours of age will follow up within 48-72 hours of discharge).
  • Any potential barriers to follow up have been identified and addressed (lack of transportation, no access to telephone services, language barriers, etc.)

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Jan 9, 2019 | Posted by in PEDIATRICS | Comments Off on Newborn Nursery
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