Care of the NewbornCare of the Newborn

Dr. Kristine Whitehead, MD, Dr. Kristine Whitehead, MD, CFPCCFPC

Riverside Family Health TeamRiverside Family Health Team

20132013

Routine CareRoutine Care

Objectives – review NB care in the Objectives – review NB care in the delivery room, PP floor or officedelivery room, PP floor or office

Distinguish normal from abnormalDistinguish normal from abnormal Management of abnormalitiesManagement of abnormalities ScreeningScreening Parenting supportParenting support TOH infonet – Depts and services – OB/gyne and NB care – Quick TOH infonet – Depts and services – OB/gyne and NB care – Quick

references – Policies and procedures – NB carereferences – Policies and procedures – NB care

Eye careEye care

Erythromycin eye ointmentErythromycin eye ointment Silver nitrateSilver nitrate GC but not chlamydiaGC but not chlamydia VD and c/sVD and c/s Evidence-based?Evidence-based?

Vitamin KVitamin K

Hemorrhagic dx of NBHemorrhagic dx of NB Vit K deficient bleeding (VKDB)Vit K deficient bleeding (VKDB) Vit K for F2,7,9 and 10 synthesisVit K for F2,7,9 and 10 synthesis Early vs. late (2-7 days)Early vs. late (2-7 days) Po vs. im - 0.5 to 1.0 mg imPo vs. im - 0.5 to 1.0 mg im 1.2-1.8/100,000 vs. none1.2-1.8/100,000 vs. none Anaphylaxis riskAnaphylaxis risk

Hepatitis BHepatitis B

InfonetInfonet Immunoglobulin (HBIG) 0.5 ml imImmunoglobulin (HBIG) 0.5 ml im Vaccine 0.5 ml im within 12 hrs.Vaccine 0.5 ml im within 12 hrs. BreastfeedingBreastfeeding Maternal vs. other family membersMaternal vs. other family members

Hepatitis CHepatitis C

Umbilical cord careUmbilical cord care

OmphalitisOmphalitis Septic clamping and cuttingSeptic clamping and cutting Single umbilical artery , <1%Single umbilical artery , <1% SGA, preemies, twinsSGA, preemies, twins Chromosome and congenital Chromosome and congenital

anomaliesanomalies 20-30% major structural 20-30% major structural

ScreeningScreening

InfonetInfonet HearingHearing Newborn screen – CHEO, 48-72 hrsNewborn screen – CHEO, 48-72 hrs 26 disorders eg. Thyroid, PKU, SS, 26 disorders eg. Thyroid, PKU, SS,

CF, CAHCF, CAH Community resourcesCommunity resources

Weight lossWeight loss

Max. 10 %Max. 10 % LC consult, supp and pumpLC consult, supp and pump BW at 7-14 daysBW at 7-14 days

HypoglycemiaHypoglycemia

Protocol - InfonetProtocol - Infonet PrematurePremature SGA or LGASGA or LGA Diabetic momsDiabetic moms Symptoms: jittery, hypotonia, Symptoms: jittery, hypotonia,

irritability, lethargy, poor feeding, irritability, lethargy, poor feeding, hypothermia, apneahypothermia, apnea

BS < 1.0 – notify MD, to NICUBS < 1.0 – notify MD, to NICU BS 1.0 – 2.0 – notify MD, feed if able BS 1.0 – 2.0 – notify MD, feed if able

and repeat 30-60 min post feedand repeat 30-60 min post feed BS 2.1 – 2.5 – feed and repeatBS 2.1 – 2.5 – feed and repeat BS >2.5 - no repeat, feed q3h BS >2.5 - no repeat, feed q3h

HyperbilirubinemiaHyperbilirubinemia

See infonetSee infonet CMNRP regional screening guideline CMNRP regional screening guideline

20122012 Hour specific bilirubin nomogram for Hour specific bilirubin nomogram for

bilirubin risk zone (Bhutani)bilirubin risk zone (Bhutani) Determine risk factorsDetermine risk factors Consider GA and follow algorithmConsider GA and follow algorithm Plot bili on guidelines for intensive Plot bili on guidelines for intensive

phototherapy curvephototherapy curve

Risk factorsRisk factors

Hemolysis – usu. IsoimmuneHemolysis – usu. Isoimmune Sibling with rxSibling with rx CephalhematomaCephalhematoma Poor feedingPoor feeding East asian or BlackEast asian or Black

Risk Factors - kernicterisRisk Factors - kernicteris

PrematurityPrematurity HemolysisHemolysis AsphyxiaAsphyxia LethargyLethargy SepsisSepsis Ongoing acidosisOngoing acidosis

Start high intensity – 3 lightsStart high intensity – 3 lights Repeat biliRepeat bili Low intensity (1/3) and repeatLow intensity (1/3) and repeat Outpatient biliOutpatient bili Community follow-upCommunity follow-up

CircumcisionCircumcision InfonetInfonet CPS Neonatal circumcision revisited 1996CPS Neonatal circumcision revisited 1996 ““circumcision of newborns should not be circumcision of newborns should not be

routinely performed”routinely performed” UTI decreased 10-12 foldUTI decreased 10-12 fold UTI incidence is 1-2 %UTI incidence is 1-2 % Risk of complication is 0.2-2%Risk of complication is 0.2-2% Reduced incidence of penile cancer and Reduced incidence of penile cancer and

HIV (<1 per 100,000)HIV (<1 per 100,000)

TechniqueTechnique

Prepuce fused to glans = physiologic Prepuce fused to glans = physiologic phimosisphimosis

50 % separated by 3 yrs, 95 % by 5 50 % separated by 3 yrs, 95 % by 5 yrsyrs

Inpatient vs. outpatient, costInpatient vs. outpatient, cost TimingTiming Analgesia: topical, po, dorsal penile Analgesia: topical, po, dorsal penile

nerve block or ring blocknerve block or ring block

Gomco vs. plastibell vs. mogenGomco vs. plastibell vs. mogen Complications – bleeding, infxn, Complications – bleeding, infxn,

cosmesis, urethral injury, meatal cosmesis, urethral injury, meatal stenosisstenosis

DischargeDischarge

Clinical pathwayClinical pathway No stool or void? No stool or void? Xs weight loss?Xs weight loss? Jaundice?Jaundice? Social concerns?Social concerns? Post-procedure bleedingPost-procedure bleeding

GBSGBS

Protocol for insufficient prophylaxis - Protocol for insufficient prophylaxis - infonetinfonet

CBC 4-8 hrs. PPCBC 4-8 hrs. PP WBC <5 or >30 x (10x9/L)?WBC <5 or >30 x (10x9/L)? Vitals q4h x 24 hrsVitals q4h x 24 hrs No early discharge, parental No early discharge, parental

counsellingcounselling

Subgaleal hemorrhageSubgaleal hemorrhage

Protocol – infonetProtocol – infonet Bleeding between scalp and periosteumBleeding between scalp and periosteum Higher than outlet, more than 3 pulls or Higher than outlet, more than 3 pulls or

pop off, other than OA, forceps and pop off, other than OA, forceps and vacuum, failed AVDvacuum, failed AVD

Min. 24 hrsMin. 24 hrs Measure HC (>0.5 cm) – within 60 mins, Measure HC (>0.5 cm) – within 60 mins,

q1H for 4 then q4h for 24q1H for 4 then q4h for 24

Physical examPhysical exam

VitalsVitals SkinSkin Head – fontanelles, caput, cephalhematomaHead – fontanelles, caput, cephalhematoma Eyes - strabismusEyes - strabismus Ears – branchial cleft cysts, tags or pitsEars – branchial cleft cysts, tags or pits NoseNose Mouth – teeth, Epstein’s pearls, lingual Mouth – teeth, Epstein’s pearls, lingual

frenulumfrenulum

Neck – thyroglossal duct cyst, Neck – thyroglossal duct cyst, torticollistorticollis

ClaviclesClavicles ChestChest NipplesNipples LungsLungs Heart – PDAHeart – PDA Abdomen – umbilical herniaAbdomen – umbilical hernia Umbilical cord – SUAUmbilical cord – SUA GroinGroin genitaliagenitalia

Trunk and spineTrunk and spine HipsHips Extremities – talipes equinovarusExtremities – talipes equinovarus NeuroNeuro

http://newborns.stanford.edu/http://newborns.stanford.edu/

FamilyFamily

RourkeRourke ScreeningScreening SupportSupport ParentingParenting Anticipatory guidance eg. Feeding, Anticipatory guidance eg. Feeding,

tummy time, vit D, intro of solids, tummy time, vit D, intro of solids, pets, safe sleep, car seats, SHSpets, safe sleep, car seats, SHS