16
Routine care of the newborn infant

Most term infants start to breathe several seconds after birth and become pink and active. If breathing normally, the baby can be dried and placed directly on the mother’s front. This will allow direct skin-to-skin contact, the baby being kept warm with a towel. Alternatively, the baby can first be wrapped in warm towels. It is at this time that most babies are alert and are ready to begin to establish nursing at the breast.

After birth, the midwife or pediatrician will examine the baby briefly to check there are no abnormalities. A more detailed examination, the routine examination of the newborn, will be performed later, but within 24 hours of birth (see Chapter 17). Name tags will be attached to the baby and a record made to confirm that the baby passes urine and meconium within 24 hours of birth.

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Routine care

Vitamin K

Vitamin K as prophylaxis against vitamin K deficient bleeding (hemorrhagic disease of the newborn) is recommended. It is most reliable if given as a single, large dose by intramuscular injection, but its disadvantage is that it is an injection. It can also be given orally, but this requires several doses to overcome its variable absorption, and protection is less reliable. Infants are at increased risk if they are breast-fed, as breast milk is low in vitamin K, if they have liver disease and if their mother is on anticonvulsant therapy.

Eye prophylaxis

In the US, most newborn infants are given erythromycin eye drops as prophylaxis against gonococcal and chlamydia eye infection. Silver nitrate eye drops have also been used, but can cause chemical conjunctivitis and do not prevent chlamydial infection.

In the UK, eye prophylaxis is not practiced, but gonococcal or chlamydia eye infection is rare.

Circumcision

This is widely performed in the US, but only for religious reasons in the UK. (see Chapter 52).

Breast-feeding

Mothers may need assistance and support to establish breast-feeding.

Umbilical cord care

• Always wash hands before handling.
• Keep dry and exposed to air.
• Clean with water; avoid alcohol as it delays cord separation.
• Fold diaper (nappy) below umbilicus.
• In developing countries, application of chlorhexidine is recommended.

Meeting the family

Visiting by siblings, grandparents and other close family should be facilitated in order to be introduced to the new member of the family.

Emotions

Some mothers are emotionally labile during the first few days after birth. Even minor problems can cause considerable upset. Explanation and reassurance are required.

Mothers who develop postnatal depression or who are unable to care for their baby or have no suitable accommodation may be identified during this postnatal period. Liaison with mental health or social services, voluntary services or health visitors and other community health professionals may be required.

Infants with disabilities or complex medical needs may require a multidisciplinary planning meeting before discharge. This is considered further in Chapter 71.

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Screening

The use of a screening test depends on:

• prevalence of the disease
• ease with which the test can be performed
• false-positive and-false negative screening rates
• whether it significantly improves the prognosis
• cost.

The availability of screening tests varies with judgment as to whether these criteria are satisfied.

Biochemical screening (Newborn bloodspot)

This is performed on all infants. Blood spots, usually from a heel prick, are placed on a card that is sent to a reference laboratory.

In most centers in the US, tandem mass spectrometry is used to screen a wide range of disorders (particular disorders vary by state), but all States screen for are least 29 disorders including:

• phenylketonuria
• hypothyroidism
• sickle cell disease
• thalassemia
• MCADD (medium-chain acyl-CoA dehydrogenase deficiency)
• Maple syrup urine disease (MSUD)
• Isovaleric aciduria (IVA)
• Glutaric aciduria type I (GA1)
• Homocysteinuria (HCU).

Cystic fibrosis screening is performed by measuring serum immunoreactive trypsin (IRT) and DNA analysis for mutations in CFTR (cystic fibrosis transmembrane regulator gene). The trypsin level is raised because of obstruction of the pancreatic ducts. It has a high false-positive rate, which can be reduced by combining it with DNA analysis.

In the UK, screening is confined to the disorders listed above, but an expanded program of tandem mass spectrometry is being assessed in some areas.

Audiology (see Chapter 62)

Neonatal hearing screening is universal for infants in the UK and in most States in the US.

Transcutaneous bilirubin

Used to identify infants at increased risk of developing hyperbilirubinemia and requiring more frequent monitoring (see Chapter 41).

Other possible screening tests

Pulse oximetry

Increasingly introduced in the US and UK to detect critical congenital heart disease in all infants (see Chapter 49).

Ultrasound for DDH (developmental dysplasia of the hips)

Used selectively in the UK and US, e.g. breech position, family history, but in all babies in some countries in Europe (see Chapter 17).

Routine hematocrit for polycythemia

Not recommended as not proven that treatment improves prognosis.

Health promotion

Parents should be provided with verbal and written advice about:

• feeding
• jaundice
• the importance of immunizations
• safe sleep practices to reduce the risk of SIDS (sudden infant death syndrome) (Fig. 16.1)
• the need for a car seat to take the baby home and whenever traveling in a car
• when to seek medical attention.

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Key points

In order to reduce the risk of SIDS:

• Back to sleep (Fig. 16.1a)
• Avoid exposure to cigarette smoke (Fig. 16.1b)
• Avoid overheating:
  • – No more than 1 more layer of clothing than an adult would wear.
  • – Head and face uncovered.
• Safe sleep environment:
  • – Sleep in own crib (cot) in parents’ bedroom, but not in their bed.
  • – Never sleep with baby on a sofa or armchair.
  • – Infant should sleep on a firm surface, with no pillows or toys.
• Breast feed
• Consider pacifier at nap and bedtimes.

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Fig. 16.1 Advice for parents to reduce the risk of SIDS. (a) Back to sleep. (b) Odds ratio for SIDS and number of cigarettes smoked per day in pregnancy. A more detailed list of advice for parents is listed above in the Key points.

(Adapted from Reduce the Risk of SIDS, Department of Health, UK, 2009 and American Academy of Pediatrics, 20011. Data from MacDorman M.F. et al. Sudden infant death syndrome and smoking in the United States and Sweden Am J Epidemiol 1997; 146: 249–257.)

Discharge

Before discharge, check that:

• feeding is being established successfully
• the nursing staff do not have concerns about the mother’s handling of the baby
• the baby is well and not significantly jaundiced
• timely follow-up arrangements are in place.

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Question

Which immunizations should be given routinely in the immediate newborn period?

US:

• Hepatitis B: initial dose recommended as part of universal immunization program and given before discharge.

UK:

• BCG for TB: increasingly offered if living in high-risk area or for certain ethnic communities. Requires intradermal injection.
• Hepatitis B: given if mother is positive for hepatitis B surface antigen.

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Key point

Every effort should be made to ensure successful breast feeding. Human milk provides not only optimal nutrients, but also provides hormones and enhances the immune system and gut microbiome.

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