To help general pediatricians navigate common newborn problems in the first few days of life. **The guidelines DO NOT indicate an exclusive course of treatment** .

1. WELL BABY NURSERY GUIDELINES 2021-2022
 Authors:
 Sitratullah O Maiyegun MD
 Rashmi Somu MD
 Maram Sati MD
 Benjamin Araya DO
 Well Baby Nursery Director: Carmen Prieto MD
 Program Director: Fatima Gutierrez MD
 Faculty:
Carmen Prieto MD Namrata Singh MD,
Maria Villanos MD, Sitratullah Maiyegun MD
Blanca Garcia MD, Cenan Antowan MD,
Jessy George MD,

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Table of Contents 2021-2022
CHAPTER TITLES PAGES
Goals & Disclaimer 3-5
Policy 6-7
Exclusion Criteria from Well Baby Nursery & High Risk Babies 8
Discharge 9-10
AMA (Against Medical Advice) 11
Social Service Consult 11
Transfers 12
Abnormal Heart Rate (Bradycardia / Tachycardia) 13
Abnormal Temperature (Hyperthermia / Hypothermia) 14
Anemia 15
Bilious Emesis 16
Blood Streaked Stools 17
Cardiac Murmur 18
Clavicle Fracture 19
Cleft Lip & Palate 20
Clubfoot (Talipes equinovarus) 21
Conjunctivitis 22
Craniotabes 23
Critical Congenital Heart Defect (CCHD) screening 24-27
Cryptorchidism 28
Delayed Passage of Meconium 29
Delayed Passage of Urine 30
Developmental Dysplasia of the Hip (DDH) 31
Diarrhea 32
Dimple (Sacral) 33
Disorders of Sex Development (DSD) 34
Down Syndrome 35
Ear Abnormality 36
Emesis 37
Esophageal atresia with tracheoesophageal fistula 38
Extracranial injury & Large Fontanel 39-40
Gestational Age and Size for Gestational Age 41
Hydrocele 42
Hydronephrosis / Fetal Pyelectasis 43-44
Hypoglycemia 45-48
Hypospadia 49
Infant of Diabetic Mother (IDM) 50

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Table of Contents 2021-2022
Infant of Substance Abusing Mother 51
Jaundice (Unconjugated hyperbilirubinemia) 52-53
Jaundice (Conjugated hyperbilirubinemia ) 54
Jitteriness and Abnormal Movements 55
Magnesium given to Mother 56
Maternal Infection (COVID-19) 57-59
Maternal Infection (GBS+ with ROM < 18 hrs) 60-62
Maternal Infection (Gonorrhea / Chlamydia) 63
Maternal Infection (Hepatitis B/ C) 64
Maternal Infection (HIV) 65
Maternal Infection (HSV) 66-67
Maternal Infection (Syphilis) 68-70
Maternal SLE 71
Maternal HELLP Syndrome 71
Micro / Macrocephaly 72
Nasolacrimal duct obstruction/ Dacrostenosis 73
Peripheral Nerve Injuries 74
Plexus injury-Brachial 75
Petechiae 76
Polycythemia 77
Polydactyly 78
Prolonged Rupture of Membrane (PROM) 79
Refusal of Vaccine, treatment, or Newborn screen 80
Stuffy Nose 81
Tachypnea / Respiratory Distress 82
Teeth and Tongue 83
Thrombocytopenia 84
Tone 85
Two Vessel Cord (Single Umbilical Artery) 86
Appendix – Neonatal Pictures – 87
References 100

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Goals
1. Evaluate newborns with history, physical exam, and routine screening procedures
including measurement of head circumference and provide appropriate counseling.
2. Manage and provide appropriate counseling for breast and formula feeding in
newborns.
3. Evaluate, recognize, and manage common conditions, such as jaundice and
hypoglycemia, in the normal newborn.
4. Provide anticipatory guidance at nursery discharge that relates to normal infant behavior such
as crying, sleep, and wakefulness, and how to deal with common problems (hiccups, sneezes,
vaginal bleeding, breast masses/discharge, care of the umbilical cord, care of the penis), family
adjustment and any red flags.
5. The senior resident is expected to know the active issues for all patients, and the overview of
admissions and discharges, as they would on any other service.
6. All “pre-rounding” (i.e., review of delivery records, overnight vital signs, growth parameters,
labs, imaging, consultant and nursing reports, etc.) should be done before faculty rounding.
7. Arrange rounding time with the faculty scheduled for mother baby unit.
8. The attending on call for MB is available to residents as backup for any questions or concerns.
9. Be familiar with assessment tools and tests used by obstetricians to assess normal pregnancies
and fetal well-being prior to and during delivery.
10. Recognize and develop a strategy to evaluate, manage and/or refer newborns in common
clinical situations after birth (ex: hypoglycemia, poor feeding, delayed voiding or stooling, etc.).
11. Become familiar with the protocol for prevention of mother-to-infant transmission of HIV
infection.
12. Recognize and manage newborns at risk for bacterial sepsis by history, physical exam, and
laboratory studies.
13. Demonstrate interpretation of transcutaneous bilirubin monitoring. Obtain laboratory tests
judiciously and interpret them accurately for management of the jaundiced infant. Describe
indications for phototherapy.

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Resident Rotating in Well Baby: Regular work hours
Monday, Tuesday, Thursday and Friday - 7 am - 5 pm
Residents are responsible for admission orders and H&P for all babies born before 4pm and all
babies that arrive in the Well Baby unit before 5pm.
Wednesday - 7 am- 530 pm
Residents are responsible for admission orders and H&P for all babies born before 12 pm and
for all babies arriving to the WB unit before 1 pm. After didactics they are expected to return to
WB - receive check out from the WB nurses and attending and then check out to the NICU team
(30 minutes extra time given on Wednesdays is for this purpose)
Saturday and Sunday - 7 am to 1 pm
Residents are responsible for admission orders and H&P for all babies born before 12 pm and
for all babies arriving to the WB unit before 1 pm.
Well baby regular rotators will alternate working Saturdays and Sundays.
To all residents covering Well Baby Nursery
 For Saturday and Sunday, residents in NICU (intern with supervision of the senior) are
responsible for admission, orders and H&P for all babies between the hours of 1200-
1700.
 For babies born after 1700 on Saturday and Sunday the NICU team will be responsible
for starting Physician Power Plan and specific orders for babies.
 The H&P, assessment, and Ballards will be for the next day WB team to complete.
 Residents working in WB on the weekends will do the evaluations and Ballards for all
admissions that occurred from the previous day (after 1600 on Friday or after 1700 on
Saturday and Sunday).
 For known discharges, residents in WB are to have the depart and discharge summaries
completed prior to sign-out to the NICU team, so that the NICU residents only need to
update the dc summary in case there is something pending for discharge as well as to
put in dc order.

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 AMA babies must have an AMA note and a discharge summary on the chart. You can do
the discharge summary and have the AMA note stated at the end of the dc summary that
way you only do one note.
 For babies that are being discharged, a progress note for the day of discharge will
also need to be done. Now, this does not have to be a full progress note. It can be a
short note, for example: Overnight baby has been doing well, has been breastfeeding
exclusively, has had 5% weight loss since birth, voiding and stooling well, last J-meter 5
at 28 hours of life. CCHD Passed. Pending NB screening and ALGO to be
discharged. Baby will follow up at TT. Please see DC summary.
 Please ensure a thorough and complete sign out is done, both when transferring the
care of the patients to NICU in the afternoon/evening and back to WB in the morning.
Important reminders
Sick babies’ calls from the mother-baby unit should be addressed by the NICU
senior/intern on-call.
The Pediatrician on-call should be informed of any concerns in the babies (as per
Neonatologists’ request)
Please document brief event and/or transfers notes for all babies who required any
intervention.
Disclaimer
1. The guidelines DO NOT indicate an exclusive course of treatment or serve as a
standard of medical care.
2. Appropriate management can be modified according to individual circumstances.
3. Please apply evidence-based medicine as appropriate.
4. If you notice any errors or change in guidelines, please talk to authors to keep book
up to date.

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Policy
*For more information, refer to each chapter.
General
 Wash hands before and after examining any infant.
 All babies must be examined within 24 hours of birth.
 All admission orders (entered by nurses) must be signed.
 Admission and discharge diagnoses to be documented in problem lists.
 Maternal prenatal lab results (HIV, RPR, Rubella, HBsAg, GBS status, COVID-19,and
blood type) and infant’s blood type must be updated within 12 hours of delivery.
 Update maternal and infant’s labs, including last J-meter, prior to discharge
 Any abnormal results reported to the intern must be reported to the senior and/or
faculty.
 Nursing procedures and further assessment will be done while the baby is with the
mother.
Admission
 All babies, including asymptomatic babies born to diabetic mother or mother on
magnesium, will be placed skin-to-skin with mother for breastfeeding for as long as they
are stable.
 Babies will be transferred to room with mother from L&D.
 Symptomatic babies will go to the nursery for further assessment. Remember to do a
transfer order from the mother’s room to the nursery.
 Babies will be placed under radiant warmer in the nursery until stable for transfer to
mother’s room.
Treatment, Labs, and Screening
 Eye prophylaxis with 0.5% erythromycin ophthalmic ointment, Vitamin K 1mg IM X1,
Hepatitis B vaccine x 1(after consent) will be given.
 According to 2017 AAP guidelines, newborns with mothers with sero-negative Hep
B should receive vaccine within 24 hous of life, newborns with mothers with sero-
positive Hep B should receive Hep B vaccine and immunoglobulin within 12 hours of
life, infants of mothers with unknown serology should receive vaccine within 12
hours of life
 Cord blood studies if mother is O+ or Rh (-).
 Newborn hearing screen before discharge
If failed ALGO twiceTo return to Well Baby Nursery for a Repeat X1 and if failed then
Refer for BAER (Neurology)

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 Newborn screen at 24 – 48 hrs of life
 J-meter reading upon admission and q shift until discharge.
 Critical CHD Screening after 24 hours of age
 Peripheral hematocrit in high-risk babies.
Breastfeeding and Supplementation
 Breastfeed as soon as possible. If not possible, medically indicated, or if mother chooses
supplementation with formula, formula feeds need to be ordered by the resident (Baby-
friendly policy).
 Breastfed and formula fed infants should be supplemented with 400 IU/day of vitamin
D beginning in the first few days of life until the patient is weaned to at least 1 L/day
vitamin D–fortified formula (1 liter of regular infant formula contains 406 IU of
Vitamin D)
Glucose Series
 Perform on babies that are: LGA, SGA, IDM, PROM, BW < 2500g, BW > 3800g,
symptomatic (Jittery, jaundice, respiratory distress, poor feeding, etc)
Discharge (refer to discharge chapter for more information)
 Vaginal delivery and meets discharge criteria 24hr observation
 If risk factors are present, including C/S  48hr observation (Can be discharged home if
no risk factors and mom with C/S is discharged prior to 48hrsDiscuss with Faulty !) .
 If parents want to leave AMA (against medical advice), discuss with your attending.
Explain the risks and responsibility to the parents, obtain consent form, and write progress
note on blue sheet. CPS may need to be notified in critical situations (again, discuss with
attending first). For further information, refer to AMA chapter. (Page 9)
 Residents are to measure the head circumference themselves, prior to discharge.
TO BE WRITTEN IN CERNER PROGRESS NOTE
 Daily percentage of Weight loss (document this daily on the progress note)
 Daily J-Meters (document this at the time of discharge as well)
 Occipito-Frontal Circumference at discharge (taken BY THE RESIDENT on
discharge). To also recheck if OFC at anytime

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EXCLUSION Criteria from Well Baby Nursery
 Newborns delivered weighing 2250 grams or less.
 Gestational age < 35 wks by OB dating criteria and confirmed by Ballard.
 Newborns with anomalies requiring specialized care.
 Newborns requiring constant monitoring for abnormal cardiac or respiratory rate and
rhythms.
 Maternal chorioamnionitis diagnosed before or after admission to well baby nursery
 Initial rectal temp > 38.9 C (102 F)
 Newborns of mothers with documented history of prolonged rupture of membranes
(PROM) greater than 72 hours( with abnormal labs and symptomatic) .
 Newborns with persistent respiratory distress requiring oxygen therapy generally
greater than 40% FIO2, and/ or those newborns requiring oxygen greater than 1 liter
per minute via nasal cannula more than 4 hours or sooner if worsening.
 Newborn with suspected acute abdominal condition(s).
 Newborn requiring work up for sepsis, Triple I (intrauterine, inflammation, infection)
and subsequent antibiotic therapy.
 Newborns with glucose level less than 25mg/dL after feeding or glucose gel.
 Newborn requiring IV therapy.
 Newborn of mothers with documented history of drug dependent or usage.
 Newborn with 5-minute Apgar less than 5.
High Risk Babies
 Maternal history of diabetes
 Maternal Fever
 PROM >18hours (CDC, AAP), >16hours (UMC policy)
 <37wks
 Weight ≥3800 gms and ≤ 2500 gms
 LGA >90th percentile or SGA/IUGR < 10th percentile for weight
* Close monitoring required.
* Management will be explained further in detail in each chapter
Maternal Chorioamnionitis
At least 2 of the below + Maternal fever (Intrapartum temperature > 38 C, > 100.4 F):
- Maternal leukocytosis (> 15,000)
- Maternal (> 100 bpm) or Fetal (>160 bpm) tachycardia
- Uterine tenderness
- Foul odor amniotic fluid

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Discharge
General Rules
 If no risk factors + clinically well d/c after 24 hrs.
 If risk factors are present, clinically not well appearing, or required limited evaluation 
d/c after 48 hours.
 Discharges < 48 hours
 follow up within 1 to 2 days or 72 hours if earlier visit is not possible.
24 hr Discharge Criteria
History
 Adequate prenatal care≥ 4 visits
 Prenatal care in Mexico or MLL (Maternidad La Luz, a midwife) does NOT count.
 Maternal age > 17 years.
 No maternal drug use.
 Mother is not A1 or A2 diabetic.
 Mother is not GBS, Chlamydia, RPR, HIV, COVID-19 or HepB/C positive.
Delivery
 Vaginal delivery in the hospital.
 Rupture of Membranes < 18 hrs.
 No maternal fever (< 38 C, 101 F) or concern of maternal chorioamnionitis.
 Apgar score at 5 minutes was at least 7.
Examination
 Gestational age of at least 37 weeks on Ballard
 No findings that require further monitoring.
 Vital signs are in normal range and stable for the last 12 hours prior to discharge.
(Axillary temperature of 36.5°C - 37.4°C, RR<60, HR 100-160)
 No Jaundice in the first 24hrs.
 Normal voiding and stooling pattern.

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Labs
 Baby is not on 24-hour glucose series (LGA, SGA, IDM, PROM, or initial hypoglycemia) or
CBC/CRP at 24/48 hrs.
 Bilirubin in the normal range as per risks.
 Maternal RPR, HIV, HBsAG status known- must have these lab results no more than 12
hours after birth, if not available call OBGYN and request tests be done asap.
 If Rubella non-immune inform OB resident to make sure mother receives vaccination
prior to discharge
 No ABO setup and baby is Coombs negative
 ALGO hearing test (Otoacoustic emission) and CCHD done
Psychosocial
 No poor feeding and able to coordinate sucking, swallowing, and breathing while
feeding.
 At least 2 successful feedings without the help of nurses (lactation consult if needed).
 Good maternal-baby bonding, no maternal depression.
 No nursing concerns.
 Mother is able to provide cord, skin, and genital care for infant, recognizes signs of
illness andcommon infant problems, particularly jaundice, provides proper infant safety
(proper use of car-seat andsupine positioning for sleeping)

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AMA (Against Medical Advice)
 Discuss with your attending. Discuss with parent(s) regarding what observation and
treatment the infant needs.
 Explain to the parent(s) of the possible consequences for their infant leaving
(e.g sepsis, jaundice, hypoglycemia, respiratory distress, poor feeding, etc)
 Explain the need for F/U in 1 or 2 days and ER warnings
 Have parents sign consent form for AMA
 Use Cerner and update using a progress note and write AMA status by including
discussion with parents, the risks and F/U ASAP if warning signs present
 Choose on Cerner “Discharge Patient ( T;N, Against Medical Advice)
(Follow with your attendings’ preference. Some attendings will prefer not to put in
discharge order)
 Go to Depart and click on Patient Education, enter AMA in the search box and choose All
and use the template AMA instructions. Available in Spanish as well.
 Consult with the social worker (SW) if medical diagnosis or concerns may result in
immediate harm to the infant
 SW will assess and consult CPS (Child Protective Services) or Crisis Care (after
hours/weekends) as necessary. CPS has the authority under the Children and Community
Services Act 2004 to protect the welfare, care, and protection of children.
Remind parent(s) that their action is contrary to the welfare of their infant and that
Department for (CPS) will be notified.
 Child can be kept in the nursery if mother wants to go home.
Social Service Consult
 Teenage mothers <17 years
 Mothers without family or support system in place or other specified problems (i.e.
depression, lack of planning, bonding).
 Mothers with substance abuse (positive screen or previous hx).
 Mother with previous hx of post-partum depression.
 Discharge against medical advice, if needed.

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Transfers
1. If you think a baby needs to be transferred to IMCN or ICN, discuss with your attending.
2. If attending agrees with the transfer, give brief report to the NICU resident and NICU
attending, if not done yet.
3. Discontinue WB medical power plan and D/C from WB (UMC) to IMCN (EPCH) on Cerner.
(Be careful NOT to accidentally D/C mother from system!!)
4. Explain situation and obtain consent form for transfer (memorandum of transfer: MOT)
from the parent(s) (Risk: Falling from crib during transport, Benefit: Higher level of care).
5. Write transfer note in SOAP format as an addendum note on Cerner

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Abnormal Heart Rate
 Normal Resting HR in newborns ranges from 90 – 160/min HR may decrease to 70/min
during sleeping and increase to 190/min during movements or crying.
 Episodes < 15 seconds of sinus bradycardia (low as 60/min when asleep, as low as 80
while awake) or tachycardia is benign. Episodes lasting longer may require EKG.
Bradycardia
 Definition: HR persistently < 80-100/min (awake), <70-90/min (asleep) or > 2SD below
the mean for age.
 DDx: Sepsis, reflux, increased vagal tone (bowel movement, suctioning, placement of
NG/OG tube, yawning, rectal stimulation) medications, obstructive apnea, mechanical
airway obstruction, pneumothorax, IVH, temperature instability, acidosis, electrolyte
abnormality, endocrine abnormality and heart block.
Plan
 Physical exam: Check for signs of heart failure or sepsis (poor pulse / perfusion,
crackles, tachypnea, poor feeding, reflux, hepatosplenomegaly, hypothermia, irritability,
significant weight gain in the first few days of life, etc)
 Ionized Ca, Mg, and BMP. EKG and CXR (pneumothorax/heart shape/arrhythmia)
 Cardiology consult and order Echocardiogram after discussing with the attending
 Ask mother for hx of SLE (refer to “Maternal SLE,” page 69)
 Consider Head US, after discussing with the attending.
 If there is concerns of sepsis, consider transferring to IMCN / ICN.
Tachycardia
 Definition: HR persistently above 160-175/min or > 2SD above the mean for age
 DDx: Post-delivery, painful stimuli, medications, fever, sepsis, anemia, CHF,
metabolic disorders, and arrhythmias
Plan
 Monitor temperature for fever
 Maternal hx of thyroid disorder
 Birth Hx (forceps or vacuum) and Maternal medication prior to delivery
 EKG, CXR, CBC stat, and CBC and CRP (at 24 hrs of life)
 Inform attending for transfer to IMCN

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Abnormal Temperature
Hyperthermia
Definition: Rectal temp > 37.5 C (99.5 F)
Plan
 Unwrap baby & check rectal temperature q 30 mins
 If temp does not decrease in next 2 hrs  Inform attending for transfer to IMCN for
concern of sepsis.
 Review maternal hx (GBS status, PROM, fever, signs or symptoms of chorioamnionitis)
- If infant is at risk of infection
 CBC stat or CBC & CRP (if > 24 hrs of life)
 Have low threshold to transfer to IMCN
Hypothermia
Definition: Rectal temp < 36.5 C (97.7 F)
Plan
 Evaluate environmental conditions
(Cool room, exposed to room temperature with no clothes, etc)
 Check gestational age, weight, and feedings (Preterms are more prone to heat loss)
 Review maternal hx (GBS status, PROM, fever, signs or symptoms of chorioamnionitis)
 If there is concern of sepsis, consider transferring to IMCN immediately
 Place under radiant warmer & check rectal temperature q 30 mins
 If low temps persists > 2hrs under radiant warmer
 CBC stat or CBC & CRP (if > 24 hrs of life).
 If results are abnormal, transfer to IMCN
 If temperature drops 2 consecutive times
 CBC stat or CBC & CRP (if > 24 hrs of life).
 If results are abnormal, transfer to IMCN
 If temperature drops 3 consecutive times  Transfer to IMCN

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Anemia
Problem
 Initial HCT of < 40 % (spun Hct)
 Pale newborn
Plan
 Physical exam: Splenomegaly, tachypnea, tachycardia, shock, CHF, murmur,
Cephalohematoma, Subgaleal hemorrhage, bulging anterior fontanelle, hemangioma,
umbilical cord hematoma  if present, consult attending
 Check maternal hx for:
 Severe prenatal anemia. Perinatal blood loss, 3rd trimester bleeding.
 Maternal blood type & antibody screen.
 Abruptio placenta or placenta previa ± Drug abuse (Cocaine can induce abruption).
 FHx of erythrocytic defect, autoimmune hemolytic anemia.
 Check birth hx:
 Asphyxia & Apgar scores.
 C-section (3% incidence of anemia).
 Special circumstances (eg. Delayed umbilical cord clamping, twin, Umbilical cord avulsion).
Labs
 CBC & peripheral smear, Retic count, D-bil
 Cord blood, or Blood type & direct coombs
 Maternal Kleihauer Betke test (Request OB resident to order test)
 Repeat Hct in 12 – 24 hrs  If decreasing, notify attending
 Consider Head ± Abdominal US (liver, adrenal hemorrhage)
 Hand outpt lab form to mom to check Hct in 2 days. No need to prescribe iron.
 Follow-up as outpatient in 2-3 days.
Learning points
- Microcytic (MCV < 90): Fetomaternal transfusion, twin-twin hemorrhage, orα- thalassemia
- Normocytic: Acute hemorrhage, systemic disease, hypoplastic anemia
- Increased Retic: Blood loss, hemorrhage, or hemolytic anemia
- Blood smear: 1) Spherocyte: Hemolytic anemia or hereditary spherocytosis,
2) Elliptocyte: Hereditary elliptocytosis
3) Schistocyte: Consumption

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Bilious emesis
Problem
 Infant with light to dark green emesis.
 This can be a sign of intestinal obstruction distal to the ampulla of Vater, which is a surgical
emergency (not all cases of bilious emesis are caused by intestinal obstruction).
 However, bilious emesis = intestinal obstruction until proven otherwise!
DDx
Duodenal atresia, malrotation, volvulus, meconium ileus, necrotizing enterocolitis,
jejunoileal atresia, Hirschsprung disease, idiopathic, electrolyte abnormality (hypokalemia,
hypermagnesemia), hypothyroidism, and sepsis.
Plan
 Make infant NPO.
 Perform a physical exam, check vitals, and Order KUB STAT.
 While waiting for KUB results, check maternal hx for risk of infant sepsis, hypothyroidism,
and administration of magnesium sulfate.
 Low threshold to transfer infant to IMCN
 Call NICU senior / attending to discuss further management (i.e.: sepsis rule-out,
involvement of Pediatric Surgery and radiologist on call)
For more information search for the Emesis guidelines on Scientific American Surgery (2017)

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Blood Streaked Stool
 Problem: Blood streaked diaper with normal stool
 Plan: Check for symptoms such as poor feeding, vomiting, fever; if mother is bleeding from
nipples; Maternal Meds#1; and the following;
Small laceration/fissure or area of irritation in anal area
 If no fissure is present ....
 Stool for occult blood, culture, WBC, rotavirus, and reducing substance.
 CBC with diff: look for inflammatory response, thrombocytopenia, anemia.
 BMP: Elevated BUN may indicate upper GI bleeding.
 Apt test#2 (Please call the lab ) to assess if the origin is from swallowing maternal blood.
 If maternal blood – f/u.
 If fetal blood – Discuss with attending.
 Make sure Vitamin K IM has been given.
Abdominal distention (May be sign of NEC)
 Stat KUB
 Stat CBC & CRP
 Discuss with attending
Learning points
#1 Maternal medication such as anticoagulants, anticonvulsants, and Thiazide can cross the
placenta and cause coagulopathy in the infant.
#2 Apt test: Obtained blood will be placed in alkali to see if any change in color occurs.
(Fetal hemoglobin resists degeneration from alkali more than adult hemoglobin does)
 If the blood in stool is from swallowing maternal blood, the blood will degenerate into a brown
color whereas if the blood is the infant’s blood, it will remain pink)

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Cardiac Murmur
Perform CCHD screening for all patients and follow the CCHD guideline.
(refer to “CCHD screening,” page 24-27)
 Grade 1-2 murmur on day 1 with no significant problems  re-examine @ 2nd day of life
 Grade 1-2 murmur on 1st day of life with symptoms ± positive CCHD screening
 Discuss with faculty for possible transfer to IMCN/ICN
 Grade 3-4 on day 1 or significant murmur found on 2nd day of life
 Full cardiac exam, look for hepatosplenomegaly and poor feeding, 4 limb BP’s, CXR,
Pulse ox - spot / continuous as appropriate, Echocardiogram, EKG as needed
 Cyanosis or severe respiratory distress ± positive CCHD screening  transfer to IMCN
 All diastolic murmurs are pathologic  obtain an ECHO
 Ask about family Hx of congenital cardiac disorders and add into patient’s H&P

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Clavicle Fracture
Problems:
◦ Shoulder dystocia @ birth
◦ Tenderness / swelling over clavicle
◦ Crepitus over clavicle
◦ Decreased movement of arm
DDx: Partial dislocation of the elbow, Erb palsy, Klumpke palsy, fractured humerus
Plan: X-rays of the clavicles, reassure mother, and inform about subsequent callus formation
Orthopedic referral as out-patient, if severe (Discuss with attending)
Learning points
 Babies may be asymptomatic.
 May have associated nerve injury (refer to “peripheral nerve injuries,” page 56)
 Generally, there is no treatment other than lifting the child gently to prevent discomfort.
The arm on the affected side may be immobilized by pinning the sleeve to the clothes.
 Full recovery usually occurs without treatment
Sleeve pinned for immobilization

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Cleft Lip & Palate
 Problem
◦ Abnormal buccal cavity
◦ Maybe unilateral, bilateral, or midline
◦ Maybe mild, severe, or partial
◦ Maybe submucosal with bifid uvula
 Plan
◦ All Cleft Palate patients must have OMFS evaluation and consultation.
◦ If feeding difficulties or multiple congenital anomalies, admit to IMCN
◦ Obtain family hx, prenatal hx (meds)
◦ If midline  head U/S to r/o holoprosencephaly
◦ Assess feeding
 Special nipple - Haberman nipple or Pigeon Nipple
 No bottle propping
 Feed in upright position
 Occupation therapy (OT) consult/ Social service as needed
 Genetics consult as outpatient if indicated
Learning points
 May be part of a syndrome but more commonly a solitary nonsyndromic defect.
 Conductive hearing loss may result due to eustachian tube dysfunction.
 Midline cleft with midline hypoplasia may be associated with brain anomalies.

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Clubfoot (Talipes equinovarus)
 There is a genetic predisposition. Intrauterine positioning may contribute.
 Problem
◦ Forefoot in fixed adduction
◦ Calcaneal tendon is shortened
◦ Foot is inverted with plantar flexion
◦ Classified into two groups: fixed or flexible (positional)
◦ If it is fixed, will be unable to passively correct it to the anatomical position.
 Plan
If fixed:
◦ Check hips
◦ Ortho consult as in-patient (X-ray, stretching, and serial casting)
◦ Discuss with mother
If flexible (positional): Reassurance and passive stretching by mother q prn
If other orthopedic abnormalities are present:
 Discuss with attending for Ortho consult

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Conjunctivitis
Problem: Newborn with eye discharge; Can be unilateral or bilateral;
Possible periorbital edema; Eyelids may be erythematous or appear glued shut.
Plan
◦ Check Maternal hx of GC, Chlamydia, Herpes, and delivery hx.
(Maternal vaginal discharge, PROM)
◦ Evaluate timing of onset, amount, color, consistency, and tendency to return.
◦ Gram stain and culture  If positive for bacteria or PMN’s, discuss with attending
◦ Cleanse eyes with sterile water.
Learning points
- Eye prophylaxis with 0.5% erythromycin ophthalmic ointment: should be applied to the
infant’s conjunctival sac w/in 1 hour after birth.
 Effective for prevention of gonococcal ophthalmia
 NOT effective in preventing Chlamydial conjunctivitis or extraocular infection.
- Chemical conjunctivitis:
 Develops within hours after birth & resolves in 36-48 hours.
 Gram stain negative but PMN’s are present.
- GC conjunctivitis:
 Presents usually 1-4 days after birth but can present within a few hours after birth.
 Signs: Lid edema, copious purulent exudate, chemosis, clouding of the cornea
 Gram stain  PMN’s & intracellular Gram negative diplococci
 Tx: Transfer to IMCN for Ceftriaxone/Cefotaxime, and sepsis workup for disseminated
infection (sepsis, arthritis, meningitis)
 Reportable to Department of Health within 72hours
 Eye irrigations with saline immediately and frequently until the eye discharge resolves.
 Topical antimicrobial treatment alone is inadequate and is unnecessary when
recommended systemic antimicrobial treatment is given
- Chlamydia conjunctivitis:
 Presents 5-14 days after birth
 Purulent discharge, eyelid edema & conjunctival inflammation
 Scrape conjunctiva for Chlamydia swab: Infectious disease consult
 Reportable to Department of Health within 72hours
 Oral azithromycin (20mg/kg/day) for 3 days or erythromycin base or ethylsuccinate for 14
days
 If unstable or respiratory distress IV erythromycin after evaluation for sepsis in IMCN
 Infantile hypertrophic pyloric stenosis (IHPS) in < 6weeks (erythromycin)
 If mother is Chlamydia positive &
 Baby is asymptomatic  no treatment FU in out-pt for signs of infection
 Prompt treatment of mother and her sexual partner(s)

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Craniotabes
Problem
◦ Infant with soft or ping-pong skull.
◦ Usually over parietooccipital region & along suture lines.
◦ Can be detected by applying pressure to the cranial bones.
Causes:
Hydrocephalus, Osteogenesis Imperfecta (OI), syphilis, thalassemia, rickets, hypophosphatasia,
hypervitaminosis A, normal variation (sagittal suture craniotabes in preemies)
Plan
◦ Perform full physical exam. If there are no signs of generalized osteomalacia or other
skeletal deformities, and no risk factors, most likely it is benign.*1
◦ No tests or treatment is required in normal infants*2
◦ Check Maternal Hx for Syphilis, Rickets, family Hx (Rickets, OI, Thalassemia, etc)
 Check maternal RPR, if positive follow syphilis protocol.
 If other risk factors exist, discuss with attending.
◦ Head US & skull X-rays, if needed (rare)
◦ Reassure parents. Prognosis is mostly excellent and there is no need for special handling
or precautions for the soft skull.*1
Learning points
・Most of the Craniotabes are a normal finding in babies, may be found in up to 30% of normal
babies, especially adjacent to the suture lines, and generally resolves within months.*1, 3
・More common in first-born baby.
・Theory: When the fetus is in the vertex position for an unusual long time, it diminishes the
mineralization within the compressed region, mostly the parietoocipital bone.*1
*1 Vertex Craniotabes, Smith's Recognizable Patterns of Human Deformation 4th edition,
Chapter 36
*2 U.S. National Library of Medicine and National Institute of Health
*3 Rickets and Hypervitaminosis D, Nelson’s Textbook of Pediatrics 20th edition, Chapter 51

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Critical Congenital Heart Defect (CCHD) Screening
Primary targets Secondary targets
Truncus arteriosus Coarctation of the aorta
Transposition of the Great Arteries Interrupted aortic arch
Tricuspid Atresia DORV
Tetralogy of Fallot Ebstein anomaly
Total Anomalous Pulmonary Venous
Return
Single Ventricle
Pulmonary Atresia
Hypoplastic Left Heart Syndrome
 Early detection of CCHD can decrease morbidity and improve outcomes.
 10-25 % of positive screening have CCHD*4, 5.
 Screening Algorithm is shown on the next page.
 Management (for positive screening)
 Thorough Clinical Assessment, and Infectious or Pulmonary pathology should be
excluded by CBC, CRP, CXR as appropriate & Inform faculty as soon as possible.
 Complete Echocardiogram must be requested and Cardiology referral as indicated

26. .
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Revised algorithm AAP 2020 for CCHD screening with pulse oximetry. RH, right hand4

28. .
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The new CCHD algorithm has 2 key differences:4
(1) requiring 95% or greater in both the right hand and foot to be considered passing and
(2) having only 1 retest instead of 2.
These changes are expected to simplify the algorithm interpretation and screening process, and
they may increase the overall sensitivity of POS. However, these changes may also slightly
increase the false-positive rate.
Any infant who would have failed the initial algorithm will also fail with these changes, and a few
additional children may also fail.
Some of these additional failed test results may represent a true-positive result with CCHD, and
others may be false-positive results.
*4: Martin GR, Ewer AK, Gaviglio A, et al. Updated Strategies for Pulse Oximetry Screening for
Critical Congenital Heart Disease. Pediatrics. 2020;146(1):e20191650
*5:Results From the New Jersey Statewide Critical Congenital Heart Defects Screening Program.
Pediatrics Aug 2013;132; Issue 2
"As such, the algorithm used for CCHD screening in any particular birthing location is state
dependent”
Before implementing changes, clinicians should consult relevant state regulations

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Cryptorchidism
Problem:
 Empty scrotum or hemiscrotum. Failure of the testicle/testes to descend into the scrotum.
Plan:
 Unilateral: No intervention  Refer to Urology as out-patient
 Bilateral with no palpable testes in canal: Abdominal US (testes, ovaries, adrenals)
 If U/S shows abdominal testes, refer to Urology as out-patient
 If no testes on US, refer to DSD (disorders of sex development) chapter.
 Bilateral with palpable testes in inguinal canal
 No intervention *7. Refer to Urology as out-patient.
 If there are associated genital findings, refer to DSD chapter.
Learning points
・Occurs in about 1-4 % of term and 1-45% of preterm male babies. *8, 9
・Majority are isolated and non-syndromic.*9
・Testicular descent is regulated by Leydig cell hormones and Androgen.
・50 to 87% descend spontaneously by 3 months of age and majority by 6 months of age.*3, 9
・Treatment: Usually delayed until 6 months of age. If there is failure of testicular descent,
Orchiopexy( is performed by 12 months of age to maximize fertility)
・Increased risk of Testicular cancer (Seminoma is most common) and torsion of the
undescended testis.
・It is controversial if Orchiopexy reduces the risk of malignancy.*3
*3 Disorders and Anomalies of the Scrotal Contents, Nelson’s Textbook of Pediatrics, Chapter
545
*7 Choosing Wisely: American Urological Association
*8 Urologic Disorders, Atlas of Pediatric Physical Diagnosis, Chapter 14
*9 Etiology, Diagnosis, and Management of the Undescended Testis, Campbell-Walsh Urology
Chapter 148

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Delayed Passage of Meconium
Problem: No meconium passage in the 1st 48 hrs of life.
(99% of term and 76% of preterm pass stool in the 1st 24hrs*10)
DDx: Hypothyroidism (most common), sepsis, imperforate anus and other anorectal
malformation, intestinal obstruction, Hirschsprung disease, malrotation, meconium plug/ileus,
cystic fibrosis, duodenal atresia, small left colon syndrome (due to IDM), maternal / neonatal
medication such as magnesium sulfate or opiates, electrolyte abnormalities
Plans:
 Do not discharge until passage of stool is documented.
 Physical exam:
 Document patency and location of the anus (use rectal thermometer or feeding tube)
 Abdominal exam (distension, rigidity, bowel sounds, mass)
 Other anomalies such as in VACTERL association or Down syndrome
 Review medications in mother and infant: MgSO4, Opiates, Heroin, Narcotics
 If there is maternal hx of drug use
 Urine and meconium toxin screen in baby
(Refer to “Infant of substance abusing mother,” page 43)
 Serum Mg level if mother received MgSO4
 Review maternal hx (DM, Chorioamnionitis, PROM, Thyroid disease, etc)
 If set up for sepsis  CBC stat or CBC& CRP (>24 hrs of life)
 BMP if there is concern for electrolyte abnormality
 KUB stat
 FT4 and TSH  If abnormal, consult ENDO
If all labs are normal and no meconium passage > 48 hrs
 Consider barium enema and consult surgery for rectal biopsy (for Hirschsprung disease)
- Discuss the use of Glycerin suppository with attending. Do NOT use enemas, mineral oil, or
stimulant laxatives at bedside.
*10 No stool in 48 hours, Neonatalogy 7th edition, Chapter 67

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Delayed Passage of Urine
Problem: No urine passage in the 1st 24hrs of life.
DDx: Undocumented void in the delivery room, dehydration, renal failure, sepsis, CHF,
nephrotoxic medications (Indomethacin, aminoglycosides, ACE inhibitor, etc), congenital
renal anomalies, urinary tract obstruction (posterior urethral valve in boys), etc.
Plan:
 No discharge until the passage of urine is documented
 Review prenatal hx for Oligohydramnios (renal anomalies) and prenatal U/S
(Hydronephrosis, ARPKD, abdominal mass, etc)
 Check blood pressure  If abnormal, transfer to IMCN
 Physical exam: Check hydration status, palpable bladder (indicates urine in the bladder),
or abdominal masses, edema (CHF), number of umbilical vessels, hypospadia and other
genitourinary abnormalities, Potter facies (low set ears, wide separate eyes, etc)
 Try Credé maneuver (compress the bladder to stimulate voiding)
 Make sure there is adequate intake and consult lactation if necessary.
Supplement with formula if needed.
 Place a cotton ball between the labia or a urine bag to check urine.
 Consider bladder scan to check if there is urine in the bladder.
 Consider bladder catheterization after discussing with attending.
 Discuss with attending and consider nBMP and US of the bladder and kidneys after
procedures above showed no urination.
If baby continues to have no urine output after intervention
Discuss with attending for transfer to IMCN for further workup
Learning points
- 100% of normal & healthy neonates pass urine in the 1st 24 hrs of life.

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Developmental Dysplasia of the Hip (DDH)
 Problem:
 Abnormality of shape of coxo-femoral joint, usually shallow acetabulum
 Prone to dislocation/subluxation
 Female > Male, Unilateral > Bilateral
 Idiopathic (may be related to abnormal intrauterine position) > Teratogenic
 Early diagnosis enables better outcome
 Risk factors: Family history, Breech presentation, female, incorrect swaddling
 Physical findings:
◦ Positive Barlow or Ortolani sign (Hip Click / Clunk) or Allis sign
◦ Asymmetric thigh/gluteal creases or leg lengths (will not be apparent if bilateral DDH)
 Plan:
(Hip clicks without the sensation of instability is clinically insignificant)
◦ If “click” is present, re-examine at discharge
 If “click” is still present at discharge, f/u with PCP and re-exam in 2 weeks (AAP)
◦ If “click” is present & positive strong family history  Ortho consult as outpatient
◦ If “clunk” present at any time Ortho consult
 Risk factor with abnormal click/clunk  Ortho consult prior to discharge
 Breech with stable hips  Consider US hip at 4-6 weeks of age and/or radiographic
imaging at 4-6 months (AAP)
 Repeat hip examination at every well-child-check to ensure hip stability until a normal
gait is established
Learning points (AAP recommendations)
 X-ray is useful by 4 – 6 months of age when ossification of the femoral head occurs.
 Acetabular dysplasia is best found by a radiographic examination at 6 months of age or older.
 US screening of all breech newborns will not eliminate the possibility of later acetabular
dysplasia.
 Video for Barlow and Ortolani is available at http://www.aap.org/sections/ortho
 Selective US is recommended after 3 - 4 weeks of age for suspicious DDH when physical exam
is positive or to detect clinically silent DDH in the high-risk infant from 6 weeks - 4 to 6
months of age

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Diarrhea
Problem: > 2 abnormal stools (watery and foul smelling with blood or mucous) in 8 hr period.
Plan
 Examine baby, review vitals, and check stool
 If stool is very watery  send stool for electrolytes
 nBMP
 Suspect chloride diarrhea if the mother had polyhydramnios
 Suspect withdrawal if mother has hx of drug abuse.
 Urine and Meconium toxin screen, when suspicious or when mother is toxin screen (+)
 Send stool for reducing substances, leucocytes, RBC & culture, rotavirus
 If reducing substance (+)  switch to lactose free formula
 Discuss normal variations in stooling patterns with mother:
Breast fed stools: frequent, without form, may be mucous like; affected by maternal diet (fruit,
laxatives, medications).
If baby looks sick, has abnormal vitals, or abdominal distention
 KUB stat, CBC, (CRP if > 24hrs of life), BMP
 Inform attending

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Dimple (Sacral)
Simple or low risk:
 Position: Within the gluteal fold or coccygeal position
 Single dimple
 < 5 mm diameter
 Distance < 2.5 cm from anus
 Base of dimple is visible
 Dimple is oriented straight down (i.e. caudal) not cephalically (i.e. toward the head)
 No other dermal abnormalities or masses
(eg. Hemangioma, tuft of hair, hypo/hyperpigmentation, and skin tags)
 Normal neurological examination
Plan:
 If difficult to clearly distinguish all variations  consider US spine
 Midline / vertebra appearance of significant tuft of hair, hemangioma, skin tag,
hypo/hyperpigmentation, or nevus  US spine
Learning Points
 Sacral dimple is present in 3-8% of newborns and the possibility of occult spinal
dysraphism (OSD) is more likely if the dimple is above the gluteal cleft (truly sacral in
location) because they are more likely to be contiguous with the dura.
 If the lesion is within the gluteal fold: less likely to be contiguous with the dura and are
much more likely to be a normal variant.

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Disorders of Sex Development (DSD)
Problem: Any deviation from completely normal external male or female genitalia.
(Do not include prominent labia minora in a preterm).
 Clitoral enlargement (> 1.0 cm)
 Labioscrotal fusion of any degree
 Hypospadias with unilateral or bilateral cryptorchidism.
 Micropenis (stretched length < 2.0 cm or 2SD below mean length)*11
 Bilateral cryptorchidism with other anomalies
Plan
 Congratulate parents first. No gender assignment. Refer the infant as “Your baby”. Explain
that this is an immaturity of sex development and reassure that in most cases the gender
will be determined after tests by ENDO.
 Peds ENDO consult STAT !!!
 Ask for FHx of:
1) Early neonatal death (CAH with adrenal crisis)
2) CAH (autosomal recessive)
3) Syndromes
4) Female relatives with amenorrhea and infertility
 As soon as possible after birth 
 US abdomen (uterus, testes, adrenals)
 Labs (follow ENDO’s recommendations): Electrolytes nBMP (Na, K, Glu), Karyotype, LH,
FSH, 17-OH progesterone, Testostorone, dihydrotestostrone, Anti-Mullerian hormone,
Androstendione

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Down Syndrome
 Problem: Infant with features of Down syndrome
◦ Talk to the family (mom)
◦ No D/C prior to 48 hrs of age
◦ Evaluate feeding / vomiting (poor feeders, r/o duodenal atresia)
◦ Glucose series (hypoglycemia)
◦ CBC with diff (polycythemia, leukemoid reaction or leukemia)
◦ Ensure good follow-up
 Plan
◦ Review maternal and family history
◦ Karyotype (with informed consent)
◦ Echocardiogram prior to discharge
◦ Cardiac consult as needed
◦ Genetics consult as out-patient

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Ear Abnormality
Problems:
◦ Grossly abnormal ears
◦ Significant low set and posteriorly rotated ears
◦ Incomplete auricle
◦ No visible ear (anotia)
◦ Multiple significant ear tags (pre-auricular tags)
◦ Do Not include simple pre-auricular sinus/pit with a blind end as an ear abnormality
Plan
◦ Check for family history of similar defects
◦ Hearing test “ALGO (Otoacoustic emission), if failed, refer for BAER test
◦ Complete a Referral form for Audiology/Neurology as well as nurses to complete ECI
referral
◦ Renal US to r/o abnormalities after discussing with faculty
◦ Look for other dysmorphic features and associations, such as CHARGE syndrome
Charge Syndrome
 C: Coloboma
 H: Congenital heart Defects
 A: Choanal atresia
 R: Retardation of growth and development/ CNS
 G: Genitourinary anomalies
 E: Ear and/or auditory anomalies

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Emesis
Problem
Projectile or forceful vomiting with >2 feedings
*Spit-ups are effortless regurgitation, separate from vomiting.
“Gaggy babies”
DDx
Sepsis, Down syndrome, delayed passage of meconium (refer to relevant chapter), upper GI
anomaly (Tracheoesophageal fistula, annular pancreas, abdominal mass, etc), increased
intracranial pressure.
Plan
 Confirm it is emesis rather than spit ups from gastro-esophageal reflux.
 Observe feeding technique
 Confirm passage of meconium
 Physical exam: Abdominal distension and tenderness, palpable mass, dysmorphic features
(Down Syndrome), anorectal abnormalities, features of VACTERL association, CNS exam,
lethargy or bulging fontanelle.
 If there is set-up for sepsis  CBC stat, or CBC & CRP (if >24hrs of life)
 KUB stat (NEC, pneumoperitoneum, double bubble, etc )
 Inform faculty
 Transfer to IMCN as necessary.
Bilious emesis is a surgical emergency. (Please refer to “bilious emesis” chapter)

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Esophageal atresia with tracheoesophageal fistula
Problem
 Newborn with copious oral secretions and episodes of coughing, choking, and cyanosis
 Hx of pregnancy complicated by polyhydramnios may be present.
Plans: Place an orogastric tube and obtain a chest radiograph
May be an association with VACTERL:
 V: Vertebral or Ventriculoseptal defects
 A: Anal atresia
 C: Cardiac anomalies
 T/E: Tracheoesophageal fistula/ esophageal atresia
 R: Radial dysplasia / Renal anomaly
 L: Limb anomalies
Pediatric secrets 6th edition, Esophageal disorder*12

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Extracranial injury & Large Fontanel
Management (Cephalohematoma and Subgaleal hematoma)
・Obtain delivery history: SVD, forceps and vacuum (Increases risk of birth trauma).
・J-meter q 12hrs. If concerned about blood loss, obtain Hct and Retic.
 If there is signs of shock  transfer to IMCN
Large Fontanel
Problem
 Large anterior fontanel (>5 x 5 cm) with/without large posterior fontanel (> 2 cm)
 Open metopic suture. Open coronal suture.
Plan
 Check Head circumference yourself; neurologic exam
 Discuss with attending for Free T4 & TSH( hypothyroidism) and Head US
Cephalohematoma
・Reassure parents.
・ If baby had a difficult delivery and has a
depressed skull with neurologic abnormality or
depressed consciousness, perform:
 AP & Lat skull X-Rays or CT head
(Discuss with attending) & CBC, PT/PTT
 If Hct dropped rapidly  inform attending 
US head or CT head to r/o ICH/IVH
Subgaleal hematoma
・CBC, PT/PTT
・Close observation
・Serial examination for signs of shock
& measurement of head circumference
・If the patient has severe symptoms
 transfer to IMCN

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Caput Succedaneum
Left: Unilateral Cephalohematoma. Right: Bilateral Cephalohematoma

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Gestational Age and Size for Gestational Age
Gestational Age
・Preterm: ≤ 36 6/7 weeks
・Early term: 37 0/7 weeks – 38 6/7 weeks
・Full term: 39 0/7 weeks – 40 6/7 weeks
・Late term: 41 0/7 weeks – 41 6/7 weeks
・Post-term: ≥ 42 0/7 weeks
Large for Gestational Age (LGA)
Definition: Birthweight > 2 SD or > 90th percentile of the mean weight for gestational age.
Problem: Risk of birth trauma (extracranial injuries, peripheral nerve injuries, and clavicular
fractures), polycythemia, and hypoglycemia.
DDx: Constitutional, congenital heart defect, hydrops fetalis, IDM, and syndromes such as
Beckwith-Wiedemann syndrome and Sotos syndrome.
Plan
 Check maternal hx and prenatal hx
 Labs: Hct , Glucose series
 Physical exam for birth injuries
Small for Gestational Age (SGA)
Definition: Birthweight < 2 SD or < 10th percentile of the mean weight for gestational age
DDx: Constitutional, maternal factor (Chronic disease; HTN, pre/eclampsia; smoking; drug
abuse; malnutrition; multiple gestation; placental abnormality such as infarction, previa,
abruption, anatomic malformation), congenital infection (TORCH), IUGR
Problem: Risk of hypoglycemia, infection, asphyxia, polycythemia, poor feeding,
and hypothermia
Plan
 Review maternal h/o placental insufficiency, TORCH infections, nutrition hx, h/o chronic
diseases & drug use, IUGR
 Check HCT and glucose series, and follow feedings and temperatures
 If hx suggestive of TORCH infection
 Discuss with attending for CBC or CBC & CRP (if >24 hrs of life) and Total IgM levels

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Hydrocele
Problem: Infant with enlarged scrotum
Plan
 Physical exam to palpate testes
 Transilluminate, if unable to palpate testes.
 If scrotum is hard, indurated, and discolored
 Doppler US of testes for possible testicular torsion or mass
 If Doppler US indicates Testicular torsion  surgery consult immediately
 Reassurance, if no concerns
Enlarged Lt scrotum Scrotum transilluminates, indicating hydrocele

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Hydronephrosis / Fetal Pyelectasis
Problem: Evidence of pyelectasis on prenatal ultrasound, enlarged palpable kidneys on physical
exam, and hydronephrosis on US done for other anomalies (such as 2 vessel cord and ear
anomalies). Most anomalies seen in 2nd and early 3rd trimesters fetal sonograms resolve by
birth in a term baby.
Plan
Monitor for urine output. If no voiding in 24 hrs  Order a bedside bladder scan to check for
presence of urine, and if concerning order renal sonogram after 48 hours of life (For further
details, refer to chapter “Delayed passage of urine”)
 Timing of US and other imaging are controversial. Follow each institution’s guideline.
 Minimal hydronephrosis (RPD ≦7 mm in 2nd trimester and/or ≦9mm in 3rd trimester)
 Moderate hydronephrosis (7-10 mm in 2nd and/or 9-15 mm in 3rd trimester)
 Severe hydronephrosis (>10 mm in 2nd and/or > 15mm in 3rd trimester)
 Discuss with attending & mother for transfer to IMCN
Sources: http://www.tandfonline.com/doi/abs/10.1080/01443610500041446
Evaluation of fetal hydronephrosis (Cited from UpToDate: Overview of fetal hydronephrosis)

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658301/
UTD grades and recommended monitoring:
-UTD A1(central): on 16-27 week Sono APRPD (anterior posterior renal pelvic dilation) 4-
<7mm OR on 28 week or greater sono with APRPD 7-10mm with central or no calyceal dilation
[[NO Nephro consult needed]]
→ Post-natal f/u: 2 additional US: 1. >48 hours up to 1 month and 2. 1-6 months of age
- UTD A2-3: On 16-27 week sono APRPD ≥7mm OR on 28 week or greater sono with APRPD ≥
10mm showing peripheral calyceal dilation, parenchymal thickness abnormalities, parenchymal
appearance as abnormal, ureter abnormalities, bladder abnormalities, unexplained
oligohydramnios
→ Post natal f/u: US at 48 hours up to 1 month of age and Consult: Nephrology/Urology
- UTD P1: US > 48 hours of life, APRPD 10 - 15mm with central calyceal dilation
→ F/u US in 1-6 months of age ( VCUG and Antibiotics can be started at discretion of attending,
Functional scan is not recommended)
- UTD P2: US done > 48 hours of life, APRPD ≥ 15mm with peripheral calyceal dilation or
ureteral abnormalities
→F/u US between 1-3 months of age, VCUG, Antibiotics and functional scan can be done per
attending’s discretion. Consult: Nephrology/Urology
-UTD P3: US > 48 hours of life, APRPD ≥ 15mm with peripheral calyceal dialtion, parenchymal
thickness abnormalities, abnormal parenchymal appreance, utrethral abnormalities, bladder
abnormalities
→F/u US in 1 month, VCUG and antibiotics are recommended, Functional scan is per discretion
of clinician. Consult: Nephro/Urology
*When considering a functional scan, give an outpatient form to patient’s since this is done at 3
weeks of age or greater
*If patient is ok to be discharged in 24 hours but needs a renal US after 48 hours give an
outpatient slip and follow up with results
*When to consult urology: bladder wall thickening, dilated urethra, uterocele, posterior urethral
valve, solitary kidney ( as an outpatient unless solitary kidney has dilation)
*Regarding antimicrobial prophylaxis: Per the study published in the NEJM in June 2014, fewer
UTI’s were seen in the prophylaxis group vs the placebo group however there was no significant
reduction in renal scarring when using antimicrobial prophylaxis hence why prophylaxis is at
the discretion of the attending since it is a controversial subject currently
*Reflux grade 1-3 usually resolve by 1 year of age

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Hypoglycemia
Hypoglycemia:
 Defined as glucose < 40 mg/dL in newborns
 “Hypoglycemia” may occur in up to 10% of healthy term newborns, especially in the first
24 to 48hours after birth.
 Most causes of hypoglycemia are transient but rarely persistent.
DDx: Poor feeding, IDM, IUGR, SGA, LGA, sepsis, respiratory distress, CHD, asphyxia,
maternal medications (insulin, sulfonylurea,β-blockers, thiazide), hypo/hyperthermia,
polycythemia, hyperinsulinism, inborn error of metabolism, and etc.
Currently there is an ongoing discussion between the AAP and Pediatric Endocrine Society
(PES) regarding the management of hypoglycemia, including the blood glucose values that
should prompt concern, particularly after 48 hours of age.
The AAP concedes that the current “definition” of neonatal hypoglycemia (blood glucose
<47 mg/dL [2.61 mmol/L]) is based on an observational study of preterm infants weighing
less than 1,850 g who had asymptomatic hypoglycemia occurring multiple times during
their neonatal intensive care course.
As per recent PES recommendations, a blood glucose value of less than 50 mg/dL (2.77
mmol/L) in the first 48 hours after birth is being suggested as the threshold for neonatal
hypoglycemia. In addition, the PES endorses a threshold of 60 mg/dL (3.33 mmol/L) in the first
48 hours if there is concern for a congenital hypoglycemia disorder.
As per the AAP a lower blood glucose value, ranging from 25 to 45 mg/dL (1.39-2.50
mmol/L) in the first 4 to 24 hours after birth, should prompt a treatment strategy that
includes provision of enteral feedings and/or intravenous dextrose solution and continued
blood glucose monitoring.
Plan
 If low glucose is reported before initial feeding, request nurses to feed baby first.
 Formula can be prescribed as “medically indicated”
 Discuss with faculty for transfer to IMCN /NICU in Newborns with glucose level less
than 25mg/dL after feeding or glucose gel.

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Hypoglycemia: Oral Glucose Gel
Introduction:
Typical treatment for neonatal hypoglycemia includes supplementation with formula or, in some
cases, intravenous glucose administration. These treatments are effective at treating
hypoglycemia but they interrupt exclusive breastfeeding and interfere with mother -infant
bonding. Studies showed buccal administration of glucose gel to reverse hypoglycemia in
neonates is highly effective. It is being used as a standard treatment in our nursey.
Advantages of oral glucose gel:
 Reduced NICU admission.
 Compatible with exclusive breastfeeding.
 Simple to administer and well tolerated.
 Cost effective.
 Not associated with any adverse effect and no rebound hypoglycemia

48. .
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49. .
48
Glucose Gel Algorithm for Newborns
Harris (2013) ‘Dextrose gel for neonatal hypoglycemia (the Sugar Babies Study): a randomized,
double-blind, placebo-controlled trial’. The lancet. 382 (9910). pp 2077-2083.
Glucose level <40mg/dL
Notify provider
<
<
<
<
Give dose of glucose gel as
ordered.
Feed 5-10 mL of colostrum or
formula (if not breastfeeding)
I-stat check after fed for 30 min
Glucose <40mg/dL notify provider.
Additional dose of glucose gel may be
ordered(limit 3 doses). Glucose level
checks every 30 minutes after feedings.
Glucose >45 do Glucometer checks
every 4 hours for 24 h or as per
pediatrician’s orders.
40 % Glucose Gel Dose
0.5 mL/kg

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Hypospadia
Only minorities with Hypospadia have DSD. Approximately 90% are isolated anomalies. *1
Hypospadia is classified as below:
1. 1st degree (glandular): urethral meatus opens on the underside of the glans penis in about
50–75% of cases.
2. 2nd degree (Midshaft): when the urethra opens on the shaft
3. 3rd degree (penoscrotal and perineal): when the urethra opens on the perineum) occur in
up to 20 and 30% of cases respectively.
 Severe degrees are more likely to be associated with chordee.
 The phallus is incompletely separated from the perineum or is still tethered
downwards by connective tissue. (Chordee can present with or without hypospadia)
Plan
 If testicles are palpable and the baby has 1st or 2nd degree:
 Observe and refer to Urologist outpatient
 Does not need Renal US
 Advice against Circumcision (Prepuce will be needed for repair)
 If testicle is not palpable, refer to DSD chapter

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Infant of Diabetic Mother (IDM)
Problem: Maternal h/o diabetes.
Types of Gestational Diabetes:
A1DM – diet-controlled
A2DM – insulin-controlled
Plan
 Monitor baby for signs and symptoms (Jitteriness, tremors, convulsions, apnea, tachypnea,
poor sucking, weak cry, jaundice, edema, etc)
 Physical exam for associated anomalies
 Place on glucose monitoring series and no D/C within 48 hrs (Follow glucose protocol).
 Monitor urine output and stool. If no urine output in the 1st 24 hrs or no stool in the 1st
48 hrs  Discuss with attending for possible renal agenesis, small left colon syndrome, etc.
 Check HCT
 If > 65 (central) and symptomatic, transfer to IMCN
 If jittery, check serum Calcium & Glucose
Learning points
IDM are at risk of macrosomia, SGA, hypoglycemia, hypocalcemia, hypomagnesemia,
respiratory distress due to TTN and surfactant deficiency, congenital heart defects
(hypertrophic cardiomyopathy and septal hypertrophy, VSD, aortic stenosis, TGA),
polycythemia, hyperbilirubinemia, congenital malformations, and etc.
In severe cases, the polycythemia may lead to Renal Venous Thrombosis.

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Infant of Substance Abusing Mother
Problem: Maternal h/o substance abuse during pregnancy, positive toxicology in mother, or
baby has symptoms/signs suggestive of withdrawal or maternal drug or alcohol use.
Plan
 Always discuss with faculty in Newborn of mothers with documented history of drug
dependent or usage for IMCN/NICU transfer.
 If the mother has h/o or positive toxin screening for Cocaine, Amphetamine, and/or opiate
during pregnancy or after delivery  Transfer the baby to IMCN
 Send meconium and urine toxin screen for the baby, including suspicious cases.
 If urine / meconium toxin screening is positive in the baby for Cocaine, Amphetamine,
and/or opiate  Transfer to IMCN
 If h/o or positive toxin screening is positive for marijuana  Observe for 48hrs
 If urine / meconium toxin screen is negative for suspicious cases  Observe for 48hrs
 Look for dysmorphic features on physical exam. (Facial dysmorphology, SGA, etc)
 Observe infant for symptoms/signs of withdrawal.
(Wakefulness, irritability, temperature instability, jitteriness, tachypnea,
respiratory distress, apnea, high pitched cry, hypertonia, diarrhea, poor suck, rhinorrhea,
poor weight gain, lacrimination).
 Check mother’s urine toxin screen, HBsAg & HIV status.
 If mother has positive urine tox, she needs to pump and dump (per CPS protocol), until
repeat U-Tox is negative.
 If any signs of withdrawal are present, discuss with attending.
 *** Social service consult ***
 No D/C prior to 48 hrs of life.
Learning points
・ Lab tests for detecting drug abuse: Hair is the most sensitive test, but is expensive and not
available in all facilities. Meconium is easy to obtain, has higher sensitivity than urine test,
contains metabolites gathered over up to 20 weeks, and metabolites may be found up to 3 days
after delivery. Urine only reflects intake in the last few days before delivery.
・ Fetal Alcohol Syndrome: Microcephaly, microphthalmos, thin vermilion border, and small
maxilla.
・ AAP recommends continuing breastfeeding unless mother is HIV (+) or using street drugs.
Ƒetal Alcohol Syndrome

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Jaundice (Unconjugated hyperbilirubinemia)
Problem: Total bilirubin above normal range.
DDx: Excessive bruising, Cephalohematoma, Subgaleal hematoma, Subdural hematoma, IDM,
Polycythemia, Breastfeeding, Breast milk, Galatosemia, G6PD deficiency,
Autoimmune Hemolytic Anemia, Hemoglobinopathy, Ileus, UTI , TORCHES etc
Signs of Pathologic causes:
Appears within 24 hrs, Level rises > 0.5mg/dl/hr, Evidence of hemolysis (Elevated indirect
bilirubin and Retic, and decreased Hct), Physical exam is abnormal (Hepatosplenomegaly, etc),
Direct bilirubin.
Plan
 If mother’s blood type is O or Rh (-), order cord blood study
 J-meter q shift,
 If any child is jaundiced in the 1st 24 hrs of life and J-meter is above the curve
 Order initial T – bili and D-bili
 If above the curve as per the risks in the child  Start phototherapy (PT)
 If below the curve as per the risks  F/U J-meter q shift and T- bili q 12 hrs as necessary
 If concerning  F/U T- bili q 4-6 hrs
 If the rate of rise is greater than 0.5mg/dl/hr or above or on the bili curve  Start PT
 For Rh & ABO incompatibility J-meter q 6 hrs ( T.Bili and Retics @24hrs)
 If set-up for sepsis, discuss with attending for possible transfer to IMCN
 If Coombs is positive, f/u T-bili 24-48 hrs after discharge. Give mother lab order for outpatient.
Phototherapy (PT)
 Obtain informed consent from mother prior to starting PT
 Use total bilirubin (do not subtract direct bilirubin)
 Increase surface area as much as possible (Cover genitalia and eyes)
 Monitor temperature and thermal environment
 Monitor input/output and increase fluid intake by 10ml/kg/PT
 Use double or triple overhead light with biliblanket, if level is high or rapidly rising
Lab workup in infant’s under PT
CBC at 24hr of life (for possible sepsis); Retic count (for ABO/Rh incompatibility, polycythemia)
 Follow T- bili q 6-12 hrs  If bili is rising, order Hct and Retics (for hemolytic diseases)
 BMP ± Urine SG (dehydration)
 If Coombs negative consider the labs written below after discussing with attending:

54. .
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 Urine reducing substance  Galactosemia
 Peripheral smear  Spherocytosis, Elliptocytosis, Fragmented RBCs in hemolysis
 If African/Asian/ Middle Eastern and severe indirect-hyperbilirubinemia  G6PD assay
Discontinue PT: When bili decreases 2 consecutive times
Learning Point: J-meters are good for screening but are inaccurate for bilirubin levels of >10 mg/dL.
Confirm with serum T-bili.
When to check for rebound bilirubin level?
According to the AAP it is not necessary to keep infants in the hospital to check for rebound
serum bilirubin levels in infants treated with phototherapy. They do recommend repeat serum
bilirubin checks 24 hours after discharge to identify those at risk for rebound (ABO or Rh
incompatibility). Some studies showed neonates, < 37 weeks gestation, those with direct
Coombs test positivity, and those treated ≤72 hours, are at high risk for significant post-
phototherapy rebound.
Chang (2017) ‘A Clinical Prediction Rule for Rebound Hyperbilirubinemia Following Inpatient
Phototherapy’. Pediatrics. 139 (3)
Kaplan (2005). ‘Post-phototherapy neonatal bilirubin rebound: a potential cause of significant
hyperbilirubinemia’. Original article. 91:31–34

55. .
54
Jaundice (Conjugated hyperbilirubinemia)
Definition: an abnormal direct/conjugated bilirubin is defined as a serum value >1.0 mg/dL.
 Etiology:
1. Biliary obstruction/atresia
2. Choledochal cyst
3. Hyperalimentation
4. Alpha 1 antitrypsin deficiency
5. Hepatitis
6. Sepsis
7. Infections (especially TORCH and urinary tract infections)
8. Hypothyroidism
9. Inborn errors of metabolism
10. Cystic fibrosis
11. Red blood cell abnormalities
No phototherapy or discontinue if already started.
 Discuss with attending/GI for transfer to IMCN for further work-up. Speak to your attending to
obtain CBC, CMP, PT/INR and PTT and an abdominal sonogram to look for infection, initial metabolic
screen, liver disturbance. Order urine reducing substance (URS), (will screen for galactosemia if URS
is positive), UA for bilirubin, look for hepatosplenomegaly

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Jitteriness /Abnormal Movement
Jitteriness: The movement resembles a tremor, and no autonomic changes are associated with
it. Generalized and symmetrical. Not associated with ocular deviation. It is stimulus sensitive
(easily stopped with passive movement of the limb by holding onto the baby’s arm).
Plan
 Check Maternal h/o drug use, diabetes, and infections, and FHx of hypocalcemia
 Check maternal urine toxin screen if it was ordered
 Urine and meconium toxicology screen for baby, in suspected cases
 Order Ionized Ca and Glucose level (For hypoglycemia, refer to glucose protocol)
 If severe, check Mg, Phosphate, and Parathyroid hormone (PTH)
 If set-up for sepsis, check initial CBC stat or CBC & CRP (if > 24hrs of life)
 Discuss with attending if:
 CBC / CRP is abnormal
 Symptomatic and serum Ca is < 8.0mg/dl and ionized calcium < 1.0mmol/L
(4.0mg/dl)
 Serum calcium < 7.0 mg /dl and ionized calcium < 0.9mmol/L (3.6mg/dl)
 Serum Magnesium < 1.0 mg/dl with hypocalcemia (Discuss for transfer)
Jitteriness and abnormal movement
Problem: Differentiating epileptic seizures from nonepileptic movements is extremely important.
While neonatal seizures are usually a sign of serious intracranial pathology, nonepileptic motor
events may be benign. Epileptic seizures are associated with ocular phenomena, such as forced
eye deviation; and autonomic changes such as hypertension or apnea.
Other common nonepileptic movements in neonates:
 Myoclonus:
 Brief shock-like movement of a limb caused by muscle contraction. It is irregular and
arrhythmic, can be either localized or generalized. It can be a single event, or
repetitive.
 May be benign or may signify severe central nervous system pathology.
 Benign neonatal sleep myoclonus, occur in healthy, full-term newborns, and is
characterized by rhythmical myoclonic jerks seen only during sleep.
 EEG is normal.
Huntsman (2008). ‘Nonepileptic motor phenomena in the neonate’. Paediatr Child
Health.13(8):680-684.

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Magnesium given to mother
Problem: Mother might receive MgSO4 for pre/eclampsia management. Maternal magnesium
administration can depress neonatal respiratory and gastrointestinal tone.
Plan:
 If the baby is stable in the nursery or in the mother-baby unit and is asymptomatic
 No serum Mg necessary. Monitor closely.
 If baby is symptomatic (Poor feeding, low APGAR scores, apnea, respiratory distress,
frequent desaturation, cyanotic, or no meconium passage in >48hrs)
 Consider obtaining serum Mg & discuss with attending
± Transfer to IMCN/ICN if needed
Learning Points
・Only 1 % of body Magnesium is extracellular. Thus it is hard to interpret serum Mg levels. *3
・In older children excessive Mg is excreted by the kidney but infants are vulnerable to high
levels because they have lower GFR.
・Hypermagnesemia inhibits acetylcholine release at he neuromuscular junction, leading to
hypotonia, hypoventilation, poor suck, and hyporeflexia. Other symptoms include nausea,
vomiting, and hypocalcemia.*1
*3 Magnesium, Nelson’s Textbook of Pediatrics 20th edition, Chapter 55.5

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Maternal Infection – COVID-19
 The majority of the currently reported COVID-19 infections in pregnant women
occurred during the 3rd trimester. It is recommended to follow closely infants born to
mothers who tested positive during their 1st or 2nd trimester as there is no information
on long-term neurodevelopmental outcomes amongst infants born to mothers who
confirmed COVID-19 infection during pregnancy. 1,2,3
 Reported signs among neonates with SARS-CoV-2 infection include fever, lethargy,
rhinorrhea, cough, tachypnea, increased work of breathing, vomiting, diarrhea, and
feeding intolerance or decreased intake. 1,2,3,4
 Testing is recommended for all neonates born to women with confirmed or suspected
COVID-19, regardless of whether there are signs of infection in the neonate.
 The ideal setting for care of a healthy term NB in the hospital is couplet care with
the mother in a negative pressure room.
 Thorough Physical Examination !
 Direct breastfeeding after donning PPE and appropriate breast hygiene.

 Labs
 CBC, CRP and COVID-19 Biofire (PCR) at 24 hours.
 CBC, CRP and COVID-19 (Rapid Antigen) at 48 hours
 Infants who start showing symptoms will be transferred to EPCH for higher level
of care as indicated.
 Discharge home after 48hrs, if stable
 Virtual calls can be arranged to follow up 48-72hours after discharge to monitor
the clinical status prior to in-person visit, and as needed.
 Baby can follow-up with PCP for in-person after 10 days, if stable.
 Below are the guidelines established by UMC :

59. .
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Upon notification of
possible COVID -19
patient in LD/Triage a
MB Primary RN will be
assigned to couplet. If
low risk is called to
delivery primary
newborn RN will
attend. Isolette will be
brought and left
outside LD room.
Appropriate PPE
applied before entering
room.
Assigned MB negative
pressure room with
be set up with all
necessary supplies to
avoid unnecessary
trips in and out of
room. Any extra
supplies/medications
will be brought into
the Ante Room for the
primary nurse to
grab.
▶Low Risk Delivery
newborn will be
transferred to MB
negative pressure room
by the MB RN via isolette.
▶High Risk Delivery
EPCH RN will transfer
newborn to MB negative
pressure room where
MBRN will receive report
on newborn.
Isolette to be terminally
cleaned after use.
Conservative
Approach
Explain risks and
benefits
Mother and Baby
Separation
▶Formula Feed only
▶EBM pump and
dump until mother is
asymptomatic and
clear of infection.
Modified Approach
Explain risks and benefits
Mother and Baby Separated or in
same room with barrier or 6 ft
apart.
▶EBM – Appropriate breast &
hand hygiene, mask, glove, cleaning
& sanitizing of manual breast pump
before and after every use. EBM
given to newborn by healthy
caretaker or taken to EPCH by MB
staff with mother’s label, date, time
in a biohazard bag to HUC.
▶Direct breastfeed after donning
PPE and clean breast.
Manual Breast pump
is to be cleaned by
patient and/or
MBRN.
▶Clean with hot
soapy water in gray
washbasin, rinse in
fresh water and air
dry.
▶Sanitizing-Using
“Clean Micro-Steam
Sanitizing bags” in
microwave.
Newborn will be managed by Pediatric Residents or
Faculty
No skin-to-skin contact with mother

60. .
59
References:
1. Expert Consensus for managing pregnant women and neonates born to mothers with
suspected or confirmed novel coronavirus (COVID-19) infection. Int. J Gynecology Obstet. 2020
May: 149(2):130-136. E pub 2020, April.
1.1 World Health Organization. Novel Coronavirus-China [WHO website]. March 18, 2020.
2. Coronavirus disease (COVID -19) and Neonate: What neonatologists need to know. J. Med
Virology.2020. March 12:10.1002/jmv.25740.
3. Neonatal Intensive Care Unit Preparedness for the Novel Coronavirus Disease-2019
Pandemic: A New York City Hospital Perspective. Elsevier Public Health Emergency Collection.
Curr. Probl Pediatric Adolescent Health Care. 2020 May 14:100795.
4. Evaluation and management Considerations for Neonates at Risk for COVID-19 according
CDC.
Discharge considerations
Neonates determined to be infected, but with no
symptoms of COVID-19, may be discharged home with
appropriate precautions and plans for outpatient follow-
up on a case-by-case basis.

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Maternal Infection (GBS)
GBS+ Mother:
If excellent prenatal care, term (≥ 37wks), SVD, sufficient intrapartum antibiotic prophylaxis given
(> 4 hours), mother is able to comply with home instruction for observation, and baby is
asymptomatic (case by case basis and only if patient has close access to medical care, for any
hesitancy then 48 hour stay )
 May consider discharging home after 24hrs if other discharge criteria are met and patient has a
proper follow up plan to see PCP in 1-2 days after discharge. Discuss with attending if patient can
be discharged home (please follow attending’s preference)
GBS+ mother with 1 dose of intrapartum abx < 4hrs PTD (prior to delivery) OR If onset of labor
prior to C/S and inadequate tx
 ≥ 37 weeks and ROM < 18hrs  CBC&CRP at 24 hrs and 48hrs (if 24hrs is abnormal and child
is stable). Observe for 48 hrs.
 < 37 weeks and/or ROM >18 hrs CBC at 6-12hrs and CBC &CRP at 24hrs±48ℎ𝑟𝑠. Observe
for 48 hrs .
Discuss with faculty for possible need to transfer to IMCN.
GBS+ mother with at least 1 dose of intrapartun abx > 4hrs PTD OR If elective C/S and baby is
asymptomatic routine care  Observe for 48hrs
For GBS babies at risk Discuss with faculty:
If baby is symptomatic at <24hrs of life, CBC stat ± transfer to IMCN as appropriate
If symptomatic at > 24hrs of life, CBC and CRP ± transfer to IMCN as appropriate
**See Algorithm Below
GBS unknown
(Low threshold for transfer if symptomatic)
IAP indicated for:
 <37weeks
 PROM >18hrs
 Intrapartum Maternal fever >100.4
 Positive intrapartum GBS NAAT
If CRP elevated or WBC>30 or <5, even if clinically stable, discuss with attending for possible transfer
to IMCN.
No PNC (Prenatal Care)
Definition: No documented PNC, PNC at lay midwife maternity center or in Mexico,
less than 4 PNC visits starting later than 28th week of gestation.

62. .
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Plan:
 Check perinatal maternal labs and document prior to D/C
 If baby is stable: NO screening with CBC and/or CRP is necessary
 Observe for 48 hours in the hospital

63. .
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Limited Evaluation:
 Our typical work up is CBC at birth, 24hrs, & CRP at 24hrs
 Repeat CBC and CRP at 48hrs ordered after 24-hour lab is reviewed
 Recommended evaluation includes blood culture, however, UMC well baby unit does not
perform blood cultures or give antibiotics, so CRP replaces blood culture
 For full evaluation and/or antimicrobial therapy, transfer to NICU
Learning points: Adequate Intrapartum antibiotic prophylaxis (IAP) for GBS (Red Book, July
2019)
Universal maternal antenatal vaginal-rectal culture-based screening continues to be
recommended, however the optimal time for screening is 36 0/7 through 37 6/7 weeks of
gestation (rather than beginning at 35 weeks of gestation).
Penicillin G is the preferred choice for GBS IAP; ampicillin is an acceptable alternative.
Cefazolin is recommended for those women with penicillin allergy at low risk for anaphylaxis.
For women with penicillin allergy at high risk for anaphylaxis, clindamycin or vancomycin
should be used for GBS IAP, depending on the antibiotic susceptibility of the colonizing GBS
isolate.
Women with reported penicillin allergy are encouraged to have allergy testing, because most
women who have a reported penicillin allergy are penicillin tolerant.
Penicillin, ampicillin, or cefazolin given > 4 hrs prior to delivery. Penicillin and ampicillin
rapidlyachieve therapeutic levels in the fetal circulation and require 3 hrs to achieve therapeutic
levels in amniotic fluid. Cefazolin has similar pharmacokinetics and is preferred for IAP in
penicillin allergic women with no history of anaphylaxis, angioedema, respiratory distress or
urticaria. Duration of IAP < 4 hrs and all other antimicrobial regimens, including Clindamycin &
Vancomycin, are considered inadequate because no data regarding efficacy are available.

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Maternal Infection (Gonorrhea / Chlamydia)
Maternal Gonorrhea during pregnancy or delivery
 Check Maternal h/o tx & documentation of cure
 If inadequate or no documented test of cure  Ceftriaxone 125 mg IM x 1
 Observe for signs and symptoms of infection
 Low threshold for transfer to IMCN
 No discharge prior to 48hrs
Maternal Chlamydia
Chlamydia positive mother, with or without treatment at delivery.
 Asymptomatic baby:
 No treatment. Prophylactic Abx is not recommended due to lack of evidence.
 f/u as out-pt for signs of infection (Conjunctivitis, Pneumonia, Otitis Media).
 Prompt treatment of mother and her sexual partner(s)
 Symptomatic baby: Transfer to IMCN for diagnosis and treatment
Mother and baby must be reported to the Department of Public Health. Usually OB/GYN
department will report however call down to make sure it has been taken care of. If OB/GYN has
not reported it please call attending, report if needed. ADD IN # of state health
Counsel mother on getting treatment for father/sexual partners as well.
Department of Public Health: 915-212-6537

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64
Maternal Infection (Hepatitis B / C)
Hepatitis B virus infection prevention in newborn
Problem: Mother with h/o hepatitis of unknown etiology or jaundice, known HBsAg carrier, or
high risk for Hep B carrier (known or suspected IV drug use, mother from endemic region)
Plan
 Verify maternal HBsAg status and make sure labs were drawn
If mother is positive
 Bathe baby first before any injections !!!
 Administer Hep B Ig (0.5 cc IM) as soon as possible and Hep B vaccine (0.5 cc IM) at a
different site
 Breastfeeding is NOT contraindicated
 ID consult as out-pt
If maternal HBsAg status is unknown prior to discharge in baby >2000 grams (such as in cases
when there is a machine breakdown for labs)
 Bathe baby first before any injections !!!
 Administer Hep B vaccine (0.5 cc IM) at birth
 Administer Hep B Ig (0.5 cc IM) within 7 days, if maternal HBsAg comes back positive
(CDC).
Infants born to HBsAg-positive mothers should receive immunoprophylaxis as recommended
whether or not their mother received antiviral therapy during the third trimester. *1
Maternal Hepatitis C (HCV RNA) positive
 Confirm maternal HIV status and that other maternal labs are WNL.
 NOT a contraindication to breastfeeding.
 Mothers who are HCV positive and choose to breastfeed should consider abstaining if their
nipples are cracked or bleeding.
 To Follow-up with ID and PCP to order HCV RNA with reflex to genotype at 18 months of age.
 The duration of passively acquired maternal antibody in infants can be as long as 18 months
 If earlier diagnosis is desired, a NAAT to detect HCV RNA may be performed at or after the
infant’s first well-child visit at 1 to 2 months of age( Red book 2019)

66. .
65
Maternal Infection (HIV)
Problem: Mother’s HIV status is positive.
Plan
 Obtain detailed hx for risk factors
 The newborn infant should be bathed and cleaned of maternal secretions (especially bloody
secretions) as soon as possible after birth.
 Send HIV DNA PCR within the first 24 hours after birth (Cord blood should not be used)
 Give Zidovudine (AZT) as soon as possible after birth (within 6 to 12 hours after delivery).
If maternal HIV is confirmed
 Treatment and Prophylaxis Dosage: ≥35 Weeks’ Gestation at Birth: 4 mg/kg/dose PO BID
daily
 ID consult as in-patient
 If HIV testing is pending for baby after birth and the mother is ELISA positive
 Breastfeeding should not be initiated until the WB (Western Blot) has been
reported negative
 If mother’s WB is (+)
 Stable baby  Start PO AZT
 Unstable baby  IMCN to start on IV AZT
 If mother’s WB is (-) No issues. No further work up needed.
Higher Risk of Perinatal HIV Transmission
Combination ARV prophylaxis with 6 weeks ZDV and 3 doses of NVP prophylaxis dosage
Prophylaxis Dosage: Birth Weight >2 kg: 12 mg dose orally once daily , with doses given
within 48 hours of birth, 48 hours after first dose, and 96 hours after second dose)
Newborn with confirmed HIV: 3 drug combination ARV regimen at treatment dosage
Learning point
 Post-exposure prophylaxis with a 2- or 3-drug Antiretroviral regimen results in a lower
rate of mother-to-child transmission of HIV than zidovudine alone.
 A 2-drug regimen of zidovudine for 6 weeks with 3 doses of nevirapine during the first
week of life (at birth, at 48 hrs, and 96 hrs of life) is as effective but less toxic than a 3-drug
regimen of zidovudine, lamivudine, and nelfinavir.

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66
Maternal Infection (HSV / Genital Herpes)
Problem: Mother identified as having vaginal herpes; or history of oral or genital lesions in mother
and caregivers close to delivery.
Incidence: In United States, estimated to range from 1 in 2000 to 1 in 3000 live births
Plan Physical exam of the baby for rash (vesicles)
 Delivery hx-C/S or vaginal (vaginal delivery has higher risk)
 Instruct mother on care of infant (good hand washing, etc)
 A mother with herpes labialis or stomatitis should wear a disposable surgical mask
when touching her newborn infant until the lesions have crusted and dried.
 Mother should not kiss or nuzzle her newborn until lesions have cleared.
 Herpetic lesions on other skin sites should be covered.
 Infants born vaginally to mother with active genital ulcerative lesions
 IMCN for isolation
Transmission: HSV is transmitted to a neonate most often during birth through an infected maternal
genital tract. Other less common sources of neonatal infection include postnatal transmission from a
parent, sibling, or other caregiver, most often from a nongenital infection (eg, mouth or hands), and
intrauterine infection causing congenital malformations.
Infant born via C/S to mother with active genital ulcerative lesions:
 If onset of labor or ROM > 4hrs and < 37 weeks GA  Please discuss with faculty for possible
need to transfer to IMCN for isolation
Infant born to a mother with a history of HSV infection and no active lesions at delivery:
 Neither HSV cultures nor empiric therapy with IV Acyclovir are indicated. No isolation
necessary.
(For further information please refer to Red Book: Algorithm for the evaluation of asymptomatic
neonates following vaginal or cesarean delivery to women with active genital herpes lesion)
Learning point

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(* AAP: Guidance on Management of Asymptomatic Neonates Born to Women With Active
Genital Herpes Lesions)
 Risk of transmitting HSV to an infant during delivery heavily depends on the mother’s
immunity to HSV. Mothers with primary genital HSV infections who are shedding HSV at
delivery are 10 to 30 times more likely to transmit the virus to the infant than are women
with recurrent HSV infection who are shedding virus at delivery.
 Time of transmission of HSV for most infected infants (∼85%) is during the intrapartum
period.
 Congenital HSV infection can be categorized into the categories below.
(1) Disseminated: Involving multiple visceral organs (lung, liver, adrenal glands, skin, eye,
and/or brain) (2) CNS: Central nervous system (CNS) disease, with or without skin lesions
(3) Skin, eye, mouth: Vesicle lesion limited to the skin, eyes, and/or mouth

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Maternal Infection (Syphilis)
Problem: Maternal RPR (+)
Plan
 Obtain detailed maternal hx (Treatment hx and other hx of STI):
 Treatment hx: Timing of tx, medication used, evidence of x4 decreased titers after tx,
and evidence of spouse tx
 Confirm maternal TP-PA:
 If negative  RPR was a false positive (because it is non-specific) and there is no issue.
 If positive
 Obtain Serum RPR on baby and follow CDC guidelines for congenital syphilis.
(Umbilical blood may be contaminated with maternal blood and can cause false positive)
 Transfer to IMCN for full work-up, depending on the scenario
 If the mother has documentation of satisfactory treatment, nontreponemal serologic
titer remained low and stable during pregnancy and at delivery (RPR < 1:4) and the
baby’s serum quantitative nontreponemal serologic titer is equal to or less than
fourfold the maternal titer  Refer to Out-pt ID after discussing with attending.
For further details, refer to CDC web page for
Sexually Transmitted Diseases Treatment Guidelines, Syphilis*24
Learning points
・Treponemes can cross the placenta during pregnancy and infect the baby. It can cause
stillbirth, prematurity, congenital infection, or death. Transmission does not occur by breast
milk but may occur if the mother has an infectious lesion on her breast.
・Early manifestations: Nasal discharge, rashes on palms and soles, abnormal bone
radiographs, hematologic abnormalities, and non-specific symptoms such as fever.
・Conducting a treponemal test (e.g. TP-PA, FTA-ABS, EIA, or CIA) on neonatal serum is not
recommended because it is difficult to interpret.
・Nontreponemal antibodies are detected by the rapid plasma reagin (RPR) assay, which is
typically positive during current infection and negative following treatment or during
late/latent forms of syphilis.

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Evaluation and treatment of infants born to mothers
with reactive serologic tests for syphilis.
(Red book 2018)

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If evaluation is warranted, admit to IMCN. Reference Red Book 2018 Table 3.76 below
for details

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Maternal SLE
Problem: Maternal h/o SLE can cause fetal complications such as stillbirth, IUGR,
neonatal lupus, congenital heart block, and prematurity.
Plan
 EKG (Bradycardia, congenital heart block)
 If abnormal, discuss with attending for Cardiology referral.
 CBC (thrombocytopenia/leukopenia/anemia)
 Examine skin for rash (erythematous annular lesions)
 If present, discuss with the mother the importance to avoid sun exposure.
 FU with PCP
Learning Point
・10-30% of babies born to mother with SLE are IUGR, low birth weight, and/or SGA.
・Neonatal Lupus (NL) is caused by maternal antibody (Anti- Ro/SSA or Anti-LA/SSB)
transmission through the placenta and can cause cutaneous, cardiac, hematologic, and hepatic
disorders. There are no specific diagnostic criteria for NL. Most serious complication is
congenital heart block (80-95% of all congenital heart block is due to NL). The rash is self-
limiting and resolves by 6-8 months of age.
Maternal HELLP syndrome
Problem: Mother with HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet)
during pregnancy.
Plan: Obtain CBC at birth for baseline Plt levels. Discuss with attending if f/u CBC is needed.
Learning Point
Most common complications are prematurity, IUGR, and abruptio placenta. Neonatal prognosis
is most strongly associated with gestational age. Neonatal thrombocytopenia and leukopenia
may occur but are more related to the prematurity, IUGR, and maternal HTN, rather than HELLP
syndrome itself, and is usually transient. It does not affect the baby’s liver function.

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Micro/Macrocephaly
Microcephaly
Problem: Head circumference < 10th percentile or 2 SD below the mean for age and sex.
DDx: Familial, Syndromes (> 500 genetic syndromes involved including Trisomy 13/18/21,
Cornelia de Lange, Smith-Lemli-Optiz), TORCH syndrome, fetal alcohol syndrome,
fetal hydantoin syndrome, maternal DM and/ or PKU, inborn errors of metabolism.
Plan
 Recheck HC yourself
 Check maternal labs/hx of TORCH infections, drug (Phenytoin, Phenobarbital,
Carbamazepine, etc), or alcohol use.
 Check for FHx of small heads and intellectual disability.
 Make sure the baby will have good f/u and the 2nd newborn screen done @7-14 days of life
Macrocephaly
Problem: Head circumference > 90th percentile or 2 SD above the mean for age and sex.
DDx: Constitutional, familial, hydrocephaly (excessive CSF), hydrancephaly (absence of brain
hemisphere), intracranial mass, TORCH, skeletal dysplasia, and megalencephaly (true
increase in brain substance) such as Soto syndrome, neurocutaneous syndromes, and
mucopolysaccharidoses.
Plan:
 Recheck HC yourself and serial HC measurement
 Review FHx of large head, neurocutaneous disorder, and neurologic disorder
 Review Maternal h/o TORCH infections
 Physical exam for increased intracranial pressure (split sutures, bulging fontanelle),
cutaneous lesions, skeletal dysplasia, abnormal transillumination of the skull (Dandy-
Walker Malformation & Hydrancephaly), cranial bruits (AVM & Cerebral hemangioma),
ocular abnormalities (sun-setting sign for hydrocephalus), or organomegaly
 If any abnormal findings are present, inform attending. Consider Head US or CT.

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Nasolacrimal duct obstruction/ Dacrostenosis
 Usually caused by imperforate membrane at the distal valve of Hasner; excessive tearing
causing discharge; no eyelid edema or conjunctival injection.
Plan
 Frequent nasolacrimal massage
 Warm compresses
 Consider outpt ophthalmology consult f/u.
 Congenital dacryocystitis can have significant morbidity and mortality. Needs to be
treated promptly and aggressively. Complications include orbital cellulitis, brain abscess,
meningitis, sepsis, and death. → Needs Ophthalmology consult and systemic/ophthalmic
antibiotics as advised by ophthalmologist

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Peripheral Nerve Injuries
Facial Nerve Palsy
 Problem: Unilateral decreased facial movement and forehead wrinkling.
 Most obvious symptom is asymmetrical movement of mouth when crying.
 Plan: Reassurance and Observation
Learning points
* Facial nerve injury may result from birth trauma from forceps or passing the birth canal.
* Prognosis of facial nerve palsy is excellent and recovery generally occurs in the 1st month.
http://www.rheumatologynetwork.com
e502 NeoReviews Vol.10 No.10 October 2009

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Brachial Plexus Injuries
 Problem- Not moving arm & held limply extended to the side with hand flexed
◦ Erb-Duchenne palsy (C5 - C6), Klumpke’ s paralysis (C7-8, T1). Distinction may be
difficult in some cases.
 Plan: Examine infant for the followingClavicular crepitus (order CXR with Clavicles)
 Presence of grasp (Absent in Klumpke’s, causing claw hand deformity)
 Associated respiratory distress (Erb’s); Horner’s syndrome (Klumpke’s)
 Management
 If clavicle is fractured, immobilize arm by pinning sleeve to shirt
(refer to “clavicle fracture,” page 19)
 Physical, Occupational, and Speech Therapy (+Facial Nerve Palsy) referrals as out-
patient.
 Micro-Neurosurgery referral (Brachial Plexus Palsy clinic) as outpatient if severe
palsy or no improvement in 6-8weeks. Most recover completely and may take up to 6 months.
If diaphragmatic paralysis is suspected secondary to brachial plexus injury: first obtain CXR to
look for elevated hemi-diaphragm. If CXR is normal but there is still high-suspicion for
diaphragmatic paralysis, order diaphragm fluoroscopy, after discussing with attending, to look
for diaphragm movement. If found to be true diaphragmatic paralysis, transfer to NICU for
ventilation support.
Brachial plexus and Hypoplasia of Depressor anguli oris 

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Petechiae
Problem: Red/purple, non-blanching spots on skin / face
DDx:
Birth trauma, autoimmune (maternal SLE), thrombocytopenia, coagulation disorder, sepsis,
TORCH, maternal drugs (steroids & salicylates), congenital leukemia cutis
Plan
 Review perinatal h/o asphyxia, nuchal cord, traumatic delivery such as usage of
forceps
 Review maternal hx of TORCH infection or risk for ascending infection
 Review maternal labs: Thrombocytopenia, TORCH antibody, antibodies for SLE
 CBC stat, and CBC & CRP at 24hrs of life
 Observe for signs of sepsis & discuss with attending

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Polycythemia
Definition: Central (Venous) Hct > 65% or Hemoglobin > 22 g/dL.
Problem:
May result in hypervicosity, which could cause hypoperfusion, acidosis, peripheral hypoxia, and
increase risk of hypoglycemia, hypocalcemia, hyperbilirubinemia, and thrombosis, such as renal
venous thrombosis.
DDx:
Primary / Secondary polycythemia, dehydration, false result, delayed cord clamping, Twin-twin
transfusion, infant of diabetic mother, LGA, Beckwith-Wiedemann syndrome, Trisomy 21, 18 and
13, endocrine disorders such as congenital adrenal hyperplasia, hypo or hyperthyroidism.
Plan:
 If sample was obtained from heel-stick, recheck value from venous sample.
 Check glucose level
 Physical exam to assess hydration status.
 Asymptomatic baby and Central Hct is 65-69%  Repeat Central Hct in 24 hrs. If baby is
dehydrated, supplement with formula. May repeat Central Hct in 6 hrs if needed.
 If Hct ≥ 65% and the baby is symptomatic  Transfer to IMCN
 If Hct ≥ 70%  Transfer to IMCN
Learning points
・NEVER treat based on heel-stick. Heel-sticks have falsely elevated Hct levels by 5-20% !!
・Hct peaks at 2 hrs of life, then decreases to baseline at 24 hrs of life.
・Most common symptoms are poor feeding and lethargy. Others involve multiple systems such
as hypotonia, irritability, apnea, heart murmurs, CHF, respiratory distress, vomiting, NEC,
oliguria, proteinuria, HTN, thrombosis, thrombocytopenia, and etc.

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Polydactyly
Problem: Skin tag or extra digit on healthy infant or dysmorphic infant.
Plan
 Document if polydactyly is pre- / post- axial, or central
 If skin tag has a thin pedicle
 Tie off with Vicryl suture after obtaining informed consent from mother
 If it is an extra digit, central, or preaxial  X-rays to document if bone is present
 If NO bone is present and it is postaxial
Tie off with Vicryl suture after obtaining consent from mother
 If bone is present  Refer to Pediatric Orthopedics as outpatient
 If it is central, preaxial, or any other forms of lower limb polydactyl or abnormalities are
present  Referral to Orthopedics
Ulnar or postaxial
(5th digit duplication)
Central
(2nd, 3rd, 4th digit)
Radial or Preaxial
(Thumb duplication)
Frequency AA✴
>> Caucasian
Male > Female
1 per 3,00 (in AA)
Rare Caucasian and Asian > AA
Male > Female
1 per 3,000
Transmission Autosomal dominant Mostly sporadic
Syndromic? No Yes Rarely
Other Associated with more
serious abnormalities
if seen in Caucasian
Usually unilateral
Treatment Tie off / Excision Surgical correction Surgical correction
✴AA: African American
*14 Congenital Anomalies of the Hand. Campbell’s Operative Orthopaedics, Chapter 79, 3713-
3794

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Prolonged Rupture of Membrane (PROM)
Definition: Rupture of Membrane >18hrs (UMC policy is > 16 hrs)
Plan:
 Initial screening CBC at birth or within 6 hrs**. Repeat CBC & CRP at 24 hrs and re-
evaluate if necessary (Even if mother was given Penicillin, it will not cover penicillin
resistant gram-positive organisms and gram-negative organisms. Thus, important to
screen CBC and CRP).
 Glucose series (risk of sepsis).
 Have low threshold to transfer to IMCN if baby becomes symptomatic.
 Added risk factors: PROM (> 18 hours) & Preterm (<37 weeks).
 PROM >72hours (Evaluate and discuss with the faculty)
 No discharge prior to 48 hrs of age.

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Refusal of Vaccines, Treatment, or Newborn screens
Problem: Mother refusing to give Hep B vaccine, Erythromycin eye ointment, Vitamin K injection
and/or obtaining Newborn screen/ALGO/CCHD.
Plan:
 There is no immediate danger to the baby not to receive Hep B. Explain the risk of not
receiving Hep B (increased risk of infection of Hep B) and have mom sign form to decline.
 Vitamin K (to prevent hemorrhagic disease of the newborn), Erythromycin eye ointment
(most efficacious within 2 hours of birth to prevent neonatal conjunctivitis (AAP
Redbook)) or not receiving Newborn screen (not being able to detect detrimental
disorders in newborns at an early stage)
 In all above situations, have the mother sign form to decline.
 There is no need for social service consult

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Stuffy Nose
Problem: Newborn with rhinorrhea and trouble breathing.
DDx:
 Mucous plug, congenital narrowing (Choanal atreasia/stenosis, Binden syndrome)
 Mass (Hemangioma, septal hematoma, nasolacrimal duct cyst, hamartoma, etc)
 Genetic (Fetal alcohol syndrome, CHARGE syndrome, Treacher-Collins syndrome, etc)
 Infection (Congenital syphilis, Chlamydial nasopharyngitis)
 Iatrogenic (Irritation from nasal suction, NG tube)
 Maternal drugs (Methyldopa, Tricyclic antidepressant, Propanolol, substance abuse)
 Hypothyroidism
Plan
 Review maternal hx: Medications, Syphilis, Chlamydia PCR, Alcohol/drug abuse
 If there is suspicion, follow relevant chapters for further management.
 Check patency of nares:
 Pass 8 Fr feeding tube in both nostrils and auscultate for air passing through each
nare after blocking the other one.
 Place small mirror under nostrils. Absence of fog on a mirror may indicate atresia.
 If concerned, discuss with attending for possible need of CT.
 Pulse Ox PRN, saline nasal drops, gentle bulb suction (Cool Mist Humidifier no longer
recommended in WBN because of infection risks)
 Follow feedings (look out for poor feeding)
 If symptoms are severe  discuss with attending
Learning points
・50-70% of choanal atresia is associated with other congenital abnormalities (CHARGE,
VACTERL association, Kallmann syndrome, Treacher-Collins).
・Bilateral choanal atreasia can cause severe respiratory distress (Neonates may be obligate
nasal breathers up to 2 months).
*15 Diagnosis and Management of the Newborn and Young Infant Who Have Nasal
Obstruction. Pediatrics in Review, Vol 21; No 12; 416-420