Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics! I am Auggie, a third year pediatrics resident at the University of Virginia.
So this podcast will focus on what you need to know for your first newborn visit as a medical student rotating through pediatrics. There are a few social things that I think are really important to remember before you walk into the patient’s room. Having a child is one of the most, if not the most, special events in parent’s lives. 9 months have passed with numerous doctors visits, ultrasounds and lab tests. For 9 months there has been so many different emotions, cravings and sleepless nights. There’s been baby showers and gender reveals and celebrations all for that one special day. I want to lead with this because whether you’re a parent or not, you need to remember that this is an incredible experience for those parents.
Newborn follow ups are seen at a general pediatrics or family medicine clinic. You may be working with other 3rd or 4th year medical students, residents, nurses and attendings. Make sure you introduce yourself to everyone you’ll be working with and check in to see which resident or attending you may be working under. Many clinics have specific note templates they use depending on what type of visit they are doing. You’ll want to check to see if there is a specific note template for a newborn follow up as this will help guide what information you need to gather and present.
Now, let’s get into the information you need to know before you walk into that room.
History
1.) Let’s start with the prenatal history. Now, a lot of this information should also have been gathered while in the newborn nursery, which makes it easier to check if they were born within your hospital system. You want to know how the pregnancy itself went.
a.) What is mother’s G and P status? How many times has she been pregnant? Has she had any miscarriages? How many living children does she have?
b.) Did the mother receive appropriate prenatal care? Was she late to prenatal care? Did she receive the appropriate number of visits during the prenatal period? Were there any barriers to receiving prenatal care?
c.) Were there any complications during the pregnancy? Did the mother need to be hospitalized for any reason? Did the mother take any medications for pre-existing conditions? Did the mother develop hypertension or gestation diabetes? Was she using any alcohol, tobacco or other illicit drugs during her pregnancy?
d.) What type of testing did the mother undergo Did she do any prenatal genetic testing and if so what were the results? Did her ultrasound scans show anything concerning such as abnormal anatomy or positioning? Did she undergo an infectious workup and if so was there anything she was positive for any needed to receive antibiotics or antivirals? What was her blood type and has she received RhoGam?
2.) Now let’s move on to the day the baby was born. This is really important so that you have a framework for what this delivery looked like as well as the following days.
a.) One of the most important aspects of this newborn’s history that you MUST know is when they were born! Yes of course I mean their birth date, but what I really mean is how many weeks and days they were when they were born. This piece of information changes how I begin to this about the baby before I even walk in the room. Depending on how far along this mother was born when she had her baby, this may change what growth chart they are on, what they do for feeds, risk factors and how long they were in the hospital. Ok, you get my point. Know if they were pre-term and if so why, early term, term or late term. Know what time they were born as well so you know how to appropriate calculate their bilirubin curve, which we will get to later.
b.) You will want to know how this baby was delivered. Was is a spontaneous vaginal delivery or a c-section. If it is a c-section, you will want to know why. Was it mother’s choice, a recommendation by her OBGYN possibly because she’s already had a c-section or was this an emergency? Did any instruments need to be used such as forceps and or a vacuum and why? Was the amniotic fluid clear or meconium stained? How long was the mother’s membranes ruptured for? Prolonged rupture of membranes, which is defined as greater than 18 hours, puts the infant at higher risk for infection so that’s why this piece is important.
c.) So how did the baby do after they were delivered? What were ALL the recorded APGAR scores and what, if any, type of resuscitation did the baby receive? The APGAR scores really puts a picture into my mind of what this baby looked life when they were born, so this is important.
f.) If you have access to the newborn H&P, you will want to read over the documented physical exam to check if there is any part of your physical exam that you will want to go over carefully. You’ll want to know what the baby’s weight, height and head circumference are and whether they were small for gestational age, appropriate for gestational age or large for gestational age in any of those categories. Reminder LGA is the 90th percentile or greater and SGA is 10th percentile or less.
d.) After the baby was born, did they stay in the newborn nursey for the remainder of their stay or did they need to go to the NICU? If this baby went to the NICU, you MUST know why, for how long and what was done during their stay.
e.) There are 3 preventive treatments the baby should receive within the first few hours of life that is recommended by the American Academy of Pediatrics. They are vitamin K, erythromycin eye ointment and the hepatitis B vaccine to decrease the prevalence of hemorrhagic disease of the newborn, gonococcal ophthalmia neonatorum and hepatitis B. This is important to know as it may guide your clinical judgement and recommendations when seeing the newborn.
Now, like I said, most of that information will be very similar to the information you gathered before you saw the infant for the first time on the newborn nursery. However, it is always important to look over this information yourself as things can slip through the cracks or be missed.
Newborn Nursey Course
Let’s move onto what was done while this baby was in the newborn nursey. You will have infants that stayed in the NICU or were discharged from the NICU and hopefully you will have access to a discharge summary so you know everything that was done while the baby was there. But for this podcast, I am going to assume that the baby you are about to see was discharged from the newborn nursey and did not need to go to the NICU, but if they did, know why, for how long and what was done.
So now that you know mother’s prenatal history and the delivery history, let’s turn our focus to what’s important to know while the newborn was in the nursery?
a.) Another very important piece of information to know is how was this baby fed? I can also not stress enough how important this is as it is one of the main activities that newborns do! They eat, sleep, pee and poop. But how much they pee and poop depends on how much nutrition they are getting and they wake up from sleep because they are hungry! The AAP recommends breastfeeding exclusively till 6 months of age, but not all parents can and want to breast feed for this long and it is not our job to judge their feeding choice. Sorry I got a little side tracked. So you want to know whether this baby is breast fed or formula fed. Breast feeding is tricky and takes time and practice on both the mother’s and infant’s side and you’ll want to know how this went while they were in the hospital. If the mother has breast fed another child before, then sometimes they need less support, but new moms often require a lactation consultant and this is important to know before you see them. If the mother decided to start with formula, I think it’s important to know why, but remember feeding a baby can be so challenging for parents so respect their decision.
b.) You’ll want to know if the baby had any suspicion for infection. This can be based off mother’s history, the delivery or the baby’s vital signs while in the nursery. Any abnormal vital signs can be an indication of infection in newborns, but it is particularly important to know whether they ever had a fever or were hypothermic during their newborn stay.
c.) Bilirubin, Bilirubin, Bilirubin. Probably the most frequent issue Pediatricians monitor in the newborn period is a baby’s bilirubin level since hyperbilirubinemia can lead to kernicterus and is easily preventable. I won’t get into it too much, but there are different processes that can lead to hyperbilirubinemia, some benign and some pathologic, so if the baby has risk factors for hyperbilirubinemia or was treated with phototherapy, fluids, medications or an exchange transfusion, you need to know. Depending on the mother’s blood type, they may or may not check the baby’s blood type, but if they do, know what it was as ABO or Rh incompatibility increases the infant’s risk of hyperbilirubinemia through hemolysis.
d.) Before the baby is discharged, they should receive a hearing screen. Know these results as you may need to refer them to audiology if they did not pass. If they didn’t pass, know what was done. Was repeat testing done or was there infectious etiology such as CMV suspected and testing done.
e.) They may also have a CCHD or critical congenital heart disease done, and you’ll want to know whether the newborn passed this screening test or if they failed and cardiology saw them.
f.) A newborn should also undergo a newborn screen collected, which screens for possible genetic diseases and this is important to know that it was done. If you are seeing the newborn and they are only a few days old, this test likely won’t be back, but it is important to keep an eye out for to make sure it was done and done properly in case you need to do repeat testing during their newborn visit.
So we’ve talked about the newborn nursey course and let’s summarize what is important to take away from this time. What was the baby doing for feeds and how did they do? Did the mother or baby require any extra support for feeding while in the newborn nursery? What was their birth weight and their discharge weight? Was there any concern for infection for the newborn during their nursery stay and if so what was done? Does the newborn have any risk factors for jaundice, did they require treatment for hyperbilirubinemia, what was the level of their last bilirubin check and how many hours old were they, what was the phototherapy threshold based off their level and were they on the low risk, medium risk or high risk curve? Did the newborn complete all the appropriate discharge screening tests such as hearing, CCHD and newborn screen and what were the results?
The Newborn Visit
So I know that sounds like a ton of information to gather for a patient that is only a few days old, but it can change how you think and approach the newborn visit. Hopefully, you can quickly gather all of this information from the newborn H&P, progress notes and discharge summary.
So for example, before I walk into the patient’s room I can already say:
This is a 4 day old male born term at 39 weeks 3 days to a 27 year old G2P2002 mother on 12/7/22 at 6PM via spontaneous vaginal delivery. Rupture of membranes was 4 hours and amniotic fluid was clear. APGARs at delivery were 8 and 9 at 1 and 5 minutes respectively and resuscitation included nasal suctioning at birth. Mother received appropriate prenatal care and her pregnancy was complicated by gestation diabetes. Mother’s blood type is O+ and baby’s blood type is O+. Infant received appropriate preventative treatments including erythromycin eye ointment, vit K and hepatitis B.
The newborn nursery course was uncomplicated. Mother elected to breast feed after birth and did see lactation during her stay. The bilirubin level was 5.4 at 27 hours with a LL of 12.1 on the low risk curve. There were no concerns for infection and mother’s prenatal serologies including GBS status were negative. Infant’s birth weight was 3.5 kg and discharge weight was 3.33 kg down 5% from birth. The infant passed their CCHD and hearing screens and the newborn screen was collected and pending.
Now that you can summarize the relevant prenatal, delivery and newborn history, let’s go see the patient.
Always remember to knock before walking into any patient’s room, but particularly when seeing an infant. Mother’s may be breast feeding and you’ll want to be respectful and allow time for her to cover up if she needs to. And remember, these parents have just had an incredible and exhausting experience so be patient and kind.
This is a unique history to gather as a newborn may have just been discharged from the hospital the day before you are seeing them.
I recommend that you start by asking if they have any questions or concerns about their newborn. Many first time parents understandably may have lots of questions and your job during this visit is not only to perform a history and physical exam, but also provide parents with reassurance and anticipatory guidance. You may not know the answers to parent’s questions about what formula is the best or what that funny sound is that they make when they sleep, but that’s ok. I learned those answers by listening to my attendings answer those questions, so if you don’t know the answer say “I’m sorry I’m not sure, but I will ask my supervising resident or attending and we will let you know.”
Now let’s move onto feeding. Like I said earlier, this is one of the most important activities that newborns do so it’s important to get a thorough feeding history. You’ll want to know whether they are breast feeding or taking formula and what the parent’s goal for feeding is. Some parents may be supplementing with formula as the mother’s breast milk hasn’t completely come in yet. So for example, if they are formula feeding, ask if their goal is to breast feed or stick with formula. Next, you’ll want to find out how frequently and for how long the newborn is feeding. During the newborn period, infants should be feeding every 2-3 hours without going longer than 4 hours without a feed, including during the night time. If they are breast feeding, you’ll want to ask for how long the infant is on each breast, if mother is alternating breasts, and if she is having any pain or difficulty getting the infant to latch. We recommend that a baby should feed for 10-15 minutes on each breast, if they are staying on the breast longer than this, it is likely for comfort. If there is any pain or difficulty latching, this is a great time to see if the mother would be interested in getting a lactation consult to give some tips and tricks. You’ll want to know if and when the mother is pumping and if so, how much milk does she produce. This can give you a measure for whether mother’s milk has come in yet. It can take several days following birth for a mother’s milk to come in and the best way to promote milk production is by stimulation through feeding or pumping. The less stimulation, the less milk production. If the infant is taking formula for feeds, you’ll want to again know how often, but also what type of formula and how much. Newborns should take anywhere from 1-2 ounces during a feed.
Now that you know the duration and amount for feeding, let’s ask some questions about what the infant looks like while feeding. If the newborn is gagging or coughing with feeds, this may be due to poor sucking coordination, anatomical issues or incorrect bottle positioning. If the parents are using a bottle to feed, the bottle should be held slightly less than a 45 degree angle. If they are holding the bottle straight up, the newborn may be getting too much volume at a time and causing they to choke or gag. The parents may also mention that they are concerned that their newborn is spitting up or vomiting and if so you’ll want to characterize it. All newborns will spit up since the distance from their stomach to mouth is so short and their lower esophageal sphincter is not as strong as in adults. You’ll also want to make sure the parents are appropriately burping their newborn. I like to recommend holding the baby so that their chest is against their parents and their head is on their shoulder and gently pat their back for at least 5-10 minutes after feeding to allow gravity to work and release any air in the stomach. You should also ask about any perioral cyanosis, sweating or tiring out associated with feeding as this may be a sign of congenital heart disease. Remember, feeding is a work out for newborns.
Let’s move onto how much the infant is urinating and stooling in a 24 hour period. If you’ve listened to the newborn nursery podcast, you’ll remember that 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 (due to withdrawal from maternal hormones) and even vaginal spotting or bleeding are sometimes mistaken as hematuria but are normal in newborn babies in the first couple days of life. By the time you are seeing them for a newborn follow up, hopefully the infant’s stool should have started to transition from the thick meconium to more yellow/green seedy stools. It’s very important to not just ask about how many stools the newborn is having as this is an indication for how much nutrition they are receiving, but also the color of the stools. Grey or acholic stools can be a sign of inappropriate bile excretion due to biliary atresia, which is an emergency and requires surgical correction.
Now let’s move onto sleep. Infants should be sleeping alone, on their back, in their own bassinet or crib without any pillows, stuffed animals or puffy blankets. This is important to ask about and provide safe sleep recommendations to decrease the risk of SIDS.
Next, its good to know who’s taking care of the baby, who’s living at home and what type of support system the parents have. Taking care of a newborn is a full time job and parents are getting little sleep and exhausted, so it’s good to know who is helping them. You should also ask whether anyone who spends time around the baby smokes and if so where. Second hand smoke is known to be associated with SIDS, so anyone spending time around the newborn should be smoking outside and changing clothes and washing their hands before interacting with the newborn.
Now by gathering the information we just talked about will answer most of the important review of system questions, but there are just a few more important questions to ask. You’ll want to ask whether the newborn seems irritable, which should raise your suspicion for an infection such as meningitis, hard to wake up, which should also raise your suspicion for infection or hypoglycemia due to not getting enough nutrition. If the newborn has had any fevers, which is 100.4F or higher. We don’t recommend that parents routinely check a temperature unless they are concerned that the infant is sick. This is a great time to ask if the parents have a thermometer and to remind them that obtaining a rectal temperature is the most accurate source and any reading of 100.4F or higher means the parents need to go straight to the emergency department for a sepsis workup. You’ll also want to ask if the baby has any rashes. There are many newborn rashes such as erythema toxicum neonatorum or milia and you should familiarize yourself with the common newborn rashes.
Let’s move onto vital signs. Normal newborn vitals are:
Temperature: appropriate range is 36.5 Celsius to 37.9 Celsius
Heart rate: normal range is 120 to 160 beats per minute
Respiratory rate: normal range is 35 to 60 breaths per minute.
Oxygen saturation: 90s on room air
But one of the most important pieces of information to know for a newborn is their weight! I think of a newborn’s weight trajectory during the first week or so to have a “U” shape. It is normal for a newborn to loose 5-10% of their birth weight in the first few days. However, they should regain their birth weight by around day 10 of life, and weight loss greater than 10% should be investigated. Weight loss greater than 10% could be due to insufficient caloric intake if an infant is exclusively breastfeeding and mother’s milk hasn’t completely come in yet. If the baby is taking formula, you will want to ensure that the parents are appropriately mixing the formula. Parents should be measuring and adding the appropriate amount of water THEN adding the powdered formula. You should also be thinking of other pathologic reasons for why this baby is struggling to gain weight such as metabolic causes, impaired absorption or increased demand such as in cases of congenital heart disease.
For the baby’s weight, height and head circumference, you’ll want to make sure they are on the correct growth chart depending on when they were born- preterm infants will be on a different growth chart compared to term infants.
Now let’s move onto the physical exam. This is very similar to the exam you heard in the newborn nursey podcast.
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: Check the pupil shapes. Colobomas are associated with other genetic abnormalities that should be investigated further. Check a red light reflex. The absence of a red light reflex could be due to a retinoblastoma or cataracts. Finally, note any scleral icterus to assess for hyperbilirubinemia
Cardiovascular: Hearing murmurs in newborns is difficult since their heart rate is so fast, but take your time. I usually like to start with this part of my exam while the infant is calm so it’s easier to hear before you’ve disturbed them by doing other parts of your exam. Check for capillary refill, normal is <3 seconds but may be prolonged due to acrocyanosis (normal), and to check a femoral pulse
Respiratory: 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.
Abdominal: Check for any abdominal masses or hernias. Umbilical hernias are common in newborns. Most close on their own by 3-4 years old, but if it doesn’t close or if it becomes incarcerated then surgery will be required. I also check for hepatomegaly and I usually start in the pelvis and slowly walk up my fingers until I can feel the liver edge.
GU:
For males, it is important to note that testicles are present and palpable bilaterally. If they have not descended by 6 months, the child will need referral to urology. This is also a good time to check for an inguinal hernia or hydrocele. If the baby has had a circumcision, make sure that it is healing well.
For females, make note of whether the anatomy appears normal and whether there is any vaginal discharge
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. You’ll want to watch a video to see how this is performed, but I remember barlow is back and ortolani is out.
Skin: Make sure the baby is completely undressed and see if the infant appears jaundiced at all. Check for any birthmarks such as nevus simplex on the forehead, an angel’s kiss, or the back of the neck, a stork bite. Make note of a gray blue spot called congenital dermal melanocytosis, often on the lower back. Check for any hemangiomas as depending on the size, number and location, the infant may require treatment or further work up. However most hemangiomas rapidly grow during the first year of life and then spontaneously regress. 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 such as the rooting, moro and Babinski, which you will want to review.
After the history and physical exam, it’s always important to provide anticipatory guidance. Although it was probably down while they were in the hospital, it’s always good to go over this again. Remember to talk about how and when to check a temperature, what constitutes a fever and when to bring their baby to the ED, safe sleep procedures, prevention of shaken baby syndrome, recognition of post-partum depression and appropriate feeding techniques.
Now typically the next follow up appointment is at 2 weeks of age, but depending on how the baby is doing and the parent’s comfort level, you may want to see them sooner for a weight check or to follow their bilirubin level.
Newborn visits are some of my favorite visits to do. It’s always nice to see a cute baby, but you can really provide some good reassurance to parents during this time.
I hope you found this podcast helpful and thanks for listening to Clerkship Ready – Pediatrics. Don’t forget to subscribe below and rate the podcast!
