"Workshop on Care of the Newborn Child"
Workshop on Care of the Newborn Child Updated 3/15/05 Objectives: 1) Review the examination and routine well newborn care 2) Be aware of the common problems arising in well newborns and discuss evaluation and management strat 3) Discuss the evaluation, care and management of the premature newborn Overview: Normal newborn care makes up 2% of visits in family practice that includes obstetrics. Premature birth is define delivery before 37 weeks completed gestation, and approximately 5/100 births are premature. In 2002, 1.96% of Births w 32 completed weeks, or very preterm. Low birth weight can be from prematurity or growth retardation. 7.8% of 2002 U births were Low Birth Weight < 2,500 gms, (5lb 8 oz), while 1.46% 2002 births are VLBW or Very Low Birth Weight o 1,500 gms (3lb 5oz). ELBW or extremely low birth weight, is < 1,000 gms. The present threshold of viability is approx 23-24 weeks and 400-500 grams, There has been movement in both normal nursery and NICU for early discharge. An early discharge from norma nursery is < 24 hours in newborns meeting reassuring parameters. An early discharge from NICU can occur upon meeti three physiologic competencies of maintaining body temperature in crib, suckling adequate nutrition, and growth. Early discharge of term normal newborns @ 24 hours old are for weight appropriate for age, established stable vitals, urination stooling, and feeding, with uncomplicated delivery history and normal exam without jaundice. These early discharges h led to need for early follow-up and monitoring in the outpatient office. Former high-risk neonates engender closer obser for neurodevelopmental morbidities. Since 2000 there have been recommendations affecting routine newborn care. The American Academy of Pedia produced guidelines in July 2004 for management of hyperbilirubinemia in newborns ≥ 35 weeks gestation, revising its recommendations with emphasis of early evaluation and timely follow-up of jaundiced newborns. In 1996, the CDC pre a two option intrapartum chemoprophylaxis, risk based vs 36 week cultured based, to reduce vertical transmission of Gr Streptococcus. In August 2002 the CDC published an update of Group B Streptococcus Guidelines, endorsed by ACOG AAP, now supporting the routine 36-week culture algorithm as superior. The new algorithm endorses a suspected sepsi workup of all newborns exposed to chorioamnionitis, and setting parameters of adequacy for chemoprophylaxis. In 199 AAP recommended universal newborn hearing screening. The benefit of early detection was to be higher percentage of eventual intelligible speech. In October 2001 the US Preventive Service Task Force rated the evidence for universal new hearing screening as inconclusive, but still appropriate in high risk/incidence subgroups. In April 2000 the AAP publish clinical practice guideline for screening and early detection of Developmental Dysplasia of the Hip where watchful wait hip clicks and early referral of hip “clunks” or equivocal exams or selective imaging screening depending on risk (high r girls, breech, positive family history) was advised. A Canadian 2001 Preventive Committee used graded evidence to com mostly similar conclusions, but against imaging of high risk with normal physical exam cases. The AAP in 1999 and AA 2002 gave policy papers on circumcision. Screening the normal newborn Identifying sentence _____ is a _____gram ____week by OB dates_____ weeks by physical assessment, _____ (SGA,AGA,LGA) newborn ____ (male, female) _____ hours old after delivery by ______ (route and indication) with APGAR _______. Symptoms and Signs at Birth There are few symptoms or signs that the immediate newborn portrays. They include alterations in vital signs, 1) temp instability, fever ≥ 38°C, hypothermia ≤ 36°C, 2) tachypnea, grunting respirations, nasal flaring and retractions, and apnea, 3) tachycardia and bradycardia. Other signs are skin signs with color, cyanosis, pallor and poor capillary refill, and neurologic status as lethargic, jittery, poor tone, cry and suck, vomiting, and seizures. History 1) Maternal screening/prenatal history a. Infections of maternal GBS colonization, GC/Chlamydia, Syphilis, HSV, Hep B, HIV b. Maternal blood type, Rh, and isoimmunization status c. Other prenatal problems affecting the newborn, alcohol and drugs, history of IUGR, maternal diabetes, maternal preeclampsia on MgSO4 etc 2) Intrapartum history a. Infectious risk with intrapartum chemoprophylaxis for GBS, presence of prolonged PROM or chorioamnionitis, use of fetal scalp electrodes b. Possible asphyxia with intrapartum fetal monitoring, need for resuscitation and depressed apgar c. Risk of birth trauma given mode of delivery, presence of shoulder dystocia d. Presence of meconium 3) Genetic history/Family history a. Risk of anomalies, cystic fibrosis, neuromuscular disorders Vital Signs 1) Respirations: normal is 20-60, with greater than 60 as tachypnea. Often in the first two hours rates will exceed 60 as part of normal transition. If the tachypnea is in the setting of infectious risk, associated with distress (retractions, grunting, high work of breathing), or hypoxia, worsening or lasting >2 hours, a workup is performed. On the other end, hypopnea (<20/min) and apnea (> 15-20 sec noted with or without bradycardia or cyanosis (ABCs), and whether self resolving or requiring stimulation, during or after feeds is abnormal. Short pauses of 5-10 seconds in duration called periodic breathing are common in immature newborns and can be considered normal. 2) Pulse: In general the same guidelines can be used for the fetal normals of 120-160. During sleep some newborns have pulses of 80-100. In the first 15 minutes after delivery heart rates of 160-180 are common as a stress response. 3) Temperature: A good rule of thumb is abnormal is one half degree centigrade or one full degree Fahrenheit above or below the normal 37°C, (98.6°F). The normals are 36.5-37.5°C, (97.6-99.6 °F) rectal, with axillary up to 1/2 °C lower. It is good to remember that there can be a maintained core temperature with peripheral vasoconstriction in early sepsis, the toe to tummy differential. Also that the newborn expends energy by nonshivering heat production to maintain thermoregulation, until cooling is too much to keep up with. Fever is 38 °C or 100.4 °F. On this end, excessive bundling has been shown to increase temp at a linear rate of 0.27 °C/hour. Temperatures that are sustained > 1 hour, high (39 C), recurrent or late onset are more likely pathologic. A single isolated low-grade temp, in an asymptomatic newborn of no risk, is infrequently associated with infection, but would be reasonable to screen and closely observe. Gestational Age Assessment and Growth measurements There are scoring systems to judge gestational maturity of the newborn. (examples, Dubowitz and Ballard). These contain physical parameters that are present immediately on delivery and neuromuscular scores that require the newborn to be at maximum capability, which may not occur for one to two days. The Ballard scores 6 physical (skin condition, lanugo, plantar creases, breast, ear, and genitals) and 6 neuromuscular, (posture, wrist square window, arm recoil, popliteal angle, arm scarf sign and heel to ear flexibility). Graphs are available for normals per gestational age on weight, height and OFC. Dating by Pediatric physical measures is less accurate than first trimester Ultrasound Obstetric dating by crown rump length. The screening newborn physical exam Three exams are done. Immediately at birth the newborn is assessed following NRP guidelines. In the first 30 seconds, 5 questions are answered, 1) term gestation?, 2) clear of meconium?, 3) breathing or crying?, 4) good muscle tone?, 5) pink color? If all are yes then routine care of clearing the airway, drying and providing warmth is done. Newborns passing this screen can be dried and brought to the mother’s chest. Complete nasopharyngeal and hypopharynx suctioning for meconium after delivery of the head and before delivery of the body, now has large randomized studies showing no difference in outcomes. Also not every meconium stained delivery requires endotracheal intubation. Intubation and suctioning are for meconium and depressed tone, but vigorous newborns from a meconium liquor (either thick or thin) require observation only. There was not a decrease in meconium aspiration syndrome in vigorous term newborns who were intubated in a randomized multicenter study. Premature newborns are more susceptible to cold stress and the close observation of transition best done in the warmer. In the NRP algorithm, if the answer is no to any of the 3 questions of breathing, tone or color a second step is another 30 second review of three parameters: 1) Looking for good respiratory effort (not gasping or apnea) 2) Heart rate greater than 100 3) Color with no central cyanosis or pallor. Newborns failing this screen are resuscitated in a warmer per protocol. A second exam is performed in the first one to two hours screening for the distressed neonate. Consideration of the newborn as high risk for infection, hypoglycemia, trauma, anomaly, or asphyxia directs the screener’s attention. Symptomatic newborns from high-risk background will call for more immediate evaluation. The STABLE mnemonic is helpful in approaching stabilization, and includes sugar, temperature, air (airway, oxygenation and ventilation, Chest X-ray), blood pressure (shock and acidosis), lab (sepsis, blood gases) and emotional support. It is helpful to have a sense of normal transition and employ watchful waiting for mild abnormality in low risk cases. The detailed newborn screening exam is done at 12-24 hours. One approach is the look, listen and feel. The newborn is viewed for tone, color, respiratory effort, and movements. By listening next the examiner can obtain a quiet auscultation of cardiac sounds, lung and bowel sounds. Finally the newborn is fully undressed and a sequential head to toe review of physical signs. Area Head Face Ears Nose Mouth Eyes Neck Chest Cardiac Abd Umbilicus Genitals male Genitals female Anus Back Hips Extremities Neuro Skin Abnormalities Cephalohepatoma, abrasions, lacerations, microcephaly, macrocephaly, subgaleal hematoma Cleft lip, fetal alcohol facies, trisomy 21 Down’s facies Atresia, preauricular pits or skin tags Choanal atresia Cleft palate, Pupil shape, reactivity and size, red reflex Masses, branchial cleft cysts, cystic hygromas Chest wall deformities, retractions, tracheal deviation, clavicle fracture, breathing pattern of tachypnea, hypopnea or apnea Cyanosis, capillary refill, murmurs, femoral pulses, consistant with congenital heart disease Scaphoid, tumors, gastoschisis Omphaloceole, two vessel cord, infection, hernia Cryptorchidism, hernia and hydroceole, hypospadius Cysts Imperforate anus Spina bifida, midline skin changes, clefts or pits Developmental dysplasia of the hip Club foot, polydactylly, anomalies Brachial plexus palsy, hypotonia, seizures Herpes simplex, jaundice Some incidences of common anomalies are as follows: Congenital heart defects 10/1,000 VSD 5/1,000 ASD 5/1,000 Pulmonary Stenosis 0.8/1,000 Tetralogy of Fallot 0.7/1,000 Neural Tube defects 2/1,000 Cleft lip or palate 2/1,000 Congenital dislocation of hip 5/1,000 Clubfoot 1/1,000 Choanal atresia 0.2/1,000 Hypospadias 0.4/1,000 Common minor findings include: Head: molding, caput saccedaneum Skin: the most common pustular lesion is erythema toxicum neonatorum seen in up to 70% of term neonates, facial lesions such as neonatal acne in 20%, Miliaria, resolve spontaneously with no treatment, other skin findings include macules of mongolian spot, congenital nevi, hemangiomatas, aplasia cutis, sebaceous gland hyperplasia, skin tags, diaper dermatitis Mouth: Epstein’s pearls, sucking blisters, natal teeth Eyes: subconjunctival hemorrhage Torso: extra nipples, umbilical granuloma, Transition Practically transition is the first ten hours of life. However there are physiologic changes that need to successfully occur within the first 5 minutes and others that take weeks to complete. 1) Transition from fetal to newborn cardiopulmonary status Suctioning has cleared the airway and the newborn establishes respiration. Due to the meniscus effect the pressure to open the alveoli for the first few breaths is 30-40 mm Hg, while subsequent breaths ventilate at lower pressures of 20 mm Hg. However, with time 90% of the fluid in the alveoli is absorbed into the lymphatics and circulation rather than coughed up. Oxygen dilates the pulmonary artery bed, lowering the resistance, and redirects blood flow, closing the foramen ovale. Oxygen also constricts the ductus arteriosis and stops this right to left shunt. In the first 5 minutes of life grunting, retractions, and flaring are common, this is followed by up to 30 minutes of tachypnea to rates of 80. Grunting is common and seen in up to 18% of newborns, however it resolves by 1-2 hours in most neonates. This transitional tachypnea or grunting is not progressive, and is often intermittant. Tachypnea in a high-risk neonate setting, or associated with hypoxia or cyanosis, or that which sustains beyond 1-2 hours is abnormal. 2) Transition to thermal and energy self sufficiency The normal newborn has high content energy in the brown fat in the neck and thorax and glycogen stores of glucose in the liver. At birth a rise of catecholamines, ie norepinephrine, call on these energy resources for maintenance of blood glucose and nonshivering thermogenesis. A key goal of the provider is to quickly attain a dry newborn in a neutrally thermal environment. High-risk premature or starved IUGR newborns lack the stores of term AGA newborns and are more vulnerable. Temperatures of even normal newborns can dip in the first 1-3 hours of life and if too low need to be supported in a warmer. Thereafter stability can be expected. Suckling of milk provides ongoing energy resource. A coordinated suck swallow reflex is established gestationally by 32-36 weeks, and if not present may require gavage feeding to support until it is present. 3) Reactivity The stresses of transition and catecholamines at birth provide the first period of reactivity, in which the newborn is vigorous, and responsive for the first 15-30 minutes then quiet and alert up to one hour. This gives way to a normal sleep period as respiratory and pulse rates normalize, and peristalsis is more prominent. A second period of reactivity occurs at 2-6 hours of age. Wide swings in heart rate, brief tachypnea, oral mucous production and stool passage can be seen. These normal reactivities are to be contrasted with lethargy, weakness and poor suck or feeding, jitteriness, irritability or seizure activity. Seizures in newborns can be subtle and detected in eye and oral movements, posture and abnormal limb movements. Competencies before nursery discharge 1) Establishing adequate feeding. The family physician is in a unique position to support breast-feeding. Prenatally use of a nipple shield can assist with inverted nipples. Early breast-feeding in the delivery room or recovery room has been shown to foster successful continuation of breast-feeding. Colostrum is produced for the first days with engorgement, let down and milk production by the 2nd to 3rd day. The mother is coached on latching, detaching by breaking suction first, nipple care, let-down reflex, a non-traction hold, engorgement comfort measures, manual expression or pumping techniques, and need for calories and fluids for herself. Our institution uses the LATCH score, with points for successful latch, audible swallowing, type of nipple, comfort of feeding, and hold of baby. If glucose or volume is needed, cup supplementation can be provided after suckling or alternatively a butterfly catheter attached to the nipple during suckling. By the third day of life is reasonable to expect greater than 5 wet diapers per day if the neonate is suckling adequate volume. Feeding should occur on demand but intervals should not be longer than 4 hours, preferably on demand about every 2 hours. The newborn can empty most of the available milk in a breast with ten minutes of good suckling. Birth weight, discharge weight and early outpatient follow-up weight are recorded, and weight loss of 10% or more is investigated. The infant should regain birth weight by two weeks. Breast-feeding does not need to be interrupted for jaundice. There are few absolute contraindications to breastfeeding, being maternal HIV in developed nations, CMV with a premature newborn, and class D and X medications. Most Maternal infections represent relative precautions to breastfeed. Breastfeeding can occur with maternal non-acute infections: Hepatitis A after immune globulin, Hepatitis B without HbeAg high infectivity marker and after HBIG and vaccine, Hepatitis C, Mastitis after 24 hours of pump and dump and antibiotics, Tuberculosis after 2 weeks treatment and being considered non-infectious, HSV in absence of breast lesions and using proper hand-washing and clothing care. Formula and breast milk contain 20kcal/ounce. The newborn requires 100-120 kcal/kg/day to grow. Volumes can be calculated, for a 3 kg baby it is a little more than 2 ounces every 3 hours. Often babies do not reach volumes for growth in the first 24-48 hours, but should meet volumes for fluid needs of 80 cc/kg day one, 100cc/kg/day two, and 120cc/kg day three and thereafter. Coaching of bottle hygiene, proper mixing and storage are important. Microwaves can unevenly heat the formula and cause burns if not shaken and tested. 2) Elimination One stool and one urination are needed before discharge. Urination for full term newborns occurs within 24 hours in 96% of newborns and by 48 hours in 99.7%. Wet diapers range from 5-20 per day, with averages of 10-15. Time to first stool for a term newborn is 23% in the delivery room, 96% by 24 hours and 99% by 48 hours. Thereafter stools vary widely in frequency, from every 3-5 days to 5 times per day. 3) Absence of developing illness Prevention 1) Immunization, Newborn immunization with thiomersol free Hep B vaccine is performed. Note that newborns of mothers with Hep B carriage receive HBIG immunoglobulin, and note that one of the preparations Recombivax requires a double dose of Hep B vaccine. Influenza is now indicated for household members caring for medically fragile newborns. 2) RSV immune globulin, Palivisumab (Synagis®), is indicated for high risk patients: a) patients < 2 years old with chronic lung disease and have required oxygen with the last 6 months before RSV season, b) infants born ≤ 28 weeks gestation who are < 12 months postnatal age at start of RSV season, c) infants born 29-32 weeks gestation who are < 6 months postnatal age at start of RSV season, d) infants born 32-35 weeks gestation with other risk factors, including attending daycare, living in home of a smoker, or one of multiples. e) children < 2 years old with severe immunodeficiency 3) Ophthalmic chemoprophylaxis, Erythromycin and silver nitrate have similar efficacies of 80-90% in preventing gonorrheal neonatal ophthalmia, 4) Newborn blood screening, the practice varies from state to state, the US Public health services task force on preventive services 2nd edition, recommends screening for sickle cell, PKU (if sampled in the first 24 hours to be resampled within 2 weeks, and thyroid screen in the first week of life. 5) Hearing screen, identification early can impact the end result of communication, universal screening has just been recommended by AAP, the US Preventive task force has noted that there is not enough evidence to recommend for or against universal screening, but screening in high risk groups such as prematures is warranted. 6) Car seat, with appropriate counsel for facing backwards in the back seat appropriately secured Common Problems Common problems include those requiring reassurance, further work-up that can safely be done as an outpatient, problems that require in-hospital work-up. Normal physiologic transition symptoms are in the differential diagnosis of newborn illnesses. Empiric treatment in the setting of high risk or pending workup is prudent in the symptomatic newbo Up to 20% of newborns will require admission to the special care nursery. Common problems admitted to SCN are: 1) 2) 3) 4) 5) 6) 7) The 33-36 week premature feed and grow Suspected sepsis/possible or probable sepsis/culture + infections Jaundice Hypoglycemia Tachypnea, respiratory distress Meconium aspiration Apnea and bradycardia 8) Feeding difficulties 9) Infant of a diabetic mother 10) Infant of a mother abusing drugs 11) Air leaks 12) Pneumonia Common Workups 1) Maternal GBS colonization Intrapartum chemoprophylaxis has been shown to decrease vertical transmission of Group B Strep in early onset newborn sepsis. GBS sepsis accounts for half of the early onset newborn sepsis cases. The 2002 CDC guidelines also outlined an algorithm for follow-up of the newborn after the chemoprophylaxis. These CDC Newborn follow-up guidelines are expert opinion. Asymptomatic newborns > 35 weeks’ gestation with full chemoprophylaxis of one dose completed 4 hours before delivery are usually observed for 48 hours without workup or treatment and then discharged with parameters. However, 2002 guidelines note an exception for earlier discharge, “Specifically a healthy appearing infant ≥ 38 weeks gestation at delivery and whose mother received ≥ 4 hours of intrapartum antibiotic prophylaxis may be discharged to home as early as 24 hours after delivery” assuming compliant parent, intact telephone access to the provider, capable and reliable in of observing for clinical signs of sepsis. Newborns whose mothers were treated intrapartum for chorioamnionitis are recommended to receive a full septic workup and empiric antibiotic therapy for both GBS and other pathogens pending culture results regardless of clinical condition at birth. Symptomatic newborns are treated empirically and receive full workup. New recommendations are to perform an LP if feasible in newborns with clinical signs of sepsis. Newborns with alternate antibiotic, less than full prophylaxis, and gestational age less than 35 weeks receive a limited work-up, CBC with differential and blood culture, and observation of 48 hours. There is controversy about the utility of the CBC and BC screen in the limited workup. It is good to remember that use-effectiveness of intrapartum chemoprophylaxis in stopping GBS vertical transmission is not 100%, but more like 70-90%, so cases can occur despite chemoprophylaxis, and that a maternal rectovaginal culture that is negative is about 90% but not 100% accurate in it’s negative predictive value if done within 4 weeks of delivery. 2) Suspected sepsis of the newborn, Early onset bacterial sepsis has an incidence of 1-5/1,000 births with significant neonatal morbidity and mortality as well as fulminant course. High risk rates from the era before intrapartum antibiotic prophylaxis are chorioamnionitis 1/10, prematurity 1/100-1/10 depending on gestational age, prolonged ROM >24 hours 1/100 (although risk rises after 12 hours), term GBS mother 1/100, heavy GBS count 1/20. Scalp electrode, presence of meconium, maternal malnutrition or immune defect, asphyxia, IV lines, and galactosemia are other risks. In an August 2000 publication of a Kaiser study or 18,299 newborns >2,000 grams 15.2% received a workup for suspected sepsis. Kaiser had used the risk-based approach to GBS screening, and about half of the 15.2% had received intrapartum antibiotics and 76% had shown risk factors. Sepsis was defined as possible, probable or culture positive. Newborns that had risks but were asymptomatic had a 1% rate of infection, those with risks and some symptoms a 2.4% risk, and those critically ill (CPAP or vent support, pressors, NICU care, chest tube or CPR) had an 11% risk. Adjusted odds ratios were 0.26 (0.11-0.63) for asymptomatic status, 2.0 (1.15-5.0) for chorioamnionitis, and meconium stained fluid of 2.4, (1.5-5.8). The authors noted that with a 1/100 infection rate in asymptomatic newborns with risk factors treatment couldn’t be based on asymptomatic status alone. A screen would be indicated. They also demonstrated that the sensitivity of some symptoms or abnormal signs had greater sensitivity than a CBC screen. Sepsis symptoms are nonspecific and subtle. In a review of over 400 culture positive newborn sepsis cases; Temperature changes are seen with 55% with temp >100.4 and 15% hypothermic, Respiratory distress in 33% or apnea in 22%, and GI findings of anorexia 28%, vomiting 25%, distension 17% and diarrhea 11%. In term newborns with fever of 100.4 one in ten had bacterial infection. Fevers associated with infection tended to be sustained, >39oC, and of late onset from birth. Fevers without infections tended to be isolated and without other symptoms. Most institutions have symptomatic newborns treated empirically pending culture results. The first step is supportive therapy of the ABCs during workup. Sepsis screens are controversial. The options are close observation watchful waiting of asymptomatic at risk newborns versus leukocyte indicies and/or CRP. Watchful waiting has the downside of waiting for subtle findings on a fulminate disease. WBC screens have a 33% false positive rate. There are empiric retrospective protocols for screening asymptomatic newborns at risk of infection. Some treat with worsening screens or symptoms, some treat with positive lab screens. If one uses leukocyte screens combination of indicies and age specific counts may be more accurate than a single parameter. One CBC scoring system is the Rodwell criteria. Meeting 3 of 7 criteria has a sensitivity of 96%, specificity of 78%, PPV of 31% and NPV of 99%. The seven criteria are: 1) absolute neutrophil count <7,500 or >14,500, 2) total WBC count < or = 5,000 or > or = 25,000, 3) and immature neutrophil count of >1,400/mm 4) platelet count < 150,000, 5) degenerative changes in neutrophils (vacuolization or degenerative changes), 6) an I/T neutrophil count (immature/total or bands+meta+myelo /neuts+bands+metas+myelo) of >0.16, and 7) an I/M neutrophil count of > or = 0.30, (immature/mature or band+meta+myelo/neuts). In a baseline study of 193 healthy neonates with term neonates with no disease in 1993 with CBCs at 4 hours of age the mean normal distribution was total leukocytes of 24,000 (16.2-31.5, 10-90%), absolute neutrophil count of 15.6 mean, (9.5-21.5, 10-90%), absolute immature neutrophil count of 2.48 mean (0.7-4.3, 10-90%), I/T ratio of mean 0.16 (0.05-0.27, 10-90%) and I/M ratio of 0.21 mean, (0.06-0.35, 10-90%). CRP is an acute phase reactant that has been utilized as screening for possible sepsis, with a cutoff for positive of 1 mg/dL. As a reactant it can be false negative early in the infection. A 1996 DARE evidence based review noted that “while not perfect a quantitative CRP is probably the single best test for screening for suspected sepsis”. Whether to include routine lumbar puncture, cathed urine, and two blood cultures vs one is controversial. Most advocate for LP in those with positive GBS serum antigen,+ blood culture, or abnormal neuro signs. Two blood cultures is more sensitive but has higher false positives and requires more blood volume in premies. Chest xrays are indicated for respiratory symptoms. Empiric therapy for 72 hours is given with ampicillin 100 mg/kg/24 hours, and Cefotaxime 50mg/kg/24 hours or instead of Cefotaxime, Gentamicin. Gentamicin dosing varies with age and gestational age, for a term immediate newborn dose is 2.5mg/kg/dose q 12 hours. 3) Jaundice: More than 50% of newborns become visibly jaundiced in the first week of life. Most of the presentations represent physiologic jaundice for healthy term newborns. The first steps in the workup are determining pathologic vs physiologic presentations and risk factor presence. Disorders of overproduction, especially hemolysis due to isoimmunization or ABO incompatibility, altered clearance, such as albumin displacement or blockage in biliary excretion such as gut atresia, or disrupted blood brain barrier of bilirubin such as prematurity, asphyxia or sepsis promote pathologic jaundice. Direct hyperbilirubinemia is always pathologic. Pathologic jaundice requires more aggressive work-up and treatment. The AAP presented management guidelines in 2004 for newborns ≥ 35 weeks gestation. None of the 30 recommendations was based on well-designed randomized controlled trials. The 2004 guidelines list major risk factors as: 1) Pre-discharge total bilirubin in high-risk zone for postnatal age (≥ 95%) 2) Onset of jaundice before 24 hours of age 3) Hemolytic disease especially Coombs positive, RH or ABO but also G6PD deficiency hemolysis, 4) Near term 35-36 weeks gestation 5) Previous sibling needing phototherapy 6) Cephalohematoma or significant bruising 7) Exclusive breast feeding especially if weight loss of 10% nursing not going well 8) East Asian Race. Minor risk factors are: 1) Predischarge age specific total bilirubin in the 75-94%, (high intermediate zone) 2) Late near term of 37-38 weeks gestation 3) Jaundiced observed before discharge 4) Previous sibling with jaundice 5) Macrosomic infant of a diabetic mother 6) Maternal age ≥ 25 years old 7) Male gender In the presence of risk factors serial measurements of bilirubin and early follow-up are advised. Normal ranges of bilirubin have been ascertained. In a study of 13,003 healthy term or near-term newborn pre-discharge bilirubins were measured between 1993 and 97. If the bilirubin was below the 40% there was no risk of developing significant bilirubin. If there was a pre-discharge of >95% then 2/5 developed significant bilirubin levels, if 76-95 % then 1 of 8, and if 40-75% one of 46. Hours of Life 24 hours 48 hours 72 hours 96 hours 40% 5 mg/dl 7.5 mg/dl 11 mg/dl 12 mg/dl 75% 6.5 mg/dl 11 mg/dl 13.5 mg/dl 15 mg/dl 95% 8 mg/dl 13 mg/dl 16 mg/dl 17 mg/dl It is emphasized to the parents that milk creates stool, which empties the enterohepatic bilirubin excretion. IV or PO hydration is not effective treatment. Phototherapy is for the above thresholds in physiologic jaundiced term and near term newborns. In those case were watchful waiting is chosen close follow-up is indicated, with reliable caregivers, phone numbers in hand for those discharged, lab repeats and clinic visits scheduled from the hospital. The most common reason for readmission for newborns is hyperbilirubinemia. There were hour specific nomograms for recommendation to start phototherapy or use exchange transfusion for three classes of well term newborns ≥ 38 weeks, either near term (35 to 37 and 6/7 weeks) or term with risks, and near term with risks. Risks factors were isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or albumin < 3.0 g/dL. Presentations with prematurity <38 weeks, onset <24 hours, in the setting of disrupted blood brain barrier with asphyxia or sepsis, or hemolytic in Rh or ABO incompatability are. . Age In hours Phototherapy Term well, ≥ 38 weeks Near term or term + risks Near term 35-37 wks + risks 13.5 mg/dL 11.5 mg/dL 9.5 mg/dL 15 mg/dL 13 mg/dL 11 mg/dL 16.5 mg/dL 14.5 mg/dL 12.5 mg/dL 18 mg/dL 15.5 mg/dL 13.5 mg/dL 20-21 mg /dL 17-18 mg/dL 14.5-15mg/dL Exchange if intensive photo therapy fails Term well, ≥ 38 weeks Near term or term + risks Near term 35-37 wks + risks 21 mg/dL 18 mg/dL 16 mg/dL 22 mg/dL 19 mg/dl 17 mg/dL 23 mg/dl 20 mg/dL 18 mg/dL 24 mg/dL 22 mg/dL 18.5 mg/dL 25 mg/dL 22.5 mg/dL 19 mg/dL 36 48 60 72 96+ With most of the evidence expert opinion, treatment of neonatal jaundice will remain controversial. Disregard for high levels of bilirubin and risk factors played a role a sizable portion of the >90 cases in the Kernicterus registry. On the other hand it has been estimated that one would treat between 200-2,000 newborns with total bilirubins over 20 to prevent one kernicterus case. 4) Respiratory distress Respiratory distress is noted by tachypnea at >60 breaths per minute, grunting, nasal flaring, subcostal and intercostal retractions, cyanosis, and apnea. About 7.6% of newborns will have respiratory distress needing work-up. The etiology may be transition, respiratory, cardiac, sepsis or metabolic causes such as acidosis and hypoglycemia. Workup is entertained if the newborn is worsening, persists with symptoms to 2 hours of age, or has hypoxia or cyanosis. Again first is stabilization of the ABCs. Newborn positioning especially prone can be helpful. Oxygen saturation monitoring can accurately reflect O2 saturation in the presence of a strong pulse. A capillary blood gas has good correlation with pH and CO2 levels, detecting acidosis and hypoventillation. Tachycardia, delayed capillary refill, pallor give clues of volume deficiency which when corrected can improve respiratory distress. Hypothermia yields respiratory distress and warming and neutral thermal environment are applied. Oxygen, applied early enough to keep the O2sat at 95% or greater in a term newborn during stabilization assists in improving distress and reversing persistant fetal circulation. Initially by nasal canulla, then Oxygen hood if needed O2 is given. Targets for O2 sat are ≥ 95% in stabilization for term newborns first few hours, ≥ 90% term newborn after stabilization, 87-93% in premies < 28 weeks, and 87-95% in premies 28-34 weeks. Keeping the O2 sat below 95% in prematures helps avoid ROP (retinopathy of prematurity). Remember in O2 saturation monitoring by pulse oxygen measuring, that no pulse equals no ox, and is affected by clamped down circulation. If oxyhood to 40% FiO2 fails, nasal CPAP or intubation with ventilator is needed. The differential diagnosis is classically divided into pulmonary and extra pulmonary. Common causes are: Pulmonary Extra-pulmonary Persistant fetal circulation TTNB transient tachypnea of the Hypovolemia, anemia newborn RDS respiratory distress syndrome Congenital heart disease Hypoglycemia Meconium aspiration Hypothermia Pneumonia Metabolic acidosis Pnemothorax Sepsis There are many uncommon causes such as anomalies impacting the airway or chest wall, pulmonary hemorrhage, pulmonary masses, CNS lesions affecting respiratory drive, and polycythemia. After and during stabilization workup includes, Chest Xray, blood glucose, CBC with differential, serum GBS antigen, and blood culture. Assessment of adequacy of oxygenation and ventillation can be done with O2 sat monitor and capillary blood gas. Besides oxygen, these newborns receive empiric antibiotics as above for suspected sepsis and pneumonia, and volume correction if indicated. Although the case may turn out to be TTNB, use of antibiotics in suspected sepsis cases while waiting is warranted. During the stabilization process, a decision on the best place of treatment is made and transfers to a level 3 NICU with ventillator capability done in a timely fashion before respiratory failure. 5) Hypoglycemia Hypoglycemia occurs in the setting of risk factors for the most part. The main maternal risk is infants of diabetic mothers. Newborn risks include, LGA newborns, low energy stores in SGA/IUGR, or premature; stressed newborns from infection, hypothermia or asphyxia; and congenital metabolic abnormalities. Screening is often done by glucometers, which have inaccuracies in the low and high ranges. Glucometers can be calibrated to neonatal range to improve accuracy. Screening is done for risks such as LGA > 4200 gms, infant for a diabetic mother etc, or for symptoms. Symptoms are nonspecific and include jitteryness and irritability, lethargy, hypotonia, tachypnea, apnea, hypothermia, poor feeding and seizures. A positive screen on glucometer for a newborn >2,500 grams is a glucose of < 45mg/dL with symptoms, or a glucose <30 mg/dL without symptoms and be given IV therapy of D10W of 4ml/kg over 1-2 minutes followed by an infusion at 4ml/kg/hour. The screen is confirmed by a serum glucose drawn stat with ≤ 35 mg/dL being hypoglycemia on a plasma specimen, but treatment is initiated on the basis of the screen of immediate whole blood. High-risk newborns that are asymptomatic but have borderline screen glucose of 30-39 are fed early and checked in one hour, borderline glucose of 40-45 fed early and checked in 2 hours. Any relapse of glucose <40 progresses to IV therapy, and those that remain borderline and asymptomatic at 40-45 have continues AC screens and frequent feedings. If glucose falls despite the above D10W therapy then the peripheral IV can be increase to D12.5W, beyond that a central line is needed for higher concentrations. Assessing for the above list of possible causes includes electrolytes, capillary blood gas, and infection workup. 6) Physical Exam Findings on Hip exam: Tendonous hip clicks on physical exam are common. Recent guidelines promote the watchful waiting of “clicks” for 2-4 weeks, while “clunks” on Ortolani (relocation lifting and abduction) or Barlow’s (dislocation posterior with adduction) maneuvers would warrant orthopedic referral. Developmental Dysplasia of the Hip occurs at rates of 1.5-20/1,000, with high rates of spontaneous resolution 90+%. Abduction splinting (Pavlik Harness) has significant harm of 1-4% avascular necrosis. Ultrasound screening has a high rate of false positives, particularly when done less than 3-4 weeks of age. Thus it is recommended to refer to an experienced orthopedic examiner rather than obtain an US in the first month for a potential dislocating hip. AAP Guidelines note one high-risk group, breech girls, with estimated rate of 120/1,000 in whom routine imaging with US at 6 week, or x-ray at 4 months may be indicated. 7) Circumcision: Circumcision is controversial, yet it is the most common male operation, with a prevalence of 77%. Both AAP and AAFP policies recommend unbiased counseling of the benefits and harms of doing nothing versus newborn circumcision. Benefits of circumcision include: A. Less phimosis, (10% without, less with, ¾ treatable with topical steroids) B. Less UTIs, (NNT 167 for UTI in first year of life) C. Less penile cancer, (NNT 600-900 for one lifetime case D. Less STD/HIV transmission, 90% less in high risk populations in STD clinics, but unproven in US general population. The main benefit is cosmesis. Risks are small. Most large series give complications rates of 0.2-1%. Most common is bleeding at 0.1%. Bleeding may be a sign of an underlying bleeding diathesis such as Hemophilia, and 80% of deficiencies are Hemophilia A of factor VIII deficiency. Second most common is infection, < 0.1%. There is controversy in including the complication of meatitis. Undesired cosmesis, scar, and wound separation is the third major group of common complications. Rare complications include partial penile amputation, urethral fistula, and necrotizing fascitis. Death is estimated at 1/500,000. Prematurity and the family physician The family physician typically provides three roles in premature newborn care. For prematures actively cared for by neonatology an accompanying the family role, for prematures in the 34-37 week range with no illness supporting nutrition and hydration, and for graduates of the NICU outpatient followup of growth and development and morbidities of prematurity. In graduates of the NICU a multidisciplinary approach is best. 1) The 34-37 week feeder and grower The coordinated suck swallow reflex matures about 34-36 weeks and in the last month of life brown fat and glycogen stores are deposited. Newborns in the near term age may not be competent in maintaining adequate energy intake. Typically these newborns require support by gavage feeding until the nippling is adequate. The newborn is born with excess fluid from intrauterine life and in the first three days of life the goals of therapy are to obtain adequate fluid intake (80 cc/kg/day on day one, 100cc/kg on day 2, and 120cc/kg on day three) and support serum glusoce to avoid hypoglycemia. Thereafter providing adequate calories for growth at 120 kcal/kg/day is the target. Initially it is common to have an IV and then start gavage feeds, such that IV + PO equals the volume for fluid needs outlined above. The IV is weaned as the gavage advances. Gavage feeds are typically given every three hours as bolus, beginning as 3cc and increasing at 3cc/feed. This start low and go slow approach helps to avoid NEC which can occur rarely in the near term population. Prefeed gastric residuals are checked and should be less than 5cc. Newborns unable tolerate enteral feeding by 48 hours should be considered for transfer and IV hyperalimentation. The newborn can spend energy on heating or growth, and maintaining neutral thermal environment with isolette or aggressive bundling in the crib is appropriate. 2) Office follow-up of the NICU graduate The NICU graduate requires a good communication of active issues during the hospitalization and those present at discharge. Early outpatient followup every one to two weeks is performed until good weight gain at home is documented and active problems are stable. Feedings are frequent every 2-3 hours, solids are delayed until 6 months from the expected due date, and vitamins especially vitamin D with iron is given. Close attention vision and hearing is noted, with prematures <32 weeks having a discharge retinal exam for retinopathy of prematurity and a BAER or brainstem auditory evoked response hearing test. Immunizations are given by chronologic age, not gestational age. The former premature may be a candidate for RSV-IVIG, or respiratory syncytial virus immune globulin. It is given monthly during RSV season. Measles vaccines are blocked by RSV-IVIG, and should be given nine months after the last dose. Influenza is recommended for household members and newborns greater than 6 months old with chronic disease with only split virus product used for the child. Growth and development are followed. For Growth there are growth charts for premature newborns based on gestational age. Catch up growth is common and completes by about age 2-3 years old. OFC is monitored for microcephaly or macrocephaly, (particularly progressive hydrocephalous) and worked up accordingly. It is important to follow structured developmental screens such as the Denver developmental questionnaire. Similarly standardized neurologic exams such as the Neonatal Neurodevelopmental Examination assist is finding abnormalities. References Books Klaus and Fanaroff, Care of the High-risk Neonate, 5th edition, WB Saunders 2001 Faranoff and Martin, Neonatal-Perinatal Medicine, 6th edition, Mosby, 1997 Cohen, Atlas of Pediatric Dermatology , Mosby-Wolfe, 1993 Siberry and Iannone, The Harriet Lane Handbook, 15th edition 2000 Articles Newborn Exam: Coen, Fanaroff and Taylor, The Detailed Newborn Exam, Patient Care, 7/15/88, p93-108 Clarren, Astley, A screening guide for fetal alcohol syndrome, 2nd edition 1995, University of Washington, Circumcision: Position Paper on Neonatal Circumcision: AAFP, 2002, http//www.aafp.org/x1462.xml?printxml Siegfried N. et al, Cochrane HIV/AIDS Group, Male Circumcision for prevention of acquisition of HIV in men, August 2003 Task force on Circumcision, Circumcision Policy Statement, Pediatrics Vol 103, #3, March 1999 p686-693 Early discharge: Hurt H, Early discharge for newborns, when is it safe?, Contemporary Pediatrics, Aug 1994, p68-88, Vol 11 Feeding: Bedinghaus J, Melnikow J, Promoting Successful Breastfeeding Skills, Am Fam Phy, March 1992, Vol 45 # 3, p1309-1318 Spencer J, Practical nutrition for the healthy term infant, Am Fam Phy, July 1996, p138-144, Vol 54 #1 Group B Strep: Carlough, M, How should we manage infants at risk for group B streptococcal disease? Journal of Family Practice, May 2003, Vol 52, #5 Prevention of Perinatal Group B Streptococcal Disease: Revised Guideline from CDC, MMWR August 16th, 2002, Vol 51, # RR-11, p1-22 Christensen, R et al, Fatal early onset GBS sepsis with normal leukocyte counts, Ped Infect Dis, Vol 4 No3, May 1985, p242-245 Madan, A et al, Frequency and Timing of Symptoms in Infants Screened for Sepsis: Effectiveness of a sepsisScreening Pathway, Clinical Pediatrics Jan/Feb 2003, 42, 1, p 11-18 Hip Dysplasia: Patel, Hema, Canadian Task Force on DDH, Preventive Health Care, 2001 Update, screening and management of developmental dysplasia of the hip in newborns, CMAJ, Vol 164, (12) June 12, 2001, p1669-1677 Sub committee on Developmental Dysplasia of the Hip, Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip, Vol 105, 4, part 1 of 2, April 2000, p896-905 Hyperbilirubinemia: Bhutani V, et al, Predictive ability of predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near term newborns, Pediatrics, Jan 1999, Vol 133, #1 p6-14 Blackmon, L at al, Research on Prevention of Bilirubin-Induced Brain Injury and Kernicterus: National Institute of Child Health and human Development Conference Executive Summary: Pediatrics Vol 114, #1, July 2004 p229-233 Kappas, A., A Method for Interdicting the Development of Severe Jaundice in Newborns by Inhibiting the Production of Bilirubin, Pediatrics, Vol 113, #1, Jan 2004, p 119-123 Ip, S et al, Hyperbilirubinemia and Kernicterus: 50 years later: Pediatrics Commentaries, p253, 2004 Subcommittee on Hyperbilirubinemia; AAP, Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation, Pediatrics, Vol 114, #1, July 2004, p297-316 Meconium: Cleary G, Wiswell T, Meconium-Stained amniotic fluid and the meconium aspiration syndrome, Ped Clinic of N Amer, vol 40, #5, Oct 1993 Vain, N et al, Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomized controlled trial, Lancet, Vol 364, Aug 14th, 2004, p 597-602 Wiswell T, et al Deliver Room management of the apparently vigorous meconium-stained Neonate: Results of the multicenter, international collaborative trial, Ped vol 105, #1 Jan 2000, p1-7 Premature Follow-up: Trachtenbarg D, Care of the Premature Infant: Part 1, Monitoring Growth and Development, American Family Physician 5/1/98, vol 57, #9 p2123-2130 A statewide consensus project: Washington State Low Birth Weight Neonatal Intensive Care Unit Graduate, Critical Elements of Care, 1st Edition 9/98, order copies at 253-403-5525 NIH Workshop: Follow-up Care of High-Risk Infants, Pediatrics Vol 114, #5 Nov 2004, p 1377-1394 Respiratory Distress: Hein H, Ely J, Lofgren M, Neonatal Respiratory Distress in the Community Hospital: When to Transport, When to Keep, J Fam Pract 1998; 46: p284-289 Screening: Irons M, Screening for metabolic Disorders, Ped Clinic of NA, October 1993, Vol 40 #5, p1073-1085 Task Force on Newborn and Infant Hearing, Newborn and Infant Hearing Loss: Detection and Intervention, Ped vol 103, #2 Feb 1999, p527-530 Suspected Sepsis: Escobar, G et al, Neonatal Sepsis Work-ups in Infants ≥ 2000 Grams at Birth: A Population based study, Pediatrics vol 106(2), PART 1 OF 3, August 2000, pp 256-263, (The Kaiser study of suspected sepsis.) Gerdes J, Clinicopathologic approach to the Diagnosis of Neonatal Sepsis, Clinics in Perinatology Vol 18, #2, June 1991 p361 Ottolini, M Utility of complete blood count and blood culture screening to diagnose neonatal sepsis in the asymptomatic at risk newborn, Pediatr Infect Dis J, 2003;22: 430-4 Polin, R The “Ins and Outs” of neonatal sepsis, Journal of Pediatrics Vol 143 (1), July 2003, p3-4 Rodwell R, et al Early Diagnosis of neonatal sepsis using a hematologic scoring system, J of Pediatr, vol 12, p761 1988 Rozycki, H et al, Impaired sensitivity of a single early leukocyte count in screening for neonatal sepsis, Ped Infect Disease 6: p 440-442, 1987 Schelonka R, Peripheral leukocyte count and leukocyte indexes in healthy newborn term infants, The Journal of Pediatrics vol 125, #4, and p603-606 Schuchat A, et al Risk Factors and Opportunities for Prevention of Early-onset neonatal sepsis: A multicenter Case-Control Study, Ped Vol 105, #1 Jan 2000, p21-26• Singhal K, La Gamma E, Management of 168 neonates weighing more that 2000 gms receiving intrapartum chemoprophylaxis for chorioamnionitis, Arch Ped Adol Med, vol 150, Feb 1996 p158-163 Evidence Reviews: Key Practice Recommendations and EBM Documentation by topic Recommendation: AAFP Approved Source ARHQ not Website Level of Evidence Universal newborn Hearing Screen Newborn at risk of GBS management www.arhq.org www.jfponline.com/content/2 003/05/jfp_0503_00406.asp FPIN answer, May 2003 I = inconclusive Watchful waiting for asymptomatic fully prophylaxed SOR B; limited workup and treatment or watchful waiting for others, SOR D expert opinion II a and II b, SOR B that universal screening is better than risk factor alone, to prevent one infected baby, NNT is 16 if infection rate 7%, and NNT is 2,059 if invasion rate 0.1% 30 recommendations, 10 were D (expert opinion) and 15 were C level (observational studies) GBS intrapartum chemoprophylaxis Canadian Preventive Services http://www.ctfphc.org April 2nd 2002 Hyperbilirubin Management, AAP not http://aappolicy.aappublicati ons.org/cgi/content/full/pedia trics;114/1/297 Developmental Dysplasia of the hip Canadian Preventive Services July 2004, AAP http://www.ctfphc.org 2001 AAP has own grading guidelines Clinical exam screen, III, rec B US screening, II, SOR, rec D Abduction therapy, III, Rec I Brief Watchful Wait, II, Rec A