Well Baby Nursery Guidelines

Author: Sitratullah O Maiyegun MD
Editors: Namrata Singh MD
Maria Villanos MD
Jesus Peinado MD
Ashish Loomba MD
Well baby Nursery Director: Carmen
Prieto MD
07/03/13 1S O MAIYEGUN MD

 The guidelines do not indicate an exclusive
course of treatment or serve as a standard of
medical care
 Appropriate management can be modified
according to individual circumstances
 Please apply evidence based medicine as
appropriate

 Evaluate well newborns with history, physical
exam and routine screening procedures, and
provide preventive counseling and intervention
as indicated
 Manage breast and formula feeding in the
newborn period
 Evaluate and manage common conditions and
infections in the normal newborn
07/03/13S O MAIYEGUN MD 3

 Recognize and manage jaundice in the newborn
period
 Provide anticipatory counseling at nursery
discharge that relates to newborn behavior,
family adjustment, injury prevention, and access
to medical services

 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
 Maternal prenatal lab results and GBS status,
and mother and infant’s blood types
 HIV, RPR and Hep B status must be updated
within 12 hours of delivery


 Admission and discharge diagnoses to be
documented with problem lists
 Update maternal labs prior to discharges
 Any abnormal results reported to the intern must
be reported to the senior and/or faculty

 Birth weight < 2250 gms
 Gestational age < 35 wks
 Apgar score of <5 at 5 mins
 Prolonged period of abnormal transition (more
than 4 hrs )
 Initial Se. Glucose <30 mg% (after ISTAT)
 Maternal chorio detected in L&D
 Initial rectal temp 102 F or more
 Unstable baby in L&D or OR

 All babies will be placed skin-to-skin with mom
for breastfeeding for as long as they are stable
 Nursing procedures and further assessment will
be done while with mom
 Babies will be transferred to room with mom
from L&D

 Babies of diabetics and moms on magnesium
will also be placed skin-to-skin unless otherwise
symptomatic or per pediatrician order
 After skin-to-skin they will go to the NBN for
further assessment or stay with mom if mom is
stable
 Stable C/S babies stay with the relatives in
OR /L&D till mom is able to handle the baby

 Maternal history of diabetes, Fever
 PROM >18hours (CDC, AAP)
 <37wks
 Weight ≥3800 gms and ≥2500gms
 LGA >90th
percentile or SGA/IUGR < 10th
percentile for weight

 Blood glucose within 30mins-1hour of admission
in high risk babies
 Peripheral hematocrit: in high risk babies
 Eye prophylaxis with 0.5% erythromycin
ophthalmic ointment
 Vitamin K 1mg IM X1
 Hepatitis B vaccine X1( after consent)
 Cord blood studies if mother is O+ or Rh (-)

 Radiant warmer in the nursery until stable to
transfer to mom’s room
 If needed , formula feeds need to be prescribed
( Baby-friendly policy)
 Normal delivery24hours observation if all
discharge criteria fulfilled
 If risk factors  48hours
 C/S delivery  observe for 48hrs

 Breastfed and formula fed infants should be
supplemented with 400 IU/day of vitamin D
beginning in the first few days of life
 Supplementation should be continued unless
the infant is weaned to at least 1 L/day vitamin
D–fortified formula (1 or 2 months)
 1liter of regular infant formula(406 IU of Vitamin
D)

 Newborn hearing screen before discharge
 If failed Algo X2Refer for BAER
 Newborn screen at 24hrs of life
 Jaundice meter reading upon admission and q
shift until discharge

 History
 Adequate prenatal care≥ 4 visits
 Maternal age > 17years
 No maternal drug use
 Mother not A1or A2 diabetic
 Mother not GBS+ or Chlamydia +
 Mother not RPR+, HIV +, HepB/C +

 Delivery
 Vaginal delivery in the hospital
 Rupture of Membranes < 18hours (CDC)
 No maternal temperature >101 or concern
regarding chorioamnionitis
 Apgar score at 5minutes at least 7

 Examination
 Gestational age of at least 37weeks
 Baby is not on 24-hour glucose series (LGA,
SGA or initial hypoglycemia)
 No physical findings that requires further
monitoring
 Vital signs are documented as being within
normalranges and stable for the last 12 hours
preceding discharge

 No vital signs abnomalities: No Temp instability,
RR<60, HR 100-160, axillary temperature of
36.5°C to 37.4°C (97.7°F to 99.3°F)
 No Jaundice in the first 24hrs
 The clinical significance of jaundice, if present
before discharge,has been determined, and
appropriate managementand/or follow-upplans
have been put in place

 No Jaundice in the first 24hrs
 The clinical significance of jaundice, if present
before discharge,has been determined, and
appropriate managementand/or follow-upplans
have been put in place

 No history of poor feeding or emesis
 Able to coordinate sucking,swallowing, and
breathing while feeding
 Normal voiding and stooling pattern

 Labs
 No Glucose issues during the first 24hrs
 Bilirubin in the normal range as per risks
 Maternal RPR, HIV, HBsAG status known
 If Rubella non-immune inform OB resident to
make sure mom is vaccinated PTD
 No ABO setup, baby is Coombs negative
 Algo hearing test done (otoacoustic emission)
done

 Psychosocial
 At least 2 successful feedings without the help
of nurses (lactation consult if needed)
 Good maternal-baby bonding, no maternal
depression
 No nursing concerns

◦ Cord, skin, and genitalcare for infant
◦ Ability to recognize signs of illness and
common infant problems,particularly jaundice
◦ Proper infantsafety (proper use of a car safety
seat andsupine positioningfor sleeping)

 Teenage mothers <17 yrs with or without
prenatal care
 Teenage mothers <17 yrs without a family or
support system in place or other specified
problems (i.e. depression, lack of planning,
bonding)

 Mothers with substance abuse (present +
screen or previous)
 Mother with previous hx of post-partum
depression
 Discharge against medical advice

 Early discharges < 48 hours follow-up within 1
to 2 days or 72 hours (earlier visit not possible)
 If no risk factors, clinically well d/c after 24
hours
 If risk factors are present, clinically not well
appearing, required limited evaluation d/c
after 48 hours

A

 Problem-
◦ Any deviation from completely normal external
male or female genitalia
 Clitoral enlargement (> 1.0 cm)
 Labioscrotal fusion of any degree
 Hypospadias (penoscrotal, scrotal or perineal
)

 Any degree of hypospadias with unilateral or
bilateral cryptorchidism
 Micropenis (stretched length < 2.5 cm)
 Bilateral cryptorchidism ( with other
anomalies )

30
 Please do not include prominent labia minora
in a preterm
 Check the gestational age!!!!!!!
3/2/2011S O MAIYEGUN MD 07/03/13 30S O MAIYEGUN MD

 First degree (glandular): urethral meatus opens
on the underside of the glans penis in about 50–
75% of cases
 Second degree(Midshaft) :when the urethra
opens on the shaft
 Third 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, or with undescended testes
(cryptorchidism)

35
 Hypospadias ( 1st
and 2nd
degree) with
palpable testicles
 Observe and referral to urologist outpt
 No need for US kidneys (develops from
genital tubercles)
 Advice against circumcision (prepuce for
repair)

CHORDEE

 Plan-
 No gender assignment until after endocrine
consult
◦ As soon as possible after birth
 U/S abdomen ( uterus, testes, adrenals)
 Karyotype
 17-OH progesterone
 Electrolytes BMP ( virilization )

 LH, FSH, Testostorone, dihydrotestostrone,
DHT,
 Peds endo consult stat !!!!
 Parent education and counseling !!!!

 Problem-
◦ Initial HCT of <40 mg% (spun Hct)
◦ Pale newborn
 Plan-
◦ Do PE & check for symptoms ( splenomegaly,
tachypnea, tachycardia, shock, CHF, murmur )
—if present consult attending

 Plan-
◦ Check maternal history
 Severe prenatal anemia
 Perinatal blood loss
 3rd
trimester bleeding
 Maternal blood type & antibody screen
 Abruptio placenta or placenta previa

◦ Check birth history
 Asphyxia & Apgar scores
 Delivery method & special circumstances
 Plan-
◦ Lab w/u-
 CBC & peripheral smear
 Retics count, fractionated bili
 Blood type & Coombs

 Plan-
 Maternal Kleihauer Betke test (request OB
resident to order)
 Repeat HCT in 12-24 hrs – if decreasing
notify attending ( may need head &/or
abdominal US- liver/adrenal hemorrhage)

B

 Problem-
◦ Blood streaked diaper with normal stool
 Plan-
◦ Check for-
◦ Clinical activity
 Small laceration/fissure or area of irritation in
anal area
 Abdominal distention
 Other symptoms (poor feeding , vomiting
etc.)

 Plan-
◦ If no fissure-
 Stool for occult blood
 Stool for culture, WBC and rotavirus
 Stool for reducing substance
 **Apt test (send-out) take a while to get result
 If maternal blood – f/u
 If fetal blood – discuss with attending
 Make sure Vit K has been given

 CBC with diff :
◦ inflammatory response
◦ thrombocytopenia
◦ anemia
 If abdominal distention
 Stat KUB
 Stat CBC & CRP
 Discuss with attending

 Problem-
◦ Infant not moving arm ; arm & held limply
extended to the side with hand flexed
◦ Erb-Duchenne palsy (C5 - C6)
◦ Klumpke’ s paralysis ( C7-8 , T1)
 Plan –
◦ Examine infant-
 Clavicular crepitus
 Presence of grasp ( absent in Klumpke’s)
 Assoc. resp distress ( Erb’s) ; Horners synd
( Klumpke’s)

 Plan-
◦ Cxr with clavicles
 If clavicle fractured –immobilize arm
 F/u outpt with Orthopedics
◦ Physical Tx consult as outpt
◦ Neurology consult as outpt if severe Erb’s
palsy

 HR=85-160bpm (0-24hr) 100-175bpm(1-7days)
or > 2SD above the mean for age, asleep or
awake
 HR persistently < 80-100/min(awake),<70-
90/min(asleep) and/or dropped beats
 Dropped or skipped beats
07/03/13SOMAIYEGUN MD 5107/03/13 51S O MAIYEGUN MD

 Plans:
 Maternal Hx of SLE
 Ionized Ca with BMP(K+)
 EKG and CXR (pneumothorax/heart shape)
 Cardiac consult
 Echo after discussion with the attending

C

54
 Molding of the head
 Crosses the suture lines
 Subcutaneous soft tissue swelling
 Poorly defined margins
 Usually resolves over the first few days
 Observation
SOMAIYEGUN MD07/03/13 54S O MAIYEGUN MD

Subperiosteal hemorrhage
◦Unilateral or bilateral, most commonly over
parietal bone, rarely the occipital bone
◦Firm swelling or fluctuant
◦Limited by suture lines/ does not cross the
suture lines

 Plan-
◦ Obtain delivery history: SVD, forceps and
vacuum
◦ Check for jaundice q 12hrs (J-meter)
◦ Discuss with mother- reassurance
 May be felt till 3 mos of age & may calcify

 If large or bilateral, CNS signs, difficult delivery,
depressed skull fracture AP & Lat skull X-
Rays or CT head( discuss)
 If Hct dropped rapidly inform attending
 US head or CT head to r/o ICH/IVH
◦ PT/PTT, CBC (Immune
thrombocytopenia)
◦ If signs of shock IMCN

 There is increased risk of intracranial
hemorrhage among infants delivered by vacuum
extraction or forceps or unassisted vaginal
deliveries (or prolonged labor )
 ICH: subdural or cerebral hemorrhage,
intraventricular hemorrhage, subarachnoid
hemorrhage

 Problem –
◦ Shoulder dystocia @ birth
◦ Tenderness , swelling over clavicle
◦ Crepitus over clavicle
◦ Decreased movement of arm
 Plan—
◦ X-rays of clavicle

 It may be asymptomatic
 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 (Swaddle / immobilize)
 Orthopedic referral as out-patient, if severe
as in-patient ( discuss with attending)

 DD: partial dislocation of the elbow, Erb palsy,
fractured humerus
 Reassure mother and inform about subsequent
callus formation
 Full recovery usually occurs without treatment

 Problem-
◦ Abnormal buccal cavity
◦ Maybe unilateral , bilateral or midline
◦ Maybe mild , severe or partial
◦ Maybe submucosal with bifid uvula
 Plan-
◦ Obtain fam hx ,prenatal hx (meds)
◦ If midline  head U/S to r/o
holoprosencephaly

 Plan-
◦ Assess feeding
 Special nipple- Haberman nipple
 No bottle propping
 Feed in upright position
 Occupation therapy (OT) consult
 Plastic surgery consult as outpatient
 Genetics consult as outpatient if indicated

 Haberman nipple for feeding

 Problem-fixed or flexible (positional)
◦ Forefoot in fixed adduction
◦ Calcaneal tendon is shortened
◦ Foot is inverted with plantar flexion
◦ Inability to correct itself by stroking the outside
& inside of foot (fixed)
 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
 Any orthopedic abnormalities, discuss with
attending prior to ortho consult

 Eye prophylaxis with 0.5% erythromycin
ophthalmic ointment
 It is not effective in preventing neonatal
chlamydial conjunctivitis or extraocular infection
 Effective for prevention of gonococcal
ophthalmia

 Problem-
◦ Newborn with eye discharge
◦ Can be unilateral or bilateral
◦ Possible periorbital edema
◦ Eyelids may be erythematous or appear glued
shut

 Plan-
◦ Maternal hx of GC , Chlamydia , Herpes
◦ Delivery hx –( Erthromycin ointment application
, maternal vaginal discharge , PROM)
◦ Evaluate timing of onset , amount ,color,
consistency, tendency to return
◦ Plans;
 Gram stain and culture

 Plan-
◦ If Gram stain positive for bacteria or PMN’s ,
discuss with attending
◦ Cleanse eyes with sterile water
 Note—
◦ 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
 Can present within a few hours after birth
 Lid edema , copious purulent exudate ,
chemosis , clouding of the cornea

Gm stain  PMN’s & intracellular Gm negative
diplococci
Tx – Inform attending for transfer to IMCN for
Ceftriaxone and workup for sepsis
Reportable to Department of Health within
72hours

 Ceftriaxone (25-50 mg/kg, intravenously or
intramuscularly, not to exceed 125 mg) given x 1
 Cefotaxime x1 (100mg/kg IV or IM) is
recommended for infants with hyperbilirubinemia
 Infants with gonococcal ophthalmia should
receive eye irrigations with saline solution
immediately and at frequent intervals until the
discharge is eliminated

 Topical antimicrobial treatment alone is
inadequate and is unnecessary when
recommended systemic antimicrobial treatment
is given

 Hospitalized and evaluated for disseminated
infection (sepsis, arthritis, meningitis)
 Recommended therapy for arthritis and
septicemia is ceftriaxone or cefotaxime for 7
days, if meningitis is document treatment should
be continued for a total of 10 to 14 days

◦ If late onset > 1st
24 hours of life or suspected
causes other than reaction to eye prophylaxis
 Gram stain & culture
◦ Chlamydia conjunctivitis—
 Presents 5-14 days after birth
 Purulent discharge, eyelid edema &
conjunctival inflammation

 Conjunctival scraping for Chlamydia:
Infectious disease consult
 Reportable to Department of Health within
72hours

If mom is Chlamydia positive and with or
without treatment
Baby is asymptomatic  no treatment FU
in out-pt for signs of infection
 Prompt treatment of mother and her sexual
partner(s)

 Oral azithromycin for 5 days or erythromycin
base or ethylsuccinate for 14 days +
erythromycin eye ointment
 If unstable and severe respiratory  IV
erythromycin after evaluation for sepsis in IMCN
 Infantile hypertrophic pyloric stenosis (IHPS) in
< 6weeks (erythromycin)

 Problem—
◦ Infant with soft or ping-pong skull
◦ Usually over temporo-parietal region & along
suture lines
◦ Causes-
 Hydrocephalus ,OI ,syphilis, rickets ,
hypervitaminosis A , normal variation (sagittal
suture craniotabes in premies)

 Plan—
◦ Maternal Hx– infections , medications , family
history
◦ Transilluminate skull
◦ Head US & skull X-rays – if needed
◦ Check maternal RPR – if positive follow
syphilis protocol

D

90
 Problem-
◦ Hip “clunk”
◦ Positive Barlow or Ortolani sign
◦ Unequal thigh/gluteal creases or leg lengths
◦ Strong family history
◦ Breech presentation
SOMAIYEGUN MD

 Plan-
◦ If “click” present  re-examine @ D/C
◦ If “click” & + strong family history Ortho
consult
◦ If “clunk” present Ortho consult
◦ U/S hip if needed, will be ordered or advised
by orthopedics
◦ FU with PCP
◦ Only ClickRe-check hips in 2 weeks(AAP)
SOMAIYEGUN MD07/03/13 91S O MAIYEGUN MD

 Breech with abnormal click/clunk prior to
discharge Ortho consult or otherwise U/S hip at
4-6 weeks of age and/or radiographic imaging at
4-6 mos (AAP)
 US hip screening of all breech newborns will not
eliminate the possibility of later acetabular
dysplasia (AAP)

 Problem—
◦ 2 abnormal stools in an 8 hour period
◦ Numerous large watery , foul smelling stools
with blood , mucous
 Plan—
◦ Examine baby & review vitals
◦ Look at stool
◦ Send stool for reducing substances,
leucocytes, RBC & culture, rotavirus

94
 If reducing substance positive(+)  switch to
soy based formula/ lactose free milk
◦ If stool is watery++ sent stool for electrolytes
◦ BMP
◦ Suspect chloride diarrhea in mom with hx of
polyhydramnios

 Plan—
◦ If baby looks sick , abnormal vitals , abdominal
distention get KUB stat , CBC , CRP, BMP
◦ Inform attending
◦ Discuss normal variations in stooling patterns
with mother

 Breast fed stools-frequent, without form, may
be mucousy; affected by maternal diet ( fruit ,
laxatives ,medications)
 If starvation present may be frequent , small
quantity, dark green
 Stools can be less frequent & pasty

◦ Discuss normal variations in stooling patterns
with mother
 Breast fed stools-frequent, without form ,may
be mucousy; affected by maternal diet ( fruit ,
laxatives ,medications)
 If starvation present may be frequent , small
quantity, dark green
 Stools can be less frequent & pasty

 3-8% of NB
 The possibility of occult spinal dysraphism
(OSD) is more likely if above the gluteal cleft
(truly sacral in location) because they are more
likely to be contiguous with the dura
 Within the gluteal fold: less likely to be
contiguous with the dura and are much more
likely to be a normal variant

 Simple or low risk :
 Position – within the gluteal fold or coccygeal
position
 Single dimple
 < 5 mm diameter
 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
 Distance < 2.5 cm from anus
 Normal neurological examination

 Difficult to clearly distinguish all variations
consider the individual circumstances
 Plan: U/S spine
3/2/2011 102S O MAIYEGUN MD 07/03/13 102S O MAIYEGUN MD

 Midline / vertebra appearance of significant
tuft of hair ,hemangioma or nevus
 Plan: U/S spine

 Discharge diagnosis is very important
 Make an assessment regarding what
observation and treatment the infant needs and
discuss findings with the parents
 Explain to the parent(s) of the possible
consequences for their infant if they leave e.g
sepsis, jaundice
 Explain the need for FU in 1 or 2 days and ER
warnings
 Consult with the social worker (SW)

 If medical diagnosis or concerns exist which
may result in immediate harm to the infant
 Remind parent(s) that their action is contrary to
the welfare of their infant and that Department
for Child Protective Services (CPS) will be
notified
 Child can be kept in the holding nursery if
mother wants to go home

 Consult with the social worker (SW)
 They will make an assessment and consult with
CPS or Crisis Care (after hours/weekends) as
necessary
 CPS hold statutory powers and have the
authority under the Children and Community
Services Act 2004 to protect the welfare, care
and protection of children

 Infant with features of Down syndrome
◦ Talk to the family (mom)
◦ No d/c prior to 48 hrs of age
◦ Evaluate feeding / vomiting (duodenal atresia)
◦ Glucose series (hypoglycemia)
◦ CBC with diff & platelets(polycythemia,
leukemoid reaction or leukemia)
◦ Ensure good follow-up

 Karyotype (with informed consent)
◦ Maternal and family history
◦ Echocardiogram prior to discharge
◦ Cardiac consult as needed
◦ Genetics consult as out-patient

E

 Problem—
◦ Grossly abnormal ears
◦ Significant low set and posteriorly rotated ears
◦ Incomplete auricle
◦ No visible ear (anotia)
◦ Multiple significant ear tags (pre-auricular tags)
◦ Pre-auricular sinus/pit with a blind end is not
included

 Plan—
◦ Strong family history of similar defects
◦ Hearing test (ALGO 2)  if failed schedule for
BAER test
◦ Renal US to r/o abnormalities after discussing
with faculty
◦ Look for other dysmorphic features and
associations

 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

 Newborn with copious oral secretions and
episodes of coughing, choking, and cyanosis
 Hx of pregnancy complicated by polyhydramnios
 Plans: place an orogastric suction catheter and
obtain a chest radiograph

 VACTERL association
 V Vertebral or Ventriculoseptal defects
 A Anal atresia
 C Cardiac anomalies
 T/E Tracheoesophageal fistula/ esophageal
atresia
 R Radial dysplasia / Renal anomaly
 L limbs

F

 Problem—
◦ Large anterior fontanel (>5 x 5 cm)
with/without large posterior fontanel
( > 2 cm)
◦ Open metopic suture
◦ Open coronal suture
 Plan—
 Check HC yourself ; neurologic exam
 T4 & TSH ; head sono ; discuss with
attending

G

◦ GBS+ mother with 1 dose of intrapartum abx
< 4hrs PTD  CBC and CRP at 24 hrs
◦ GBS+ mother with at least 1 dose of
intrapartun abx > 4hrs PTD asymptomatic
observe for 48hrs
◦ No discharge prior to 48 hrs of age
 If baby is unstable  CBC/+ CRP (if
>24hr) stat ± transfer to IMCN as
appropriate

◦ PROM >18hrs (+ intrapartum abx given to
mum), if stable CBC & CRP at 24 hrs and
re-evaluate
◦ PROM >18hrs (no intrapartum abx given to
mum) CBC at birth and CBC & CRP at 24
hrs and re-evaluate

◦ GBS (+)mum, good PNC, term ≥37wks, SVD
◦ Adequate intrapartum antibiotic prophylaxis
(IAP) given
◦ Asymptomatic baby
◦ Mom is able to comply with home instruction for
observation
◦ Can be discharged home after 24hrs if other
discharge criteria are met
◦ If discharge criteria are not met  observe for
48hrs

◦ Intrapartum antibiotic prophylaxis (IAP)
◦ Adequate if penicillin, ampicillin or cefazolin is
given at the proper doses for four or more
hours prior to delivery
◦ Duration of IAP shorter than four hours and all
other antimicrobial regimens,
 clindamycin
 Vancomycin
◦ are considered as inadequate because no data
regarding efficacy are available

 Penicillin and ampicillin rapidlyachieve
therapeutic levels in the fetal circulation and
requirethree hours to achieve therapeutic levels
in amniotic fluid
 Cefazolin has similar pharmacokinetics and is
the preferredagent for IAP in penicillin allergic
women with no history ofanaphylaxis,
angioedema, respiratory distress or urticaria

 Problem:
◦ No documented PNC or GBS unknown
◦ Prenatal care at lay midwife maternity center
◦ Less than 4 visits starting later than 28th
week
of gestation
 Plan—
◦ Check perinatally drawn maternal labs and
please document prior to D/C

 If baby is stable: NO screening with CBC and
CRP at 24 hours
 Observe for 48hour in the hospital
 If baby symptomatic at anytime
<24hours CBC stat ± transfer to IMCN
as appropriate
 If symptomatic > 24hours CBC and
CRP ± transfer to IMCN as appropriate

◦ PROM >18hrs (+ intrapartum abx given to
mom), if stable CBC & CRP at 24 hrs and
re-evaluate
◦ PROM >18hrs (no intrapartum abx given to
mom) CBC at birth and CBC & CRP at 24
hrs and re-evaluate
◦ GBS (–)negative in the hospital and NPC 
48hrs observation

◦ Any symptoms  CBC stat or CBC and CRP if
>24hrs or transfer to IMCN as appropriate
◦ If labs are grossly abnormal CRP>20 x 2 or
CRP >40 X1, WCC>30 or <5, even if clinically
stable, discuss with attending for possible
transfer to IMCN
**48-hour CBC and CRP will be ordered after
24-hour lab is reviewed

 Problem—
◦ Maternal h/o GC during pregnancy
 Plan—
◦ Maternal h/o tx & documentation of cure
◦ If inadequate or no documented test of cure 
Ceftriaxone 125 mg I/M x 1
◦ No discharge prior to 48hrs

H

 Problem—
◦ Maternal h/o hepatitis
◦ Mother known HBsAg carrier
◦ Mother @ high risk for being a Hep B carrier
( known or suspect IV drug use , mother from
endemic region)

 Plan—
◦ Verify maternal HBsAg status
◦ If mother positive
◦ Hep B Ig (0.5 cc I/M) within 12 hrs of birth
 Hepatitis B vaccine ( 0.5 cc I/M) concurrently
@ different site
 Breastfeeding is not C/I
 ID consult as outpt

 Plan—
◦ Infants delivered to mothers who are jaundiced
,h/o hepatitis of unknown etiology or who are
in a high risk group & have not been screened
—
 Hep B vaccine (0.5 cc I/M ) within 12 hrs of
birth
 Verify mothers HBsAg status ; make sure it is
drawn. If positive give HBIG

 Plan—
◦ Mother is Hepatitis C+(anti-HCV-positive )
 Order Hep C Ag on baby : (Ig) G antibody
enzyme immunoassays for HCV and NAA
tests to detect HCV RNA
 Assays for IgM to detect early or
acute infection are not available
 Transmission of HCV by breastfeeding has
not been documented

 Not a contraindication to breastfeeding
 Mothers who are HCV positive and choose to
breastfeed should consider abstaining if their
nipples are cracked or bleeding
 F/U with ID as outpt to monitor LFT and anti-
HCV

 Problem—
◦ Mother identified as having vaginal herpes
◦ Previous h/o herpes
 Plan—
◦ PE of the baby for rash (vesicles)
◦ Delivery hx-C/S or vaginal ( higher risk)
◦ Instruct mother on care of infant (good hand
washing etc)

 Care of infants born vaginally to a mother with
active genital ulcerative lesions. Primary 1st
episode of HSV infection or known recurrent
lesion or status unknown IMCN in isolation
 Care of the infant born via C/S to a mother with
active genital ulcerative lesions (primary,
recurrent or unknown) esp if onset of labor or
ROM > 4hoursIMCN in isolation

 Care of the 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
 Care of the infant born by C/S (intact
membrane) and no active lesions at delivery.
 No isolation necessary

 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
 She should not kiss or nuzzle her newborn until
lesions have cleared
 Herpetic lesions on other skin sites should be
covered

 Problem—
◦ Mother’s HIV is positive
 Plan If complete HIV testing is pending after
birth and the mom is Elisa positive
 Western Blot (WB) still pending then breast
feeding should not be initiated until the WB has
been reported negative
◦ If mother’s WB is (+) 
◦ if baby is stable, can start PO AZT
◦ if unstable IMCN to start on IV AZT
◦ If mothers WB is (-) ,no issues

 Plan—
 Detailed hx for risk factors
 Zidovudine (AZT) must be started 6-12
hours after AZT(8mg/kg/day) PO q6hrs X 6
weeks
 Send HIV DNA PCR within the first 48
hours after birth
 Cord blood should not be used
 ID consult as in-patient

 Plan—
 If hx inconclusive
 ID consult
 FU on HIV DNA PCR in baby

 Maternal history of diabetes, Fever
 PROM >18hours (CDC, AAP)
 <37wks
 Weight ≥3800 gms and ≥2500gms
 LGA >90th
percentile or SGA/IUGR < 10th
percentile for weight

 All high risk babies are screened with blood
glucose
 Regardless of gestation a serum glucose <
40 mg/dL is hypoglycemia
 A serum glucose < 45 mg/dl if symptomatic will
be treated as hypoglycemia

 Glucose level less than 30mg/dL (<30mg/dL) by
I-STAT will be admitted to EPCH
 Treatment will not be postponed
 Newborns will be formula fed as medically
indicated for hypoglycemia less than 30mg/dl
prior to admission to EPCH at 10ml/kg

 Pre-prandial serum glucose q 3 hours during the
first 24 hours of life
 Glucometer and confirmed by I-STAT if level is
less than 40mg/dl

 Glucose Series =>
 Glucose level > 30mg/dL but < 40 mg/dL
immediate feeding and a repeat glucose 30 to
60 minutes after feeding
 If repeat glucose is > 40mg/dL monitor pre-
prandial glucoses and oral feedings every 3
hours for 24 hours

 Glucose is < 40mg/dL after initial feeding, and
result after one hour postprandial retesting is still
< 40mg/dL transfer to EPCH
 Glucose level > 40mg/dL will be treated orally by
breastfeeding every 1 to 3 hours expressed
formula and/or house formula every 2-3 hours

 Breastfeeding shall occur every 1 to 3 hours and
on demand
 If at 24 hours preprandial glucoses are < 50
mg/dL, preprandial glucose should be monitored
another 12 hours
 If preprandial glucoses are < 50 mg/dL at 36
hours, the Newborn will be transferred to EPCH
for further evaluation

 Problem—
◦ Infant with enlarged scrotum
 Plan—
◦ PE to palpate testes
◦ Transilluminate, if unable to palpate testes
◦ If scrotum is hard , indurated & discolored
Doppler U/S of testes
◦ Doppler U/S Testicular torsion surgery
consult immediately

 Problem—
◦ Evidence of hydronephrosis on prenatal ultrasound
◦ Enlarged palpable kidneys on PE
◦ Hydronephrosis on US done for other anomalies

158
 Plan—
◦ Check voiding—if no void in 24 hrs 
transfer to IMCN
◦ Minimal hydronephrosis grade 1 US and
reassurance if still minimal or negative
◦ If no urine >24hrs UA , BMP and follow
protocol for anuria >24hrs

◦ Moderate hydronephrosis grade 2  US, if still
moderate VCUG, If no urine >24hrs UA ,
BMP
◦ If VCUG is abnormal discuss with attending for
Mx, prophylactic abx
◦ Urology referral as out-pt or in-pt as
appropriately

160
 Plan—
◦ Grade 3 and 4 IMCN ( US, UA , BMP
,VCUG) discuss with attending & mother
◦ Urology referral as in-pt or out-pt as
appropriate
◦ Outpatient: FU U/S in 6 weeks (mild and
moderate) and if still abnormal VCUG
Urology referral as outpt (MAG3)

 Problem –
◦ Rectal temp > 101.0
 Plan –
◦ Unwrap pt & repeat temp in 30 mins
◦ Review maternal hx ( GBS , PROM , fever , s/s
of chorio )
 If positive  CBC stat or CBC & CRP if > 24
hrs
◦ If temp not decreased in 2 hrs – inform
atttending for transfer to IMCN

 Plan –
◦ Transfer to IMCN if symptomatic @ any time ,
temp > 102 , abnormal CBC or CRP > 20 or
rising
◦ IT ratio >0.2
◦ No d/c before 48 hrs of age

 Problem—
◦ Infant with increased muscle tone
 Plan—
◦ Perinatal hx for asphyxia , traumatic delivery ,
dysmorphic features
◦ Suspect drug withdrawal-
 Maternal hx
 Urine/Mec tox screen in baby
 Watch for other signs of withdrawal

 Plan—
◦ CT scan of head ( structural abnormalities,
hemorrhage )
◦ If dysmorphic features karyotyping
◦ No D/C prior to 48 hrs of age

 Problem—
◦ Infant with rectal temp < 97.6
 Plan –
◦ Evaluate environmental conditions
◦ Check gest age , weight , feedings
◦ Check maternal hx for possibility of ascending
infections
◦ Place under radiant warmer & check rectal
temp in 30 mins

 Plan—
◦ If persistent low temps > 2hrs – CBC , CRP
◦ If results abnormal  transfer to IMCN
◦ If 2 temp drops  CBC stat or CBC& CRP if >
24hrs If results abnormal ,transfer to IMCN
◦ If 3 temp drops  transfer to IMCN

 Problem—
◦ Floppy infant
 Plan—
◦ Complete CNS exam
◦ Maternal narcotic admn in last 4hrs PTD
 I/M Narcan ( 0.1 mg/kg )
◦ Maternal h/o of MgSO4 tx for PIH
 If present – magnesium level

 Plan—
◦ Birth h/o asphyxia ; apgar scores
◦ Check feeding
◦ Lab w/u—
 Mg , glucose , HCT , CBC ,CRP
 Head US (consult attending )
◦ No d/c home prior to 48 hrs of age

I

 Problem—
◦ Maternal h/o diabetes
 Plan—
◦ PE for associated anomalies
◦ If no stool – discuss with attending
◦ Place on glucose monitoring series
 If 2 drops in glucose ( <40 mg %) while on
the series , transfer to IMCN
 If glucose is < 30 mg% at any time transfer

 Plan—
◦ Check HCT
 If > 65 ( central ) and symptomatic transfer
to SCN
◦ If jittery , check Se calcium & glucose at once

 Problem—
◦ Maternal h/o substance abuse during
pregnancy
◦ Maternal h/o substance abuse
◦ Maternal s/s suggestive of drug or alcohol use
◦ Positive toxicology in mother
◦ Unexplained irritability /jitteriness in baby

 Plan—
◦ Observe infant for s/s of withdrawal
◦ Check mother’s urine tox
◦ Send meconium and urine tox screen in baby
◦ If h/o cocaine use during pregnancy and urine
tox is positive in baby transfer to IMCN

◦ If h/o marijuana use & urine tox is negative in
baby, observe in MB for 48hrs
◦ If h/o amphetamine use during pregnancy or
urine tox is positive in baby IMCN
◦ If negative amphetamine in baby’s urine tox
screen observe in MB for 48hrs

 Plan –
◦ If baby’s & mother’s tox screen is negative –
observe in MB
◦ Check maternal HBsAg & HIV status
◦ ***Social service consult
◦ If any signs of withdrawal ,discuss with
attending or transfer to IMCN

J

◦ All O+ and RH- mothers baby's blood group
and Coombs
◦ J-meter q shift (routine) on all babies

 Appears within 24 hours
 Level rises > 0.5mg/dl/hour
 Evidence of hemolysis(↑ bili,↑retics, ↓hct)
 Physical exam is abnormal
 Direct bilirubin > 20% of total bilirubin (Tbili)

◦ Causes:
◦ Excessive bruising
◦ Cephalhematoma
◦ Subdural hematoma
◦ IDM, breastfeeding
◦ Galatosemia
◦ G6PD deficiency
◦ Polycythemia
◦ Hemoglobinopathy, etc

 Plan—
 J-meter q shift
 Rh & ABO incompatibility J meter q 6 hrs or
12 hrs and T.bili and retics count earlier (6hr) or
at 24hrs (depending on severity)
 If retics is high and bili increasing Hct earlier
(6hr) or at 24hrs ( depending on severity)

***If any child is jaundiced in the 1st
24 hrs of life
and J-meter is above the curve
 Do initial total bilirubin ,if above the curve as
per the risks in the child  plan for
phototherapy (PT)
 If below the curve as per the risks then FU J-
meter q shift and fractionated bili q 12 hrs as
necessary

 If concerning do F.Bili q 4-6 hrs and decide
 If the rate of rise is greater than 0.5mg/dl/hr
or above the appropriate curve plan for PT
 If set-up for sepsis discuss transfer to
IMCN

 Obtain informed consent from mother prior to PT
 Start PT as per jaundice chart
 Use total bilirubin (do not subtract direct
bilirubin)
 Keep baby naked (genitalia and eyes covered)
 Monitor temperature and thermal environment
 Monitor input/output and increase fluid intake by
10ml/kg/PT
07/03/13MAIYEGUN MD 185

 Provide irradiance of at least 4µW/cm2/nm
 Provide irradiance 30 4µW/cm2/nm or > if
intensive PT is needed
 Use double or triple light with biliblanket if level
is high or rapidly rising
 Brief interruption for feeding will not interfere
with PT
07/03/13MAIYEGUN MD 186

 Lab w/u in infant’s under phototx—
◦ CBC at 24hr of life ; retics count (ABO or Rh)
◦ Follow F. bili q 6-12 hrs
◦ If bili rising then order hct and retics
◦ BMP ± Urine SG (dehydration)
◦ Urine reducing substance ( if Coombs neg) r/o
galactosemia

◦ Peripheral smear ( if Coombs neg and severe),
spherocytosis (Fx Hx) ,fragmented RBCs in
hemolysis
◦ If African/Asian/ Middle Eastern and severe
and Coombs neg  G6PD assay
◦ If there is setup for sepsis or abnormal labs
discuss for transfer to IMCN

◦ Discontinue phototx
 when bili decreases 2 consecutive times
 check bili at 12 hrs after stopping phototx
(d/c home if rebound does not exceed 3.0
mg/dl)
 Direct bilirubin > 20% of total bilirubin (Tbili)

◦ If direct bili rising, please inform attending
 Direct hyperbili >20% of the total bilirubin is
abnormal at any age
◦ Urine reducing substance (galactosemia)
◦ UA for bilirubin
◦ No PT or discontinue
◦ Physical exam (hepato-splenomegaly)
◦ Discuss for transfer to IMCN for further work-
up

 Jitteriness is not associated with ocular
deviation
 Generalized and symmetrical
 It is stimulus sensitive (easily stopped with
passive movement of the limb by holding onto
the baby’sarm)
 Also becoming most prominent after startle
 The movement resembles a tremor, and no
autonomic changes are associated with it

 Plan—
◦ Maternal h/o drug use, diabetes,infections
◦ Check initial CBC stat or CBC & CRP at
24hrs, if set-up for sepsis
◦ Urine and mec toxicology screen
◦ Ionized Ca , glucose level
◦ If severe, check Mg ,Phosphate, Parathyroid
hormone (PTH)

 Plan—
◦ Discuss with attending if CBC ,CRP abnormal
◦ Hypocalcemia: If Se Ca is < 2.0mmol/L
(8.0mg/dl) and ionized calcium < 1.0mmol/L
(4.0mg/dl) in symptomatic NB discuss
◦ Se calcium < 7.0 mg /dl and ionized calcium <
0.9mmol/L (3.6mg/dl) asymptomatic discuss

◦ If Se Magnesium < 1.0 mg/dl with
hypocalcaemia –discuss for transfer
◦ If Se Glucose < 40 mg/dl --- follow glucose
protocol
◦ FU results for discussion

L

 Problem—
◦ BW > 3800gms
◦ Wt > 90 %ile for gestational age
 Plan—
◦ Place on glucose series & follow protocol
◦ Check HCT
◦ Maternal h/o diabetes
◦ PE for brachial plexus injuries & clavicular
fractures

M

 Problem—
◦ Head circumference > 38.0 cm
◦ HC disproportionately greater than 50th
% tile to
BW & length
 Plan—
◦ Check HC yourself
◦ Family hx of large heads
◦ Maternal h/o TORCH infections
◦ Check head for split sutures

 Plan—
◦ Head US if abnormally split sutures
◦ Transilluminate skull
◦ If transillumination positive or hydrocephalus
present, inform attending for discussion
◦ CT head as needed

 Mom given MgSO4:
 If term baby, stable in nursery or MB and
asymptomatic: NO serum magnesium
necessary, but monitor closely
 If symptomatic (preterm, poor feeding, low apgar
scores, apnea, resp distress or frequent
desaturation, cyanosis, no meconium in
>48hours) then  serum magnesium ± transfer
to IMCN/ICN as appropriate

 No meconium in >48hours
 99% of term and 76% of preterm pass stool in
the 1st
24hrs
 99% of preterm pass stool in the 48hrs
 Plans :
 Medications in mother: MgSO4, opiates
 Imperforate anus, intestinal obstruction,
hirschsprung disease, malrotation, meconium
plug/ileus, duodenal atresia, small left colon
syndrome (IDM)

 PE: Document patency of the anus (rectal
thermometer or feeding tube
 Abdominal exam ( distension, rigidity, BS, mass)
 CBC stat or CBC& CRP if set up for sepsis
 KUB stat
 If Hx of drug use urine and mec tox screen
 S. magnesium level if maternal MgSO4
 FT4 and TSH

 If all labs normal, If no meconium > 48 hours
consider barium enema to evaluate for
Hirschsprung disease
 Surgical consultation for rectal biopsy
 ***Discuss the use of suppository after 48hours
with attending
 No discharge until passage of stool

 Problem—
◦ Infant with small head ( HC <10%ile) or greater
than 50th
percentile difference between head &
weight /length
 Plan—
◦ Maternal hx for TORCH infections , drug or
alcohol use ,Rxn drugs ( phenytoin)
◦ Fam hx of small heads & MR

 Plan—
◦ Head US /CT scan
◦ If needed Total IgM for TORCHES & Urine
culture for CMV
◦ Discuss with faculty

 Perinatal Hx
 Exam for resp distress
 Pulse ox stat and continuous as needed
 CXR to r/o abnormalities
 CBC stat or CBC& CRP(>24hrs) if set up for
sepsis
 If significant abnormal results consider
transfer to EPCH
 If grunting (discuss and consider transfer)

Apparently healthy infant noted to have heart
murmur on PE
 Grade 1-2 murmur @ birth
 Acyanotic with no significant problems ,re-
examine @ 2nd
day of life
 Grade 3-4 on day 1 or significant murmur found
on 2nd
day of life

 Plan—
◦ Full cardiac exam
 4 limb BP’s
 Pulse ox- spot or continuous as
appropriate
 Hepatosplenomegaly
 Feeding
 CXR (cardiac shape)
 Echocardiogram (specific and diagnostic)
◦ EKG as needed

 Plan—
◦ Cyanosis or severe respiratory distress 
transfer to IMCN
◦ Grade 1-2 murmur on 1st
day of life with
symptoms
◦ Discuss with faculty for possible transfer to
IMCN/ICN

P

 Problem—
◦ Red/purple , non-blanching spots on skin/ face
 Plan—
◦ Maternal hx of TORCH infection or at risk for
ascending infection
◦ Maternal labs –thrombocytopenia
◦ CBC stat and CBC and CRP at 24hrs
◦ Perinatal h/o asphyxia , nuchal cord , trauma ,
forceps
◦ Observe for signs of sepsis & discuss with
attending

 All high risk babies are screen with capillary
hematocrit
 Central venous hematocrit >65%
 If capillary hematocrit is more than 65%
repeat from central venous from a cubital vein
◦ Central HCT ( no tourniquet , deep vein
, no femoral sticks )
◦ Check for jaundice ; check Se glucose

 Symptoms of hyperviscosity: Plethora
 temperature instability
 feeding problems
 plethora
 irritability
 lethargy
 hypoglycemia
 respiratory distress
 hypoperfusion

 Central Hct is 65-69% and the infant is
asymptomatic no intervention is warranted,
repeat central Hct at 24 hrs
 If ≥ 65 % and the infant is symptomatic IMCN
for partial exchange reduction
 If >70% IMCN for a partial reduction exchange
 Discuss with faculty

 Ulnar or postaxial polydactyly commonly
isolated in African black children, autosomal
dominant transmission
 More frequent in blacks than in whites and is
more frequent in male children

 In contrast, postaxial polydactyly seen in white
children is usually syndromic and associated
with an autosomal recessive transmission
 Radial or preaxial polydactyly is frequently
associated with several syndromes
 Any other forms of polydactyly/syndacytly/cleft
hand or feet need orthopedic consult

 Problem—
◦ Skin tag or extra digit on healthy infant
◦ Look for other dysmorphic features
◦ Document pre or post-axial polydactyl
 Plan—
◦ Inform mother
◦ If skin tag has a thin pedicle tie off with vicryl
suture after obtaining informed consent from
mother

◦ Extra digit—
 X-rays to document if bone present
◦ If no bone  can tie off with vicryl suture after
obtaining informed consent from mother
 If bone present refer to pediatrics
orthopedics as outpatient
 Any lower limb polydactyl or preaxial need
referral to orthopedics

R

 Persistent respiratory distress beyond 4 hrs
transitional period
 Retractions (I/C and S/C), moaning, grunting
 Respiratory rate: persistently >60/min
 Frequent desaturations
 Cyanotic episodes
 Plans: CXR stat (to r/o pneumonia,
pneumothorax, cardiac shape )
 CBC and if >24hrs CBC & CRP
 Discuss with faculty for transfer to IMCN

 Problem –
◦ Mother with positive serology for syphilis
◦ RPR and TPPA
 Plan—
◦ RPR on baby
◦ Detailed maternal hx ( confirmatory labs &
treatment hx)
◦ If mothers TPPA negative no issues

 Plan—
◦ If mothers TPPA is positive 
◦ detailed h/o treatment
 documented evidence of drug used
(Penicillin)
 timing of tx
 decreased titers 4x after tx
 evidence of tx of spouse )

◦ Transfer to IMCN for full work-up
◦ If baby’s titer is at least 4 X maternal titer
◦ No h/o tx
 Last dose of PCN within the last month prior
to delivery
 Drug other than PCN used
 No evidence of decreased titers
 Possibility of re-infection( no tx of spouse)

 Plan
 If mothers TPPA + & documentation of
satisfactory treatment available (follow the CDC
guideline attached)
 refer to ID as out-pt after discussion with
faculty
◦ Transfer to IMCN if infants RPR > 1:4 after
discussion with faculty

S

 Problem—
◦ Maternal h/o SLE
 Plan—
◦ EKG ( bradycardia , complete ht block)
◦ CBC (thrombocytopenia/leukopenia/anemia)
◦ Examine skin for rash ,if present – no sun
exposure, self limiting
◦ FU with PCP

 Problem—
◦ Weight < 10%ile for age
 Plan—
◦ Determine gestational age
◦ Determine IUGR status
◦ Maternal h/o placental insufficiency , TORCH
infections , nutrition hx ,h/o chronic diseases &
drug use )

 Plan
 Place on glucose series
◦ Check HCT
◦ Follow feedings
◦ Follow temperatures
◦ If hx suggestive of TORCH infection –CBC ,
Total IgM & discuss with attending

 Problem—
◦ Stuffy nose , trouble breathing
 Plan—
◦ Check patency of nares ( pass 8Fr feeding
tube B/L ) auscultate for air passing through
each nare after blocking the other one)
◦ Pulse ox as needed
◦ Normal saline nasal drops and bulb suction
◦ Bedside Humidifier (cool mist)

 Plan—
 Check maternal h/o syphilis ( snuffles)
◦ Follow feedings
◦ If severe discuss with attending
◦ Bedside Humidifier (cool mist) @ home

 Bleeding in the potential space between the
periosteum and the galea aponeurosis
 Risk factors as in cephalhematoma
 Fluctuant boggy mass and crosses the suture
lines
 Hemorrhagic shock and significant
hyperbilirubinemia
 Labs for coagulopathy
 Close observation, if severe  IMCN

T

 HR persistently more than 160-175bpm or >
2SD above the mean for age, asleep or awake
 Plan:
 Maternal Hx of thyroid disorder
 Fever  check temperature
 Birth Hx (forceps or vaccum)
 EKG stat
 CXR and CBC stat and >24hrs CBC and CRP
 Inform attending for transfer to IMCN

 Problem—
◦ Infant born with teeth ( loose or firm) ;either
visible or soft mucoid tissue cysts along
alveolar ridge with palpable loose tooth in it
 Plan—
◦ If loose  talk with mother regarding need for
removal refer to dentist
◦ If well embedded  can FU later with dentist

 Problem—
◦ Empty scrotum or hemiscrotum
 Plan—
◦ Unilateral cryptorchidism – no intervention 
Urology consult as out-pt
◦ Bilateral, with no palpable testes in canal
abdominal US (testes, ovaries, adrenals)
◦ If U/S shows abdominal testes  Urology
consult as out-pt

◦ Bilateral with palpable testes in inguinal
canal no intervention recheck gestational
age
◦ If no testes on US ambiguous genitalia
protocol

 Problem—
◦ Maternal h/o thrombocytopenia at time of
delivery or during pregnancy
◦ Platelet count< 150,000
 Plan: Repeat platelet count before decision is
made
 CBC with platelet on baby
◦ If < 50,000 – transfer to IMCN
◦ If > 50,000 – repeat in 24 hrs
◦ Check baby for petechiae ,bruising, oozing
from cord

 4% of newborns
 Can breastfeed without difficulty, but in some
cases, a tight frenulum makes latching on
difficult
 No evidence based reason to clip the frenulum
in the nursery
 In cases of difficulty feeding , frenotomy may be
indicated

 Problem—
◦ Single umbilical artery
 Plan—
◦ Renal US
◦ Check for urination
◦ Check for dysmorphic features

249SOMAIYEGUN MD07/03/13 249S O MAIYEGUN MD

U

 Urate crystals look different from blood in the
newborn’s diaper but can be confused
 They tend to sit on the surface of the diaper and
are iridescent and completely benign
 M=F
 More observed in boys

 No urine in > 24hrs
 100% of neonates pass urine in 24 hours Plan:
 Maternal History: olighydramnios (renal
anomalies)
 Prenatal history of fetal hydronephrosis, kidney
anomalies
 Check L& D papers
 MOST likely reason: undocumented void in
the delivery room

 Make sure there is adequate intake, lactation
consult if necessary
 Supplement with formula if needed

 If no urine more than 24hrs 
 Placed a cotton ball between the labia or a urine
bag ( check urine)
 Bladder palpable (manual compression may
initiate voiding) if a boy think of PUV
 Bladder catheterization If no urine US
bladder, kidneys IMCN for further workup
 Check BP, BMP
 No discharge until the passage of stool and
urine can be documented

 There is no immediate danger to the baby, so
parents can sign that they do not consent
 There is no need for social service consult

 Projectile and forceful, vomiting with feedings
>2, ± abdominal distension/tenderness
 Greenish emesis or Bloody emesis
 Confirm passage of meconium
 Look for dysmorphic features (Down Syndrome)

 Plan: Hx of sepsis set-up
 KUB stat (NEC, pneumoperitoneum, double
bubble, etc )
 CBC stat or CBC & CRP >24hrs
 Inform faculty

Neonatal
Pictures

 Most common
 Dermal melanocytosis
 96% of African-American
 46% of Hispanic
 10% of white children
 Common locations are the buttocks, midsacral but
shoulders and extremities may be involved

Reassurance

Reassurane

 Sebaceous retention cyst
 These small, whitish-yellow
papules are found close to
the skin surface, being
particularly common around
the eyes and midface
 Reassurance

 Note the yellowish
papules on the nose of
this infant
 Sebaceous gland
hyperplasia
 Reassurance

 Caused by sweat retention
 Characterized by a vesicular eruption with
subsequent maceration and obstruction of the
eccrine ducts
 Keratinous plugging of eccrine ducts and the
escape of eccrine sweat into the skin below the
level of obstruction

 Miliaria crystallina (sudamina): clear superficial
pinpoint vesicles without an inflammatory areola
 Miliaria rubra (prickly heat): deeper level of sweat
gland obstruction, and characterized by small
discrete erythematous papules, vesicles, or
papulovesicles

 Sweat rash and heat
rash :ducts connecting
sweat glands with the
surface of the skin get
blocked & perspiration
gets trapped under the
skin
 Reassurance

 Numerous tiny
erythematous papular
lesions on face, neck,
and upper trunk
 Reassurance

 Numerous tiny
papulo-pustular
lesions
 Cytologic exam
:inflammatory cells
 Gram staining may
reveal gram+cocci
(staphylococci)
 Sepsis workup and
antibiotics as needed

Reassurance

 Pearls (sebaceous retention cyst) may be found in a
variety of locations in the newborn
 The tip of the foreskin is another relatively common
location
 The pearl is a small, firm, white nodule that contains
keratin
 It will spontaneously exfoliate and resolve with time
 It is a normal finding and is not a contraindication to
circumcision, if desired

 Numerous yellow papules
and pustules are surrounded
by large intensely
erythematous rings
 50% of full terms
 Rare in preterms
 Eosinophils + (Wright stain)
 Reassurance

 Note the reticulated bluish-
purple mottling of this infant's
thigh
 -Vasomotor instability
 -Normal
 -Poor perfusion, hypovolumia
 -septic shock
 -Cornelia de Lange
syndrome
 -Down syndrome

 Nevus flammeus
neonatorum: a typical light
red splotchy area is seen at
the nape of the neck and
forehead
 Dilated superficial capillaries
 Reassurance

 Characteristic purplish-red
lesion covering nearly half of
face
 Capillary malformation
 If neurologic signs MRI
brain and Ophthalmology
consult
 Reassurance

 Multiple soft, red, raised
lesions dot the back and
arms
 Reassurance

 The vessels that make
up this large, partially
compressible lesion are
deep beneath the skin
surface but still impart
a bluish hue to the
overlying skin. Note the
indistinctness of the
margins.
 MRI chest

 The hemangioma on
this child's nasal
bridge has both
superficial and deep
components.
 MRI brain

 A, Two small nevi with
differing degrees of
hyperpigmentation
 B, The giant nevus
covering the lower back
and buttocks, is uniformly
pigmented and has
smaller satellite nevi.
 MRI spine

 Red papules and pustules
are present over the nose
and cheeks

 Present at birth
 Pustules without surrounding
erythema
 Ruptured pustules with
hyperpigmented macules
with a rim of surrounding
scale
 Occur in 5% African-
American, rare in other racial
groups
 Pustules contain PMN’s

 While the blister created by the infant sucking on his
extremity in the womb may still be intact at the time of
delivery
 Often it appears as a flat, scabbed, healing area (as
shown)
 Sucking blisters are solitary lesions that occur only in
areas accessible to the infant's mouth
 They are benign and resolve spontaneously
 The appearance and location of the lesion is usually
sufficient for diagnosis, but if the infant is observed
sucking on the affected area, the diagnosis is certain

Breakage of small vessels
during the pressure of
delivery
Reassurance

Education on
nasolacrimal
duct massage

Refer to
ophthalmology
on discharge
for
recanalization

MUCOCELE
MUCOCELE
Reassurance and FU

Reassurance and FU
with plastic surgery/
dermatologist if severe

 Normal
 Scalp electrode placement
 Vascular compromise
 Methimazole
 Trisomy 13

NEONATAL SLE
Screen for SLE abx,
Congenital heart block or
thrombocytopenia

NEONATAL
SLE
Screen for SLE abx,
Congenital heart block
or thrombocytopenia

Rubella, dermal
extramedullary
hematopoiesis, infiltrative
neoplastic lesions of the
skin, and cutaneous
vascular anomalies
NICU transfer for workup

 http://newborns.stanford.edu/PhotoGallery
 Atlas of Pediatric Physical Diagnosis : Basil J.
Zitelli MD, Holly W. Davis MD
 Nelson Textbook of Pediatrics
 The Atlas of Emergency Medicine .Chapter 15.
Child Abuse
 Lynne Uhring, MD, FAAP Frequently Asked
Questions About Newborn Babies

 Carrie L. Byington and Carol J. Baker: CDC
updates guidelines on prevention of perinatal
GBS ,AAP News, Dec 2012
 Revised previous edition by Dr. N Singh
 Guidelines for Perinatal Care, 7th Edition Jointly
developed by the AAP Committee on Fetus and
Newborn and ACOG Committee on Obstetric
Practice

 Red Book: 2012 Report of the Committee on
Infectious Diseases, 29th Edition
 Lynne Uhring, MD, FAAP Frequently Asked
Questions About Newborn Babies
 Neonatology Management, procedure, on-call
problems, diseases and drugs: 6th
Edition,
Gomella TL

Well Baby Nursery Guidelines

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