Newborn Nursery Health

Supervision

Dr Mekone Isabelle

Pr Mah Evelyn MUE :PED 512

Academic year 2019-2020

Cible

Etudiant en master 2 Médecine Générale

Objectives

1. Discuss the importance of newborn health supervision

2. List the key components of newborn health supervision, including:

a. History Takingb. Physical Examc. Investigationsd. Safety & Education

e. Follow-Up

3. Address common parental concerns.

4. Guidance at Nursery Discharge.

Plan

1- Introduction:

- Definition and importance

- Aim

- nursery: - disposition, types of nurseries

- number of visits and duration.

2. Components of newborn health supervision:

- Assessment

- Screening

- Prevention

3- Common parental concerns

4- Danger signs and follow-up appointments.

6- Checklists

Introduction

• The birth of a child brings excitement

• New parents are overwhelmed and

anxious

• Want to know about the health of baby,

how to feed and care for newborn

• Healthcare professional evaluates baby

adaptation to extra-uterine life, screen and

prevent health problems.

Introduction: Definitions

Newborn Health Supervision is an age-

specific visit aimed at promoting health,

safety, and proper growth of the child.

• This happens in the Nursery/community

during 1st week, from 3rd day of life.

• It aims to establish a good family-to-

physician relationship for the many years

of the child's development to come.

Definitions: Nursery

• Where newborns are taken care of in the hospital

• Each baby is in a crib

• Identified with:

- Bracelet- name, sex, Bwt, date of birth

- Security sensor

• Tools used: Mother’s file

- Stethoscope,

- Ophthalmoscope,

- Measuring tape etc

Definitions

Level I, Well Newborn Nursery. Has health care providers who take care of:

• Babies born on time and stable ( breathe spontaneously and maintain body temperature)

• Babies born at 35 to 37 weeks who are stable.

• Babies who are sick or born before 35 weeks, but only until they can be moved to a nursery with a higher level of care.

NB: In our setting, this level corresponds to the maternity where mother and child are together

DefinitionsLevel II, Special Care Nursery. The clinical team takes

care of:

• Babies born at or after 32 weeks who weigh > 1,500g,

may have some health problems, but they’re not so

serious that they need a higher level of care.

• Babies just gotten out of intensive care unit, growing

and doing well before being able to go home.

• Babies born before 32 weeks or less than 1,500

grams, waiting to be moved to a higher level of care.

• Babies needing equipment to help them breathe for

<24 hours; otherwise moved to a higher level of care.

Definitions

Level III, NICU. Clinical team take care of:

• Babies born < 32 weeks, weigh < 1,500g.

• Babies of any age or weight who are critically ill.

• Babies needing equipment to help them breathe to stay alive.

Ideally, babies with conditions that are known before birth and who need this level of care are born in a Level III hospital to avoid transportation after birth.

Definitions

Level IV, Regional NICU: Highest level of care

for babies.

• Takes care of babies needing special surgery

for birth defects and other disorders.

• Has a full range of health care providers:

- Pediatric subspecialists,

- Specialized nurses and

- Equipment to care for very sick babies.

Nursery supervision

• Mother and Health care professional meet

• No. of visits depend on:

- Mode of delivery

- Maternal /newborn complications

• Duration of each Visit depends on:

- specific needs of the baby/family

2. Components of newborn health supervision

• Assess newborns, using history and

physical exam

• Routine screening procedures,

• Provide preventive counseling and

intervention as indicated

Assess newborns(1)

• Know the normal ranges of

vital signs,

stooling / voiding

• Perform a complete, careful physical examination

• Look for common problems like jaundice, infections

- assess risk and need for treatment

- explain it to parents

• Understand normal breastfeeding

distinguish "adequate" from "insufficient" feeding

Assess newborns(2)

PHYSICAL EXAM

• The physical exam for newborn is quite extensive

• Review with the parents the baby's weight, length, and head circumference.

• Plots these on the WHO Growth Charts. (correct the baby’s age until 2 or 3 years if the baby was born before 37 weeks gestational age).

Assess newborns (3)

Obtain and interpret information relevant to newborn health including:

• Maternal medical, prenatal and obstetric history

• Family history

• Results of maternal screening tests ( rubella, hepatitis B and C, syphilis, HIV, tuberculosis, group B streptococcus, herpes simplex virus, gonorrhea, and chlamydia, blood type

• Maternal medication use or substance use/abuse

• Results of prenatal ultrasound testing.

Assess newborns (4)

Evaluate and appropriately treat or refer newborns with.

• Pallor, Respiratory distress, cyanosis

• High or low temperature

• Tachypnea, Heart murmur

• Large birth marks (mongolian spots, hemangiomas, port wine spots)

• Rashes and markings secondary to birth trauma

• Papular and pustular rashes (erythema toxicum, pustular melanosis, staph. Pustulosis, milia)

Common Signs and Symptoms.

Assess newborns (5)

• Cephalohematoma or

caput

• Palate abnormalities

(cleft, submucous cleft)

• Microcephaly,

Macrocephaly, Sacral

dimple, pit, hair tuft

• Subconjunctival

hemorrhages, Corneal

opacities

• Facial palsy

• Fractured clavicle

• Brachial plexus injury

• Polydactyly, Syndactyly

• Abdominal mass

• Two vessel umbilical cords

• Genitourinary abnormalities

• Unstable hip joints

• Swollen breasts

• Vaginal bleeding

Common Signs and Symptoms

Assess newborns (6)

• Large and/or small for gestational

age babies

• Infant of a diabetic mother

• Child with ABO/Rh incompatibility

• Polycythemia

• Premature/postmature infant

• Jitteriness

• Delayed urination

• Delayed stooling

• Vomiting feeds/bilious emesis

• Poor/delayed suck

• Respiratory distress with feedings

• Jaundice

• Infant with abnormalities on

prenatal ultrasound (

hydronephrosis, choroids plexus

cyst)

• Dysmorphic infant or infant with

known chromosomal abnormality

• Eye discharge

• Abnormal newborn hearing

screen results

Evaluate and appropriately treat or refer newborns with

Commonly presenting conditions.

Assess newborns (7)

infections

Recognize and manage:

• Newborn with signs of sepsis (e.g., fever, poor feeding,

tachypnea, low temperature)

• Infant born to mother with fever

• Infant born to mother with a history of a perinatal

infectious disease (e.g., group B strep, chlamydia,

syphilis, HSV)

• Infant born to mother with prolonged rupture of

membranes

Assess newborns (8)

JaundiceRecognize and manage jaundice in the newborn period.

• Check maternal history for factors contributing to jaundice

(Rh, blood type, gestational age, infection, etc.).

• Interpret infant's history for possible etiologies of jaundice

(e.g., infrequent or ineffective feeding, poor urine or stool

output, infection, metabolic disease etc).

• Perform a physical exam to assess for jaundice or other

evidence of hepatic dysfunction (e.g., skin color, sclerae,

bruising, cephalhematoma, organomegaly etc).

• Uses and interpretation of transcutaneous bilirubin monitoring.

• Obtain laboratory tests for management of the

jaundiced infant (blood type/Coombs, T/C bili,

CBC, peripheral blood smear).

• Counsel parents about when to be concerned

about jaundice.

• Describe indications for phototherapy and

exchange transfusions.

• Describe the use of phototherapy and explain risks

(e.g. dehydration, eye injury, and disruption of

breastfeeding routines).

• Counsel parents about ways to improve jaundice

at home (e.g. frequent feedings).

Routine screening procedures/tests

Use and/or interpret clinical tests commonly used in Newborn Nursery

setting, such as:

• Physiologic monitoring (HR, RR, pulse oximetry, blood gas, doppler

BP measurement)

• Ballard exam for gestational age assessment, premature and term

infant growth curves

• CBC, ABO typing and Coombs testing, blood glucose/glucometer,

bilirubin (serum and transcutaneous), hemoglobinopathies

• X-ray of chest, abdomen

• Ultra sound of kidneys/bladder, head, hips, lower spine

Nutrition (1).

Manage breast- and bottle-feeding in the newborn

period.

• Assess a newborn's nutritional status based on maternal

medical and obstetrical history and infant's history (e.g.,

illness, feeding, stools, urination) and physical exam and

implement appropriate feeding plans.

• Counsel parents about feeding choices and assess for

potential risks/difficulties.

• Encourage and support mothers who are breastfeeding.

• Counsel and support mothers who are formula feeding.

Nutrition (2)Recognize and manage affecting nutrition:

1. Common problems for breastfeeding infants and mothers (fissures,

engorged breasts, breastfeeding position etc)

2. Maternal use of medications that are transmitted via breast milk

3. Maternal infections and risk of transmission (Hepatitis B, Hepatitis C,

HIV)

4. Preserving breastfeeding while managing jaundice

5. Newborn who is a poor feeder

6. Feeding plans for the SGA or premature infant

7. Feeding plans for the infant of a diabetic mother

8. Feeding plans for the infant with a cleft palate

9. Feeding plans for neurologically depressed/abnormal newborn

Nutrition (3)

• In addition to their oral intake, also consider their outs (urination and bowel movements).

• At this age, breastfeeding should be encouraged until approximately 6 months of age.

• Supplements:

- All babies Vitamin K at birth to prevent hemorrhage.

- 800-1200 IU/day of vitamin D as long as they are breastfed.

• Outs, healthy 1-week old babies will have at least 6 wet diapers per day.

Vaccination

• Verify vaccination

- BCG

- Oral Polio

- Hepatitis B

• Schedule: remind parents of the

vaccination schedule

• Note down in booklet

Development & Growth

Given that the baby is only a few days old,

little is expected. For now, know that a

healthy baby will be

- Eating (that is, sucking well on nipple),

- Sleeping,

- Peeing & pooping, and

- Gaining weight.

Maternal conditionsDiscuss common post-delivery obstetrical issues that mothers face, and how these affect their recovery and ability to care for their newborn:

• C-section delivery

• Tubal ligation

• Retention of placenta

• Post-partum hemorrhage

• Post-partum depression

• Post-partum infections

• Hypertension

PROVIDE ANTICIPATORY COUNSELING AT NURSERY DISCHARGE THAT RELATES TO NEWBORN BEHAVIOR, FAMILY ADJUSTMENT, INJURY PREVENTION, AND ACCESS TO MEDICAL SERVICES.

Guidance at Nursery DischargeProvide routine counseling on topics such as:

• Routine follow-up appointment time (3-5 days of age for early discharge and breastfeeding infants) otherwise 7days after discharge, 6weeks , then monthly

• How and when to contact the hospital for advice /appointment

• Warning signs: jaundice, fever, diarrhoea, vomiting, and feeding problems.

• Normal infant behaviors related to crying, sleep, and wakefulness and how to deal with common problems (hiccups, vaginal bleeding, breast masses, care of umbilical cord, care of penis)

• Injury prevention (crib safety, water temperature settings, smoke alarm, constant supervision of newborn with siblings or pets, sleep position, cigarette smoke etc)

• Provide written discharge instructions, documentation of immunization (HBV) given, and results of hearing screen.

Physical Exam Checklist • Vital Signs: Last Temperature, Current Heart Rate, Current

Respiratory Rate

• Gestational Age: May perform a modified Ballard exam if needed to confirm the age

• Weight: Note the last weight and if >12hours since your exam, weigh the baby

• General Appearance: Size, color, activity.

• Skin: Milia, petechiae, erythema toxicum, pustular melanosis, Mongolian Spot, nevus simplex

• Head: Document sutures (open, overlapping), fontanel size and fullness, moulding, caput, cephalohematoma, bruising, vacuum or forceps marks

• Eyes: Red reflex, subconjunctival hemorrhage, any discharge or erythema, any abnormal slant

• Ears: Ear position and rotation, any pits or tags, any abnormal shape

• Nose: Patency of BOTH nostrils, milia

• Mouth: Palate, uvula shape and position, mucocele, Epstein’s pearls

• Neck: General tone and appearance, excess nuchal fold

• Chest: Size and symmetry, any supernumerary nipples, nipple spacing, any retractions, point of maximum impact (PMI), rhythm disturbances

Physical Exam Checklist • Heart: S1, S2, any murmur or gallop, brachial & femoral pulses,

precordial activity

• Lungs: Auscultation for air movement, symmetry, rales, rhonchi, grunting

• Abdomen: Appearance (distention, flat, rounded), bowel sounds, liver and/or spleen tip, other organomegaly, diastasis recti

• Umbilicus: Number of vessels, appearance, discharge, erythema, odor

• Genitalia: Sex of infant, hydrocele, hernia, penile torsion, epi/hypospadias, ability to void, location of testes, hymenal tag, vaginal discharge

• Anus: Patency, location (anteriorly placed)

• Spine: Sacral dimples, hair tufts, overlying birthmarks, curvature

• Extremities: Hand position (clinodactyly), palmar creases, extra digits, flexible positional deformities of the legs or feet, hip stability.

• Neuro: Tone, activity, head lag, shoulder strength, position at rest, suck, Moro, grasp, plantar reflex, asymmetric tonic neck reflex, jitteriness

Checklist of Common Physical

Findings in the Newborn

• Caput succedaneum , Large Fontanel, Overriding Sutures, Cephalohematoma

• Subconjunctival Hemorrhage, Variations in Red Reflex by Ethnic Group

• Posterior Ear Rotation

• Nasal Congestion

• Epstein’s Pearls

• Mucocele of the Gums

• Facial Nerve Palsy

• Clavicle Fracture

• Breast Hypertrophy

• Heart Murmur

• Tachypnea, Grunting, Retractions.

• Umbilical Hernia

• Sacral Dimple

• Hip Click

• Vaginal Discharge ,Hymenal Tag

• Hydrocele, Undescended Testis, Penile Torsion

• Flexible Deformity of the Legs/Feet, Single Palmar Crease, Brachial Plexus Injury

• Erythema Toxicum, Jaundice

• Nevus Simplex or Flameus (Mongolian Spot)

• Pustular Melanosis, Nevus Sebaceous

• Petechiae, Hemangioma

• Jitteriness

Conclusion

• New parents are overwhelmed and anxious

• Want to know about the health of baby, how

to feed and care for newborn

• During newborn Health Supervision the

objective is to promote health, safety, and

ensure proper growth of the child.

• Your guidance encouragement of the parents on their parenting skill can go a long way so don't spare those compliments and encouragements!