The Newborn Infant

The newborn period is defined as the first 28 days of life. In practice, however, sick or very immature infants may require neonatal care for many months. There are three levels of newborn care. Level 1 refers to basic care of well newborns of 35 weeks’ gestation or more, neonatal resuscitation, and stabilization prior to transport. Level 2 refers to specialty neonatal care of premature infants greater than 1500 g or more than 32 weeks’ gestation. 

 

Level 3 is subspecialty care of higher complexity ranging from 3A to 3D based on newborn size and gestational age, availability of medical subspecialties, advanced imaging, pediatric ophthalmology, pediatric general surgery, cardiac surgery, and extracorporeal membrane oxygenation. Level 3 care is often part of a perinatal center offering critical care and transport to the high-risk mother and fetus as well as the newborn infant. A level 4 center has additional capabilities to care for complex surgical conditions including cardiac surgery with bypass.

Read More

Care of the Well Neonate

The primary responsibility of the Level 1 nursery is care of the well neonate—promoting mother-infant bonding, establishing feeding, and teaching the basics of newborn care. Staff must monitor infants for signs and symptoms of illness, including temperature instability, change in activity, refusal to feed, pallor, cyanosis, early or excessive jaundice, tachypnea, respiratory distress, delayed (beyond 24 hours) first stool or first void, and bilious vomiting. Several preventive measures are routine in the normal newborn nursery.

Prophylactic erythromycin ointment is applied to the eyes within 1 hour of birth to prevent gonococcal ophthalmia. Vitamin K (1 mg) is given intramuscularly or subcutaneously within 4 hours of birth to prevent hemorrhagic disease of the newborn.

 

All infants should receive hepatitis B vaccine. Both hepatitis B vaccine and hepatitis B immune globulin (HBIG) are administered if the mother is positive for hepatitis B surface antigen (HBsAg). If maternal HBsAg status is unknown, vaccine should be given before 12 hours of age, maternal blood should be tested for HBsAg, and HBIG should be given to the neonate before 7 days of age if the test is positive.

Cord blood is collected from all infants at birth and can be used for blood typing and Coombs testing if the mother is type O or Rh-negative to help assess the risk for development of jaundice.

Bedside glucose testing should be performed in infants at risk for hypoglycemia (infants of diabetic mothers, preterm, SGA, LGA, or stressed infants). Values below 45 mg/dL should be confirmed by laboratory blood glucose testing and treated. Hematocrit should be measured at age 3–6 hours in infants at risk for or those who have symptoms of polycythemia or anemia (see section on Hematologic Disorders).

State-sponsored newborn genetic screens (for inborn errors of metabolism such as phenylketonuria [PKU], galactosemia, sickle cell disease, hypothyroidism, congenital adrenal hyperplasia, and cystic fibrosis) are performed prior to discharge, after 24–48 hours of age if possible. In many states, a repeat test is required at 8–14 days of age because the PKU test may be falsely negative when obtained before 48 hours of age. Not all state-mandated screens include the same panel of diseases. The most recent additions include an expanded screen that tests for other inborn errors of metabolism such as fatty acid oxidation defects and amino or organic acid disorders and screening for severe combined immunodeficiency syndrome.

Infants should routinely be positioned supine to minimize the risk of sudden infant death syndrome (SIDS). Prone positioning is contraindicated unless there are compelling clinical reasons for that position. Bed sharing with adults, tobacco exposure, overheating, soft items in the bed and prone positioning are associated with increased risk of SIDS.

Read More