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