CARE OF THE WELL NEWBORN INFANT
Saturday, August 16, 2008
The primary responsibility of the level 1 nursery is care of the well infant. This includes promoting mother-infant bonding, establishing feeding, and teaching the techniques of newborn care. Surveillance of the infant is a key function of the staff; they must be alert for the signs and symptoms of illness, including temperature instability, change in activity, refusal to feed, pallor, cyanosis, early or excessive jaundice, tachypnea and respiratory distress, delayed (beyond 24 hours) passage of first stool or voiding of urine, and bilious vomiting. Several preventive measures are undertaken routinely in the normal newborn nursery.
Eye prophylaxis to prevent gonococcal ophthalmia is routinely administered within 1 hour after birth with either erythromycin ointment or silver nitrate 1% drops. Because of the severe chemical conjunctivitis caused by silver nitrate, erythromycin is preferred.
Vitamin K, 1 mg, is given intramuscularly or subcutaneously within 4 hours after birth to prevent hemorrhagic disease of the newborn. The area to be injected must be cleansed thoroughly before injection to prevent infection.
Hepatitis B vaccine and hepatitis B immune globulin (HBIG) are administered if the mother is known to be surface antigen-positive. If maternal HBsAg status is unknown at birth, the vaccine should be given. The mother’s blood should be tested and HBIG given at less than 7 days of age if the test is positive.
Cord blood is collected on all infants at birth and used for blood typing and Coombs testing if the mother is type O or Rh-negative. Cord blood is useful also for other tests, such as toxicology screens.
Rapid glucose testing should be performed in infants at risk for hypoglycemia (eg, infants of diabetic mothers [IDMs]; preterm, SGA, LGA, or stressed infants). Values less than 40 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.
The state-sponsored newborn genetic screen (for inborn errors of metabolism such as phenylketonuria [PKU], galactosemia, sickle cell disease, hypothyroidism, and cystic fibrosis) is performed just prior to discharge, after 24–48 hours in hospital if possible. In many states, a repeat test is required at 8–14 days of age because the PKU test is often falsely negative when obtained at under 48 hours of age. Not all state-mandated screens include the same panel of diseases. In infants with prolonged hospital stays, the test should be performed by 1 week of age.
Infants should be positioned supine or lying on the right side with the dependent arm forward to minimize the risk of sudden infant death syndrome (SIDS).
FEEDING THE WELL NEWBORN INFANT
Indications that the baby is ready for feeding include (1) alertness and vigor, (2) absence of abdominal distention, (3) good bowel sounds, and (4) normal hunger cry. All of these usually occur within 6 hours after birth, but fetal distress or traumatic delivery may prolong this period.
The healthy term infant should be allowed to feed every 2–5 hours on demand. The first feeding usually occurs by 3 hours of life, often as early as in the delivery room. Breast milk or formula (20 kcal/oz) can be given. For formula-fed babies, the volume generally increases from 0.5–1 oz per feeding initially to 1.5–2 oz per feeding on day 3. By day 3, the average term newborn takes in about 100 mL/kg/d of milk.
Although a wide range of infant formulas can satisfy the nutritional needs of most neonates, breast milk is the standard on which formulas are based (see also Chapter 10). The distribution of calories in human milk is 55% fat, 38% carbohydrate, and 7% protein, with a whey-to-casein ratio of 60:40, allowing easy protein digestion. Despite the low concentrations of several vitamins and minerals, their bioavailability is high. All of the necessary nutrients, vitamins, minerals, and water are provided by human milk for the first 6 months of life except vitamin K (thus, 1 mg intramuscularly is administered at birth), vitamin D (200–300 IU/d if minimal sunlight exposure), fluoride (0.25 mg/d after 6 months if water supply not fluoridated), and vitamin B12 (0.3–0.5 mg/d if the mother is a strict vegetarian). Other advantages of breast milk include (1) the presence of immunologic, antimicrobial, and anti-inflammatory factors, including IgA, cellular, and protein or enzymatic components that decrease the incidence of upper respiratory and gastrointestinal infections in infancy; (2) the possibility that breast feeding may decrease the frequency and severity of childhood eczema and asthma; (3) promotion of mother-infant bonding; and (4) evidence that breast milk as a nutritional source improves neurodevelopmental outcomes.
Although approximately 55% of mothers in the United States initiate breast feeding, only 20% continue to breastfeed at 6 months. Hospital practices that facilitate the successful initiation of breast feeding include rooming-in, nursing on demand, and avoiding the use of pacifiers and supplemental formula (unless medically indicated). The nursery staff must be cognizant of problems associated with breast feeding and be able to provide help and support for mothers in the hospital. It is essential that an experienced professional observe and assist with at least one feeding to document good latch-on, important in preventing the common breast-feeding problems of sore nipples, unsatisfied babies, engorgement, poor milk supply, and excessive hyperbilirubinemia (“lack-of-breast-milk jaundice”).
Eye prophylaxis to prevent gonococcal ophthalmia is routinely administered within 1 hour after birth with either erythromycin ointment or silver nitrate 1% drops. Because of the severe chemical conjunctivitis caused by silver nitrate, erythromycin is preferred.
Vitamin K, 1 mg, is given intramuscularly or subcutaneously within 4 hours after birth to prevent hemorrhagic disease of the newborn. The area to be injected must be cleansed thoroughly before injection to prevent infection.
Hepatitis B vaccine and hepatitis B immune globulin (HBIG) are administered if the mother is known to be surface antigen-positive. If maternal HBsAg status is unknown at birth, the vaccine should be given. The mother’s blood should be tested and HBIG given at less than 7 days of age if the test is positive.
Cord blood is collected on all infants at birth and used for blood typing and Coombs testing if the mother is type O or Rh-negative. Cord blood is useful also for other tests, such as toxicology screens.
Rapid glucose testing should be performed in infants at risk for hypoglycemia (eg, infants of diabetic mothers [IDMs]; preterm, SGA, LGA, or stressed infants). Values less than 40 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.
The state-sponsored newborn genetic screen (for inborn errors of metabolism such as phenylketonuria [PKU], galactosemia, sickle cell disease, hypothyroidism, and cystic fibrosis) is performed just prior to discharge, after 24–48 hours in hospital if possible. In many states, a repeat test is required at 8–14 days of age because the PKU test is often falsely negative when obtained at under 48 hours of age. Not all state-mandated screens include the same panel of diseases. In infants with prolonged hospital stays, the test should be performed by 1 week of age.
Infants should be positioned supine or lying on the right side with the dependent arm forward to minimize the risk of sudden infant death syndrome (SIDS).
FEEDING THE WELL NEWBORN INFANT
Indications that the baby is ready for feeding include (1) alertness and vigor, (2) absence of abdominal distention, (3) good bowel sounds, and (4) normal hunger cry. All of these usually occur within 6 hours after birth, but fetal distress or traumatic delivery may prolong this period.
The healthy term infant should be allowed to feed every 2–5 hours on demand. The first feeding usually occurs by 3 hours of life, often as early as in the delivery room. Breast milk or formula (20 kcal/oz) can be given. For formula-fed babies, the volume generally increases from 0.5–1 oz per feeding initially to 1.5–2 oz per feeding on day 3. By day 3, the average term newborn takes in about 100 mL/kg/d of milk.
Although a wide range of infant formulas can satisfy the nutritional needs of most neonates, breast milk is the standard on which formulas are based (see also Chapter 10). The distribution of calories in human milk is 55% fat, 38% carbohydrate, and 7% protein, with a whey-to-casein ratio of 60:40, allowing easy protein digestion. Despite the low concentrations of several vitamins and minerals, their bioavailability is high. All of the necessary nutrients, vitamins, minerals, and water are provided by human milk for the first 6 months of life except vitamin K (thus, 1 mg intramuscularly is administered at birth), vitamin D (200–300 IU/d if minimal sunlight exposure), fluoride (0.25 mg/d after 6 months if water supply not fluoridated), and vitamin B12 (0.3–0.5 mg/d if the mother is a strict vegetarian). Other advantages of breast milk include (1) the presence of immunologic, antimicrobial, and anti-inflammatory factors, including IgA, cellular, and protein or enzymatic components that decrease the incidence of upper respiratory and gastrointestinal infections in infancy; (2) the possibility that breast feeding may decrease the frequency and severity of childhood eczema and asthma; (3) promotion of mother-infant bonding; and (4) evidence that breast milk as a nutritional source improves neurodevelopmental outcomes.
Although approximately 55% of mothers in the United States initiate breast feeding, only 20% continue to breastfeed at 6 months. Hospital practices that facilitate the successful initiation of breast feeding include rooming-in, nursing on demand, and avoiding the use of pacifiers and supplemental formula (unless medically indicated). The nursery staff must be cognizant of problems associated with breast feeding and be able to provide help and support for mothers in the hospital. It is essential that an experienced professional observe and assist with at least one feeding to document good latch-on, important in preventing the common breast-feeding problems of sore nipples, unsatisfied babies, engorgement, poor milk supply, and excessive hyperbilirubinemia (“lack-of-breast-milk jaundice”).
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