Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics! I am Shakun Gupta, a general pediatrician, an associate professor of pediatrics and the associate clerkship director at the University of Virginia.
During your Pediatrics clerkship, you will get to spend some time in the newborn nursery. You may also spend some time in a transitional nursery or a neonatal ICU but today’s podcast is focused on helping you feel prepared to see well babies in the newborn nursery on day 1.
The birth of a child is a major event in a family so be cognizant that parents are often overwhelmed, exhausted and adjusting to a rapid change in their lives. This means letting them rest if they are sleeping and giving information in tidbits throughout the admission.
The newborn nursery service usually consists of a team of healthcare providers made up of an attending, some residents, and third year medical students. You may also work with a fourth year medical student, and/or a nurse practitioner. Because nurseries are typically high volume and quick turnaround, there is a lot that has to happen in a short period of time after a baby is born until they are discharged. In the US, legislation allows for up to 48 hours of hospital stay for vaginal delivery and up to 96 hours after birth via cesarean. Discharge prior to this may be considered, as long as goals of care for mom and baby or the dyad are being met. Some require longer admissions but every attempt is made to discharge both together with rooming in together as much as possible.
Due to this turnover, there can also be a fair amount of repetition in the work you will do in the nursery. This is a great opportunity to practice your newborn exam, get comfortable talking with families about common baby care education and hopefully attending some deliveries.
The goal of the newborn nursery is to prepare families for how to care for their new baby as well as ensure that any abnormality or concern for the baby is identified prior to discharge and follow up planned. Most babies will follow up with an outpatient pediatrician within just a few days of being discharged from the nursery and usually within 1-2 days if they are discharged before 48h of life is recommended.
Some general tips for success during this rotation are:
Since newborns are admitted and discharged rapidly, plan to check in with your supervising attending or resident each morning to determine which patients you’ll be following and make sure to check in with your team about the best note templates to use. This will help remind you of which data to collect. You’ll also want to get familiar with the electronic medical record and how you can easily find the information in both the baby’s and the mother’s chart. Although you are not caring for the mother while in the newborn nursery, there is a lot of information you will need to gather about her pregnancy and delivery that will be found in her medical chart.
Let’s start by reviewing the information you will need to gather on the mother and baby immediately after birth for your admission.
First for baby’s information, start with finding out the baby’s gestation age – this is the common term for the number of weeks old the baby is at birth. The pregnancy is often dated from the mother’s first day of her last menstrual period as the time of conception and the gestational age is confirmed with an ultrasound ideally in the first trimester of pregnancy. Ultrasounds in the first trimester are very accurate and there is usually not much discrepancy in the dating. If a mother did not have this accurate dating of her pregnancy, you may use a specific checklist examination done after birth called the Ballard or Dubowitz score which looks at neuromuscular and physical maturity rating parameters to determine the gestational age after birth. Babies born between 34 weeks and 0 days to 36 weeks and 6 days are considered late preterm infants. Early term babies are those born between 37 and 0 days to 38 weeks and 6 days and full term is 39 weeks and 0 days to 40 weeks and 6 days. Babies born after 41 weeks and 0 days are considered late term and those born after 41 weeks and 6 days are considered to be post term. These are important distinctions because late preterm and early term babies are at higher risk for certain morbidities in the newborn period such as hypoglycemia, jaundice, respiratory distress and temperature instability.
Next for mother’s information you will start by finding out her age and her G’s and Ps. G is for gestation, the number of pregnancies the mother has had in the past. P is for partum, which is the number of deliveries the mother has had. To further break down the numbers in P, the four numbers are: Term, Preterm, Aborted, Live, or TPAL. Next you will want to know the mode of delivery or how the baby was delivered – whether a vaginal delivery or a caesarean section. If a caesarean section, figure out why a c/s was done – was it because the mother had one before in that case a repeat c/s or because there was distress for the baby requiring an emergent procedure such as decelerations or fetal tachycardia or bradycardia or due to baby positioning such as being breech. Other reasons there might have been a c/s is if there was failure of labor progression or failure to descend. It is not the usual expected course frequently so dig around as to why.
Your first line of your presentation will often sound something like this: This is a 4 hour old boy born at 38 and 5 weeks gestation via spontaneous vaginal delivery to a 35 year old G2nowP2002 mother with diabetes managed on insulin.
Now get some prenatal history from mother’s chart. You will want to see if mother had early and regular prenatal care. If there was late initiation of prenatal care or limited or lack of prenatal care, this might indicate a social barrier to care such as transportation that needs to be addressed during this hospitalization. You will find out if her ultrasounds were normal and with normal amniotic fluid volume which may indicate medical issues in the baby. Along with this at 20 weeks mothers get a detailed anatomy ultrasound and you need to know if any abnormalities were suspected or found on this scan. In the first trimester of pregnancy, mothers have a panel of prenatal labs done. This consists of the following: Maternal blood type, if a mother is Rh negative blood type there is a possibility of Rh incompatibility with the baby’s blood type. Similarly if mother is blood type O and the baby is A or B the baby is at risk for hemolytic disease or ABO incompatibility. Mother’s also get tested for infectious serologies: HIV, Hepatitis B and syphilis antibody. These change immediate newborn management and must be known. Other tests are rubella and varicella antibody which tell us about previous immunization in mother as these can cause serious congenital birth defects. Mothers may also be tested for gonorrhea, chlamydia, Hepatitis C and urine drug screen. Between 36-38 weeks, mothers get a rectal vaginal swab for group B strep bacteria which is a major cause of neonatal sepsis morbidity and mortality. If mother is GBS positive you will want to know if she received GBS specific antibiotics during labor at least 2 or 4 hours prior to delivery as this decreases risk to baby. GBS specific antibiotics are penicillin or ampicillin.
Next, you will want to look into the mother’s medical conditions as there as several that can important consequences for the baby. Make sure to know if mother was on any medications prescribed or not during pregnancy besides prenatal vitamins and why. Some common examples are: maternal diabetes which can cause low blood sugar or hypoglycemia in baby, maternal hypertension which could cause a small for gestational age baby, maternal substance use disorder which can cause neonatal abstinence syndrome in the baby, maternal autoimmune illness, and many others.
For delivery information: You will also need to know what if any resuscitation was done on the baby at the time of delivery. There may have been a nurse in the room who took care of the baby immediately after the delivery or a pediatric team may be present if any complication is expected. Reasons to have a pediatric team present vary by hospital but some common reasons may be a baby that is late preterm, if baby passed meconium in the fluid, if a change in baby’s vital signs was observed during labor or if mother gets a fever during labor. If a baby is born vigorous they are placed on mother’s chest for skin to skin contact which helps baby stabilize their temperature quickly and are typically not disturbed for an hour. 95-98% of babies will have no resuscitation required. Other resuscitation efforts may include suctioning the mouth of the baby with a bulb syringe and stimulating the baby with rubbing on the back to elicit a strong cry. If baby starts crying they can then be given to the parent. If not, resuscitation may progress to oxygen, CPAP or positive pressure ventilation.
You will want to know the Apgar score assignment. This is a standardized way to communicate the clinical status of a newborn infant. The score traditionally is assigned at 1 and 5 minutes of life, but may be continued every 5 minutes as dictated by the clinical context. The score has five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each component is given a score of 0, 1, or 2. A 5-minute Apgar score of 7 to 10 is considered normal.
Now looking at the actual baby in front of you: You will also need to know the growth parameters of the baby. Newborns who fall outside of the normal growth percentile ranges qualify as small for gestational age (SGA) < 10th percentile and large for gestational age (LGA) >90th percentile. The Fenton charts are an example of growth charts that evaluate growth according to gestational age and are commonly used in the newborn nursery. Size for gestational age is a weight issue; length and head circumference help us better define SGA (symmetric, asymmetric), but micro and macrocephaly are better descriptors for head size and a long baby is not necessarily LGA.
The infant who is small for weight, but has preserved head size (asymmetric) frequently has experienced poor growth because of placental insufficiency. The infant who is symmetrically small is more likely to have been affected by environmental factors (such as smoking and other toxins), genetic factors or congenital infection (such as CMV)
LGA can be associated with IDM, excess maternal weight gain, genetic syndromes
Let’s focus in on the newborn exam since this is a unique part of your pediatrics experience. It’s important to do a daily thorough exam in the nursery, as this exam is the first time ever a healthcare provider is examining this patient and may catch abnormalities early.
The Newborn Exam
Vital Signs
Temperature: appropriate range is 36.5 Celsius to 37.9 Celsius. Rectal temperatures are most accurate but your nursery may monitor with axillary temperatures every 4-8 hours.
Heart rate: normal range is 120 to 160 beats per minute
Respiratory rate: normal range is 35 to 60 breaths per minute.
Oxygen saturation is the same as for adults, normal range is in the 90s on room air
General:
make note of appropriate size, level of distress, and ability to calm if fussy
HENT:
note the size and any shaping abnormalities, note the anterior and posterior fontanelles, and check for overriding suture lines. It is also important to check for bruising, like caput succedaneum or cephalohematoma
Eyes:
We'll check a red reflex every day, and it is important to note whether there is any scleral icterus to help assess for hyperbilirubinemia. Also, if the baby is brand new, make note of whether you see erythromycin ointment.
Resp:
really important to assess for respiratory distress, so make a note of retractions, grunting or tachypnea if present. Newborns often do periodic breathing, meaning that they’ll take a few fast breaths then slow down, so if you are worried, take a count for a full 60 seconds to get an accurate sense
CV:
It can be very difficult to hear murmurs in the newborn due to their heart rate, so take your time.
Remember to check for capillary refill, normal is <3 seconds but may be prolonged due to acrocyanosis (normal), and to check a femoral pulse.
If you are having a hard time finding the femoral pulse, try adding more surface area (another finger) or changing the pressure with which you are assessing.
Abd/GI:
As with any other abdominal exam, check for masses or distension. One key thing to remember is that we are the first doctors to examine this patient, so we need to check for things like a patent anus that other doctors will take for granted for the rest of this child’s life.
GU:
For males, it is important to note that testicles are present and palpable bilaterally. If they aren’t, make a specific note and the child will need repeat exams at the pediatrician’s office. If they have not descended by 6 months, the child will need referral to urology. You’ll also want to ask the family if they would like a circumcision
For females, make note of whether the anatomy appears normal and whether there is any vaginal discharge.
Vaginal discharge is often present and can be normal. A small amount of white or blood tinged discharge is due to withdrawal of maternal estrogen
MSK:
Check the clavicles for crepitus, a sign that there may have been a fracture. Also, make sure you check the hips for laxity using the ortolani and barlow maneuver. This maneuver is hard to describe, so I would recommend that you find a video on youtube to show you.
Skin:
Check for nevus simplex on the forehead, an angel’s kiss, or the back of the neck, a stork bite. Also, make note of a gray blue spot called congenital dermal melanocytosis, often on the lower back. You’ll want to check the lower back to see if there is a sacral dimple or a tuft of hair, which would be concerning for occult spinal dysraphism.
Neuro:
You’ll want to assess tone by gently pulling the extremities away from the body and watching for flexion. There are many reflexes that are unique to the newborn exam.
The rooting reflex is when you put a finger near the mouth of the child to watch for attempts to suck. Would recommend wearing a glove
The moro reflex is also called the startle reflex, and is when you gently lift the arms of the baby up and gently drop them, looking for an outstretched arms and hands response
The babinski reflex is the opposite of expectations in newborns, since the upper motor neurons are not quite developed, so you’re looking for upgoing toes on your Babinski
During the baby’s admission in the hospital you and the nursing staff will monitor and report several things simultaneously.
One of these will be input or feedings whether number of breastfeeds and quality of breastfeeds or timing and volume of formula feeds. Another will be output.
The first stool, which it thick, black, tarry and sticky is often passed within the first 24-48 hours of life. Delayed passage of stool can be associated with several conditions, including imperforate anus, Hirshsprung, small left colon (IDM), meconium plug syndrome, meconium ileus (CF) and other forms of colonic obstruction. Infants may require investigation with imaging, such as a barium enema and rectal suction biopsy. Following passage of meconium, stools transition from green/ brown to yellow seedy stools over the next few days, and can be passed as frequently as after every feed.
The first void often occurs in the first 24 hours, but may be easily missed in diapers with meconium or not documented in the delivery room. Quality of feeding should be assessed, and renal anomalies as well as urinary obstruction should be considered. It is sometimes helpful to place a cotton ball or bag over the genitalia to increase the ability to observe a void, in those infants who have not voided in the first 24 hours of life. As a rule of thumb, infants should void twice on their second day of life, three times on their third day of life, etc... up to a minimum of about 6 voids per day. Urate crystals (brick dust) and vaginal white discharge and even vaginal spotting or bleeding are sometimes mistaken as hematuria but are normal in newborn babies in the first couple days of life.
Babies also get universally screening for hearing loss before discharge home with one of two types of newborn hearing tests depending on your hospital. The AAP recommends all babies get a critical congenital heart disease screen commonly called the CCHD at 24 hours of life or later which includes a bedside pulse oximetry simultaneously placed on a preductal and postductal extremity to monitor for low blood oxygen levels or a large difference in the two that could pick up a congenital heart lesion. A screening jaundice level should be done before discharge usually with a transcutaneous bilirubin meter. Transcutaneous bilirubin (TcB) measurement is a non‐invasive method for measuring serum bilirubin level and works by directing light into the skin and measuring the intensity of the wavelength of light that is returned. At 24h of age or later a newborn screen will be collected on the baby via a heelstick. This is slightly different in each state but consists of conditions that are rare but important to identify early such as metabolic disorders, hemoglobin, and endocrine disorders. If not done shortly after birth, babies should also get one intramuscular injection of Vitamin K which provides clotting factors that babies are not born with enough of, their first dose of Hepatitis B vaccine to prevent vertical transmission or exposure to Hep B and erythromycin eye ointment to prevent certain types of neonatal conjunctivitis caused by gonorrhea of chlamydia that could lead to blindness.
There is a lot of information given to the parent before discharging a baby home. The AAP recommends talking to all families about safe sleep procedures, prevention of shaken baby syndrome, and recognition of maternal postnatal mood disorder which is still commonly referred to as postpartum depression and is quite common. You will also want to educate on signs of illness in baby and cord/skin/circumcision site care all prior to discharge.
Once this education is complete, there has been stable vital signs for 12-24 hours, at least two consecutive successful feeds without excessive weight loss, passage of urine and stool, and completion of all common newborn care tasks we discussed the dyad is ready for discharge home with a follow up appointment in place.
The newborn nursery is a great time to practice your newborn exams and be a special part of a family’s journey. I sincerely hope you enjoy it!
Outro:
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