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					Chapter 29  NEWBORN



GOAL 1: Prenatal Visit. GOAL 2: Newborn Resuscitation. GOAL 3: Transition. GOAL 4: Preventive medicine. GOAL 5: Blood Group Incompatibility and Jaundice. GOAL 6: Maternal VDRL/RPR. GOAL 7: Maternal HSV. GOAL 8: Maternal HIV. GOAL 9: Maternal TB/PPD Conversion. GOAL 10: Varicella. GOAL 11: Social Risk Factors. GOAL 12: Physical Exam. GOAL 13: Hypoglycemia. GOAL 14: Screening HCT. GOAL 15: Nutrition. GOAL 16: Voiding and Stooling. GOAL 17: Circumcisions. GOAL 18: Newborn Screening. GOAL 19: Discharge Planning. GOAL 20: Common Conditions and Symptoms of the Newborn A. THE PRENATAL VISIT. GOAL 1: Prenatal Visit. Understand the importance of and the approach to the prenatal office visit. OBJECTIVES: * Describe key history items to collect and why * Discuss basic needs and common issues for parents expecting their first child; and those expecting subsequent children. * During the prenatal visit, assess and discuss: a. parental expectations and concerns b. medical risks c. social environmental risks and strengths d. discuss the office practice with attention to Tricare vs. Champus and giving emphasis to the importance of continuity e. address parental concerns * Prepare the family for the birth of the child: a. review the birth process and nursery/MIU routines b. review rooming in, feeding choices, circumcisions, routine Hep B vaccination c. discuss infant safety

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d. discuss the impact on the parenting couple and siblings e. review the medical and genetic issues (newborn screen, eye prophylaxis, vit K, etc.) B. DELIVERY AND TRANSITION. GOAL 2: Newborn Resuscitation. Understand NRP protocol, initial evaluation of the newborn, and assigning Apgar scores. OBJECTIVES: * Discuss appropriate preparation and equipment required for adequate resuscitation * Understand and demonstrate appropriate steps in newborn resuscitation per NRP guidelines * Understand current recommendations for resuscitating infants with meconium * Understand how to assign Apgar scores and their significance **Provider and/or instructor certification in the NRP course will satisfy the above objectives** GOAL 3: Transition. Understand the importance of the transition period and the red flags for significant illness OBJECTIVES: * Recognize the signs and symptoms of significant illness in the newborn and formulate a differential diagnosis: a. tachypnea, grunting, and/or cyanosis b. temperature instability and/or fever c. poor perfusion d. hypoglycemia * Understand appropriate management and referral of symptomatic infants * Review approach to assessing and treating infants at risk for sepsis (maternal chorioamnionitis, GBS colonization, and prolonged rupture of membranes) GOAL 4: Preventive medicine. Understand the rational for routine prophylaxis in the neonate. OBJECTIVES: * Describe the rationale and use of eye prophylaxis a. initial therapy b. evaluation and differential diagnosis of subsequent conjunctivitis c. proper treatment for opthalmia neonatorum * Describe the rationale for vitamin K administration

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a. risk factors for hemorrhagic disease of the neonate b. IM vs. PO vitamin K * Describe the rational for routine hepatitis B vaccination a. protocol for HBAg negative mother b. protocol for HBAg positive mother c. protocol for unknown maternal HBAg status C. INITIAL EVALUATION: MATERNAL RISK FACTORS AND PHYSICAL EXAM. GOAL 5: Blood Group Incompatibility and Jaundice. Understand the differential diagnosis for jaundice and the relative risks of kernicterus. OBJECTIVES: * Understand bilirubin metabolism in the neonate * Identify conjugated vs. unconjugated hyperbilirubinemia and generate a differential for both * Understand the pathophysiology of Rh incompatibility and the indications for therapy * Understand the pathophysiology of ABO incompatibility and the indications for therapy * Understand the relative risks of kernicterus and the indications for phototherapy and/or exchange transfusion GOAL 6: Maternal VDRL/RPR. Understand the evaluation and treatment for infants of VDRL/RPR positive mothers. OBJECTIVES: * Describe the clinical findings in congenital syphilis * Understand the management of infants born to VDRL+ mothers with documented adequate treatment * Understand the management of infants born to VDRL+ mothers with inadequate treatment and/or a lack of decreasing titers * Discuss the management of symptomatic infants GOAL 7: Maternal HSV. Understand the management of infants at risk for neonatal HSV. OBJECTIVES: * Describe the clinical manifestations of neonatal HSV, including: a. cutaneous HSV b. ocular HSV c. CNS disease

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d. disseminated infection and DIC * Understand the relative risks to and the management of infants born to mothers with a history of HSV, but no active lesions at the time of delivery * Understand the relative risks to and the management of infants born to mothers with a prior history of HSV and active lesions at the time of delivery * Understand the relative risks to and the management of infants born to mothers with no prior history of HSV and with active lesions at the time of delivery. * Discuss the work up and treatment of symptomatic infants regardless of maternal history GOAL 8: Maternal HIV. Understand the necessary precautions, evaluation, and follow up required for infants born to HIV positive mothers. OBJECTIVES: * Discuss the relative risk of transmission to the infant and current therapies available to reduce that risk * Discuss the routine labs required of these newborns * Understand the necessary precautions for hospital staff * Discuss anticipatory guidance issues including follow up laboratories, ID consultation, vaccinations, and contraindication for breast feeding GOAL 9: Maternal TB/PPD Conversion. Understand the appropriate management of infants at risk for TB. OBJECTIVES: * Review the criteria for interpreting positive PPD’s * Discuss management of infants with a mother or household member with a positive PPD and a normal CXR * Discuss management when mother or other household member has active TB * Discuss management when mother has disseminated TB * Review anti-TB medications and compatibility with breast feeding GOAL 10: Varicella. Understand the relative risks and management of neonates exposed to varicella OBJECTIVES: * Discuss the clinical findings in and the management of congenital varicella * Understand the relative risks of neonatal varicella and the management when an infant is delivered to a mother with active varicella within 5 days prior to and 2 days following delivery

Chapter 29  NEWBORN


GOAL 11: Social Risk Factors. Understand red flags in the social history and their implications OBJECTIVES: * Discuss the policy for obtaining DDS * Review the clinical findings and prognosis associated with maternal drug use including: a. cocaine b. methamphetamines c. barbiturates d. opiates e. marijuana f. LSD/PCP g. alcohol h. cigarettes * Discuss the management and follow up of infants born to teen mothers * Discuss the management and follow up of infants when there is a positive history of domestic violence GOAL 12: Physical Exam. Understand how to perform newborn exam OBJECTIVES: * Perform a thorough newborn exam including: a. gestational age assessment b. general appearance c. skin (normal newborn exanthems) d. HEENT(caput, cephalohematoma, molding, RROU, nares, clefts) e. neck f. chest and breasts (fractured clavicle, maternal hormonal effect) g. heart (murmur evaluation) h. lungs i. abdomen (including umbilical cord) j. genitalia k. femoral pulses l. hips (Ortolani and Barlow maneuvers) m.neuro (activity, tone, primitive reflexes, sacral lesions) n. extremities (Erb’s and Klumpke’s palsy) GOAL 13: Hypoglycemia. Understand rationale for screening and management of hypoglycemic newborns OBJECTIVES:

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* Discuss policy for routine glucometer screening * Review definition of hypoglycemia (glucometer vs. serum glucose) * Understand the management of hypoglycemic infants a. glucose <35mg% and >25mg% b. glucose <25mg% c. breast fed babies * Understand protocol for follow up surveillance after initial stabilization of serum glucose GOAL 14: Screening HCT. Understand normal parameters for newborn Hct and CBC OBJECTIVES: * Understand the definition and differential diagnosis of anemia in the neonate * Understand the definition and the indications for treatment of polycythemia * Understand the definition and differential diagnosis of thrombocytopenia in the neonate * Understand the normal parameters of a newborn CBC * Understand indications for newborn CBC D. DISCHARGE PLANNING AND ANTICIPATORY GUIDANCE GOAL 15: Nutrition. Understand how to manage breast and bottle feeding in the newborn OBJECTIVES: * Discuss parental expectations regarding feeding in the first few days of life * Understand the parameters for accepted weight loss in the first week of life * Discuss effective strategies for improving latch on and lactation * Compare and contrast breast vs. formula feeding GOAL 16: Voiding and Stooling. Understand normal time parameters for first void and stool and the medical implications when these parameters are exceeded. OBJECTIVES: * Discuss the concerns raised when an infant fails to void in the first 24 hours of life a. posterior urethral valves c. UPJ obstruction d. dehydration * Understand proper management for congenital hydronephrosis * Understand significance of urate crystals in diaper * Discuss concerns raised by failure to have a stool within first 48 hours of life a. relative risk of Hirschsprungs b. meconium plug and relative risk of CF

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GOAL 17: Circumcisions. Understand the risks, indications, and procedure for circumcision in newborns. OBJECTIVES: * Interview parents, explaining the risk/benefits of circumcision and obtain informed consent * Discuss pros and cons of anesthesia and the methods of anesthesia available * Become competent in delivering adequate dorsal penile nerve block * Become competent in performing circumcisions using Gomcos and/or plastibells * Instruct parents on adequate post circumcision care GOAL 18: Newborn Screening. Understand the rationale for performing newborn screens. OBJECTIVES: * Review the following conditions which can be part of the newborn screen a. PKU b. maple syrup urine disease c. galactosemia d. hypothyroidism e. hemoglobinopathies f. homocystinuria g. CAH screening * Understand the proper timing of screens and the importance of allowing a sufficient interval after the first feeding * Understand the rationale and policy for universal hearing screening GOAL 19: Discharge Planning. Understand criteria for early discharge and provide appropriate follow up. OBJECTIVES: * Review criteria for earl discharge eligibility * Understand rationale for providing 2-3 day follow up for early discharges * Provide parents with anticipatory guidance: a. feeding instructions b. cord and circumcision care c. bathing d. thermoregulation e. signs and symptoms of acute illness d. hyperbilirubinemia precautions e. normal voiding and stooling patterns f. infant safety

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GOAL 20: Common Conditions and Symptoms of the Newborn. Understand the importance and approach to the evaluation of infants who become symptomatic after the transition period or any other potential issue of parental importance. OBJECTIVES: *Understand role of first responder to issues of hypothermia, hyperthermia, hyperbilirubinemia, tachypnea, poor feeding, etc. *Understand appropriate management and referral to NICU of symptomatic infants. *Supervise care of infants in the Specialty Nursery. “Green Team”

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CORE CURRICULUM CHECKLIST                    

Prenatal visit Newborn resuscitation Transition Preventive medicine Blood group incompatibility and jaundice Maternal VDRL Maternal HSV Maternal HIV Maternal TB/PPD Conversion Varicella Social risk factors Physical exam Hypoglycemia Newborn Hct Nutrition Voiding and stooling Circumcision Newborn screens Discharge planning Common Conditions and Symptoms of the Newborn