clinical practice guideline - denver health … · every infant should have a newborn evaluation...

CLINICAL PRACTICE GUIDELINE

Guideline Number: DHMP_CHOICE_PG1004 Effective Date: 7/1/2016

Guideline Subject: Care of the Well Newborn Revision Date: 7/1/2017

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Quality Management Committee Chair Date

NOTE:

This guideline is designed to assist providers by providing an analytical framework for the evaluation and treatment of patients, and is not intended

either to replace a clinicians judgment or to establish a protocol for all patients with a particular condition.

2. Monitoring/Evaluation/Clinical Care:

Utilization and implementation of national standards for neonatal resuscitation guideline/algorithm (DH guideline

included in attachment)

The newborn should have a thorough evaluation within 24 hours of birth by a physician

Umbilical cord care to prevent infection

Monitoring for hyperbilirubinemia and hypoglycemia:

o Evaluation/monitoring of feeding and weight loss

o Glucose screening is performed as routine care for those at risk for hypoglycemia

3. Screening:

Newborn Hearing Screen (per USPSTF recommendations)

Universal screening for hearing loss is recommended to detect infants with hearing loss and is legally mandated.

-Denver Health Policy: Automated Otoacoustic Emission Screening for Newborns, Denver Health Clinical Care

Resource Guideline, PolicyStat ID 1784172

Pulse oximeter use within 24-48 hours of birth to screen for congenital heart disease

Newborn Screening per State of Colorado Guidelines. Initial and second test required by law on all newborns.

Details can be accessed through http://genes-r-us.uthscsa.edu/sites/genes-r-us/files/nbsdisorders.pdf

PKU – after 20 hours of life and at 8 days of age

4. History and Physical Examination

History

Physical exam

Length and weigh, weight for length

Head circumference

Developmental surveillance is recommended at all Well Child Visits

5. Education and Anticipatory Guidance:

Benefits of breastfeeding, provide support and follow-up

Relevant topics include: injury prevention, nutrition, positioning the infant, appropriate urination/stooling, care of

umbilical cord/skin/genital care, recognition of warning signs, infant safety, hand hygiene, sleep positioning, Sudden

Infant Death Syndrome (SIDS) prevention, jaundice and hyper-billirubinemia

C. VISIT SCHEDULE:

1. IN HOSPITAL

Every infant should have a newborn evaluation after birth (within 24 hours of birth, prior to discharge from the hospital)

2. 1 WEEK OF LIFE - Initial Newborn Visit: a. If the hospital stay for the newborn from birth to discharge is less than 48 hours- the newborn will be evaluated in clinic

within 48 hours of discharge

http://genes-r-us.uthscsa.edu/sites/genes-r-us/files/nbsdisorders.pdf




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NOTE:



Visits can be completed by a physician or a nurse. For details on specific requirements to be met for the nurse visit,

please see the attachment: 2-7 Day Old New Baby RN Visit

b. If the hospital stay for the newborn from birth to discharge is greater than 48 hours the newborn will be evaluated within 3-

5 days of discharge. Source: The American Academy of Pediatrics recommends early follow-up care to help reduce the rate of re-

hospitalization of infants with a birth hospitalization of less than 48 hours c. Breastfeeding infants need to be seen within 48-72 hours of discharge home from the hospital. Visits can be completed

by either a physician or a nurse. In order for nurse visits to meet HEDIS requirements, the visit must be reviewed and co-signed by an MD, PA, or

NP.

3. 2 WEEKS OF LIFE

4. 1 MONTH OF AGE

Tim

ing o

f V

isit

In Hospital 1 week of age 2 weeks of age

1 month of age

<24 hours of life, prior to discharge

Hospital stay <48 hours

Hospital stay >48 hours

Breastfeeding Infants

Seen in clinic within 48 hours of discharge*

Seen in clinic within 3-5 days of discharge

Seen in clinic within 48-72 hours of discharge home *

*can be RN or Lactation Visit, reviewed by MD

D. ADDITIONAL INFORMATION:

1. Denver Health encourages participation of family in care. It is recommended that both parents/primary caregivers attend

well child checks as possible.

2. HEDIS STANDARDS- The visit must include EACH of the following criteria:

- Health history - Physical developmental history - Mental developmental history

- Physical exam - Health education/anticipatory guidance

3. Denver Health utilizes the Bright Futures Guideline and handouts for well child checks. Bright Futures is a “national

health promotion and prevention initiative, led by the American Academy of Pediatrics and supported by the Maternal and

Child Bureau, Health Resources and Services Administration. The Bright Futures guidelines provide theory-based and

evidence-driven guidance for all preventative care screenings and well-child visits.” Bright Futures content is accepted by




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NCQA for meeting HEDIS standards of care. Access to all Bright Futures content, materials & tools, and information can be

found at https://brightfutures.aap.org/Pages/default.aspx.

E. HOME BIRTHS:

1. The World Health Organization recommends the first postnatal contact should be as early as possible within 24 hours of

birth.

2. Evaluation should be completed by a qualified clinician with knowledge of pediatric care, within 24 hours of birth and

again within 48 hours of that evaluation.

3. Additional assessments and interventions may be necessary for home birth newborns due to no hospitalization stay. The

home birthed newborn should be evaluated and a plan of care will be formulated by the provider to meet the needs of the

newborn.

F. BREASTFEEDING:

Denver Health observes the current recommendation that babies should be exclusively breastfed from birth until six months of age

when possible. Mothers will be counselled and provided support for exclusive breastfeeding at each postnatal contact where

applicable.

1. The Denver Health Guideline: Breast-feeding the Healthy Term AGA Infant (PolicyStat ID 2034035) provides the

framework for support and promotion of breastfeeding as applicable to Denver Health Ambulatory Care Clinics

IV ATTACHMENTS:

A. 2-7 Day Old New Baby RN Visit

B. Newborn Bilirubin Nomogram

C. Bright Futures Overview of Priorities at Visits

Priorities for the initial newborn visit are: Family readiness

Family support, maternal wellness, transition, sibling relationships, family resources

Infant Behaviors

Infant capabilities, parent-child relationship, sleep (location, position, crib safety), sleep/wake states (calming)

Feeding

Feeding initiation, hunger/satiation cues, hydration/jaundice, feeding strategies (holding, burping), feeding guidance (breastfeeding, formula)

Safety

Car safety seats, tobacco smoke, falls, home safety (review priority items if necessary)

Routine Baby Care

Infant supplies, skin care, illness prevention, introduction to practice/early intervention referrals

https://brightfutures.aap.org/Pages/default.aspx




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Priorities for the 1-2 week visit are: Parental (maternal) well-being

Health and depression, family stress, uninvited advice, parent roles

Newborn Transition

Daily routines, sleep (location, position, crib safety), state modulation (calming), parent-child relationship, early developmental referrals

Nutritional Adequacy

Feeding success (weight gain), feeding strategies (holding, burping), hydration/jaundice, hunger/satiation cues, feeding guidance (breastfeeding, formula)

Safety

Car safety seats, tobacco smoke, hot liquids (water temperature)

Newborn care

When to call (temperature taking), emergency readiness (CPR), illness prevention (hand washing, outings), skin care (sun exposure)

Priorities for the 1 month Visit are: Parental (maternal) well-being

Health (depression, substance abuse), return to work/school (breastfeeding plans, child care)

Family Adjustment

Family resources, family support, parent roles, domestic violence, community resources

Infant Adjustment

Sleep/wake schedule, sleep position (back to sleep, location, crib safety), state modulation (crying, consoling, shaken baby), developmental changes (bored baby, tummy time), early developmental referrals

Feeding Routines

Feeding frequency (growth spurts), feeding choices (types of foods/fluids), hunger cues, feeding strategies (holding, burping), pacifier use (cleanliness), feeding guidance breastfeeding/formula)

Safety

Car safety seats, toys with loops and strings, falls, tobacco smoke

Attachment

2-7 Day Old New Baby RN Visit

A. Inclusion Criteria:

1. Newborn infants 2-7 days of age. Optimal goal to be seen 48 hours after hospital discharge

2. Healthy, stable infant at time of hospital discharge ≥ 36 weeks gestation.




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B. Exclusion Criteria:

1. Hospital discharge with health condition that requires a physician follow-up in first week after discharge

2. Babies discharged from NICU

3. Babies 8 days or older

4. Babies born at less than 36 weeks gestation.

C. For babies born outside of Denver Health, contact parent prior to appointment to obtain signed release of information for

hospital delivery/nursery records so they are available at the time of the appointment.

D. Review:

1. Inpatient documentation of assessments, interventions, discharge and patient education.

2. Review Inpatient Maternal and Newborn History and Physical to include:

a. gravida/para

b. maternal age

c. delivery type: vaginal or C-section

d. maternal/newborn blood type

e. maternal infections: group B strep, HSV

f. events during hospital stay

g. clinical social work interventions/notes

h. large for gestational age (LGA), appropriate for gestational age (AGA), small for gestational age (SGA).

i. APGAR score

j. birth and discharge weight, length and occipital-frontal head circumference (OFC)

k. bilirubin level

l. hearing screen results

m. Hep B immunization given.

E. Perform newborn physical assessment including:

1. Skin: warm/dry, birthmarks, pink/jaundice, abrasions

2. Head/mouth: Fontanels flat/bulging/sunken, palette intact, suck

3. Heart: apical pulse rate, capillary refill

4. Lungs: breath sounds, respiratory effort

5. Abdomen: bowels sounds

6. Musculoskeletal: tone, equal extremity movements

7. Genitalia: circumcision healing within normal limits

8. Pain: FLACC score and intervention




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9. Weight gain or loss.

F. Obtain Nutrition History:

1. Feeding: Breast or Bottle, number of times baby fed in last 24 hours

2. Breastfeeding assessment: frequency, duration, latch, positioning, pain during feeding, feeding from both breasts, breast

fullness/emptying/engorgement, hearing baby swallowing during feeding, nipple status, pumping and proper milk storage.

3. Bottle: Formula brand and type, mixing, amount and frequency.

4. Output: Number of wet diapers in last 24 hours, number of soiled diaper in last 24 hours. Note Stool transition.

G. Interventions:

1. Feeding:

a. Breastfeeding support: Positioning, latch, frequency, duration, rotation, sore nipples, engorgement.

b. Supplies: Initiating breast pump use (hand or electric), breast shields/shells.

c. Bottle feeding: Ensure that Mom is mixing Formula as instructed by manufacturer for every feeding.

1. Initiate WIC if not already enrolled.

2. Determine adequate weight gain:

a. Breastfed babies: the lowest weight usually occurs at 3-4 days of age for vaginal delivery and 4-5 days of age for C-

section delivery.

b. Mothers who have breastfeed before may get their milk in sooner than mothers who have never breastfed before, so

the lowest weight may occur sooner than normal

c. Formula fed infants may lose less weight because of a greater intake of formula during the first 2-3 days of life.

d. Weight gain should be 10-15 gms/day minimum

e. If the baby is not gaining weight by 4-5 days of age consider (breast) feeding problems.

f. Maximum weight loss for breastfed infants should be not more than 7-10%.

g. To calculate % of weight loss (use kg. or gm.): Birth Weight – Current Weight÷Birth Weight

h. Consult provider for weight loss greater than 10%, weight gain less than 10-15 gms/day, or other abnormal findings.

i. Schedule weight recheck RN visit in 48 to 72 hours if needed. If infant needs follow-up on Saturday, refer to clinic

with Saturday hours and contact clinic with patient report. If no Saturday appointments available, instruct mother of

infant (MOC) to take infant to DECC for weight check.

3. Jaundice/Hyperbilirubinemia:

a. If infant appears yellow, obtain provider order for serum bilirubin level (TsB) or Transcutaneous BiliChek (TcB). If

TcB is ≥ 12 mg/dl, obtain order for TsB.

b. Consult with provider for all bilirubin levels ≥ 12 mg/dl.




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c. Schedule follow up RN visit for repeat bili check within 24 to 48 hours if indicated. If infant needs follow-up on

Saturday, refer to clinic with Saturday hours and contact clinic with patient report. If no Saturday appointments

available, instruct MOC to take infant to DECC for bili check.

d. Order set-up for home photo therapy following home photo-therapy initiation guidelines if ordered by provider.

4. Evaluate for high risk issues needing social work referral

a. Maternal mental illness, severe depression, drug/alcohol use, developmental delays.

b. Social issues: Teen MOC with no support, MOC under 16 with adult father of infant (FOC), other children in custody

of social services, other concerns RN feels need social work evaluation.

c. Educate parent on importance of well child care visit schedule during first two years.

5. Follow up:

a. Schedule 2 week well child visit with PCP of choice:

1. Following clinic process, ensure MOC has 2 week follow-up visit with PCP.

2. In Family Medicine clinics, schedule 2 week well child visit and 2 week follow-up visit for MOC with same

PCP for continuity of care.

b. Give MOC appointment reminder.

H. Patient Education:

1. Give MOC Newborn Visit patient education packet.

2. Address all education areas on the encounter including breastfeeding, mixing formula, feeding schedules, urine output,

stools, jaundice, infant safety and community resources as appropriate.

3. Teach parent signs and symptoms of illness or reasons to call clinic or nurse advice line.

4. Review well child check and immunization schedule. Stress importance of keeping schedule.

I. Documentation:

1. Use the New Baby Outpatient Encounter Record.

2. Complete all areas. Add any additional findings, relevant history percentage of weight gain or loss, all interventions, plan of

care and follow up appointments.

3. Enter current weight, OFC, and length into electronic medical record to start growth curve.

4. For newborn delivered outside of Denver Health, identify Hepatitis B immunization in outside hospital record and enter

into Vax Trax.

J. Report to Provider: Newborn visits are converted to provider




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Attachment B

Newborn Bilirubin Nomogram

Attachment C – Bright Futures Schedule




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NOTE:

This guideline is designed to assist providers by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinicians judgment or to

establish a protocol for all patients with a particular condition.




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NOTE:



V. REFERENCES:

AAFP Breastfeeding Advisory Committee. (2014). Breastfeeding Support Paper. AAFP.

American Academy of Pediatrics. (2015). 2015 Guidelines for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Care of the Neonate. American Heart Association.

American Academy of Pediatrics. (2016). Bright Futures: Prevention and Health Promotion for Infants, Children,

Adolescents and their Failies. Elk Grove Village, Illinois, United States.

American Academy of Pediatrics/Bright Futures. (2016). Bright Futures Guidelines and Pocket Guide. Retrieved April

2016, from Bright Futures: https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-

guide/Pages/default.aspx

Bright Futures/AAP . (2015). Recommendations for Preventive Pediatric Health Care.

Care of the Neborn:Guidelines for perinatal care. (n.d.). 7th.

Kirsti L. Watterberg, M. (2013, May). Planned Home Birth. American Academy of Pediatrics, 131(5).

Shakib, J., Buchi, K., Smith, E., Korgenski, K., & Young, P. (2015, March). Timing of intial well-child visits and

readmissions of newborns. Pediatrics, 135(3), 469-74.

Tiffany McKee-Garrett, M. (2015, Nov 9). Overview of the Routine Management of the Healthy Newborn Infant.

Retrieved April 2016, from UpToDate: http://www.uptodate.com/contents/overview-of-the-routine-management-

of-the-healthy-newborn-infant#H24

WHO Guidelines Review Committee. (2013). Recommendations on Newborn Health. Guidelines On Maternal, Newborn,

Child And Adolescent Health. World Health Organization .

William E. Benitz, M. F. (2015, May). Hospital Stay for Healthy Term Newborn Infants. Pediatrics, 135(5), 948-953.

Denver Health Policy/Guidelines/Practice Recommendations:

HepB Denver Health Clinical Care Guideline PolicyStatID 1748156

Automated Otoacoustic Emission Screening for Newborns PolicyStat ID 1784172




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Perinatal Group B Stretococcal Screening and Treatment, PolicyStatID 1905413

Breastfeeding the Healthy, Term AGA Infant, PolicyStat ID 2034035

Admission, Readmission, Routine Care of the Newborn in the Well Nursery or Transfer to the Newborn Nursery,

PolicyStatID 2208392

Early Discharge of Mothers and Newborns, PolicyStat ID 1877401

Newborn Discharge Checklist, PolicyStat ID 1923287

Neonatal Resuscitation, PolicyStat ID 1839243

2-7 Day Old New Baby RN Visit in CHS, PolicyStat ID 2068511

Newborn Hepatitis B Vaccine and Hepatitis B immune Globulin Administration, PolicyStat, ID 1941248

Pediatric and Adolescent Preventative Healthcare Guidelines PolicyStatID 2212803

Neonatal Hypoglycemia, PolicyStatID 1839230

Care of Newborn Circumcision, PolicyStat ID 1839235

COPY

Current Status: Active PolicyStat ID: 1839243

Origination: 03/2011Last Approved: 03/2014Last Revised: 03/2014Next Review: 03/2017Owner: Tessa Staples: RN Clinical Nurse

EducatorPolicy Area: Childrens HealthReferences:

Neonatal Resuscitation

PURPOSE

INCLUSION / EXCLUSION CRITERIAA. Inclusion Criteria: Any newly born infant who requires resuscitation

B. Exclusion Criteria: Nonviable newborns based on clinical assessment

RESPONSIBILITYA. Anyone finding a newborn requiring resuscitation.

B. Central Supply (CS):

Stock and replace Newborn COR Cart. Any unlocked COR Carts should be returned to CS.

C. Unit Staff:

1. Newborn COR Cart lock integrity is checked every shift.

2. Neopuffs are checked by Respiratory Therapist every shift.

GUIDELINEA. Labor and Delivery (L&D)/OB Screening Room:

1. Initiate cardiopulmonary resuscitation using Neonatal Resuscitation Program (NRP) guidelines for

the newborn.

2. Push staff emergency button or call light.

3. When additional staff are available, call Pediatric House staff (1st year resident, 3rd year resident,

Attending), Respiratory Therapist (RT), and Neonatal Intensive Care Unit (NICU) STAT.

B. Newborn Nursery & Mom-Baby:

1. Immediately take baby to the stabilization/resuscitation bed in the Newborn Nursery.

2. Initiate cardiopulmonary resuscitation using NRP guidelines.

Document Type: Guideline

Clinical Care Guideline

To define the steps for resuscitation of newborns and the equipment available for this procedure.

Neonatal Resuscitation. Retrieved 07/19/2016. Official copy at http://denverhealth.policystat.com/policy/1839243/. Copyright © 2016Denver Health

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3. Pull COR button and call "55" and state "Pediatric Cor Zero"

4. When additional staff are available, call Pediatric Housestaff, RT, and NICU STAT

C. L&D Post Anesthesia Care Unit (PACU):

1. Immediately take baby to the stabilization/resuscitation bed in the PACU infant admit area.


3. Pull COR button and call "55" and state "Pediatric Cor Zero"

4. When additional staff are available, call Pediatric Housestaff, RT, and NICU STAT

D. NICU:

1. Initiate cardiopulmonary resuscitation using Neonatal Resuscitation Program (NRP) guidelines.

2. Push staff emergency button for help.

3. Notify Pediatric Housestaff and RT STAT

4. Consider need to contact back-up providers including Anesthesiology (for airway assistance) and

Neonatology Attending if not present on the unit. Anesthesia emergency pager is (voice pager)

123-102.

E. Emergency Department(ED) / Denver Emergency Center for Children (DECC):


2. For a newborn infant requiring resuscitation in the ED, DECC staff should be notified to respond

STAT and bring to the radiant warmer.

3. Call the delivery pager (123-466) and say "PEDS STAT TO ED" or "PEDS STAT to the DECC." This

notifies Pediatric Housestaff (3rd year, NICU Charge Nurse, & Respiratory Therapist.)

4. NICU Charge Nurse will notify NICU Attending

F. Resuscitation Supplies:

1. L&D:

a. Open bed warmers are available in every room and Respiratory equipment is available in every

c-locker, at every delivery.

b. Medication and other resuscitation supplies are located in the Neonatal COR Carts:

1. 1 Newborn Crash Cart in the 3C PACU

2. 1 Newborn Crash Cart in the brown medication area

2. OB Screening Room:

a. Open bed warmers and respiratory equipment are available in the OB Screening Room.

b. Medication and other resuscitation supplies are located in the Newborn COR Cart.

3. Mom Baby & Newborn Nursery:

a. Medications and resuscitation equipment are available in Newborn COR Cart.

b. An open bed warmer and Newborn COR Cart are available in the 4th floor nursery

c. An additional open bed warmer is available in the north forms room and is to be taken to the

antepartum rooms along with Newborn COR Cart from nursery for unexpected deliveries.

4. NICU:


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a. A newborn COR Cart with medications and resuscitation supplies is located in the NICU.

b. Additional medications for resuscitation are available in the Pyxis MedStation under override.

c. There is a portable blender and Neopuff available for infant transport.

5. L&D PACU:

a. Bed warmers and respiratory equipment are available in the L&D PACU.

b. Medication and other resuscitation supplies are located in the Newborn COR Cart.

6. ED/DECC:

a. Neonatal resuscitation equipment is in the Newborn COR Cart located in the DECC hallway,

outside Room P14, along with the radiant warmer. Both will be brought to PEDS 1 or 2 for any

outborn infant.

b. There is a Newborn COR Cart also in Red 3 in the Adult ED, which is identical to the Newborn

COR Cart in the DECC and in Pav. C.

c. Medications for resuscitation can be found in the Newborn COR Cart, and the Pyxis medstation

as override medications.

d. The infant bed warmer contains some equipment to perform initial steps of NRP, the majority of

equipment is located in the Newborn COR Cart.

REFERENCES

Attachments: No Attachments

Neonatal Resuscitation Program, current edition


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