The Neonatal History

The newborn medical history has three key components:

1. Maternal and paternal medical and genetic history
2. Maternal past obstetric history
3. Current antepartum and intrapartum obstetric history

 

The mother’s medical history includes chronic medical conditions, medications taken during pregnancy, unusual dietary habits, smoking history, occupational exposure to chemicals or infections of potential risk to the fetus, and any social history that might increase the risk for parenting problems and child abuse. Family illnesses and a history of congenital anomalies with genetic implications should be sought. The past obstetric history includes maternal age, gravidity, parity, blood type, and pregnancy outcomes. The current obstetric history includes the results of procedures during the current pregnancy such as ultrasound, amniocentesis, screening tests (rubella antibody, hepatitis B surface antigen, serum quadruple screen in the second trimester or first trimester ultrasound screening for nuchal translucency coupled with measurement in maternal serum of human chorionic gonadotropin and pregnancy-associated plasma protein

World Neonatal Death

A to screen for genetic disorders, HIV [human immunodeficiency virus]), and antepartum tests of fetal well-being (eg, biophysical profiles, nonstress tests, or Doppler assessment of fetal blood flow patterns). Pregnancy-related maternal complications such as urinary tract infection, pregnancy-induced hypertension, eclampsia, gestational diabetes, vaginal bleeding, and preterm labor should be documented. Significant peripartum events include duration of ruptured membranes, maternal fever, fetal distress, meconium-stained amniotic fluid, type of delivery (vaginal or cesarean section), anesthesia and analgesia used, reason for operative or forceps delivery, infant status at birth, resuscitative measures, and Apgar scores

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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.

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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.

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