Description
Patient Name: Rose Cunningham
Age: 20
Sex assigned at birth: female
Gender identity: female
Pronouns: she/her/hers
You are working with Dr. Martin on the newborn service. She directs you to obtain a prenatal history of Rose Cunningham, a 20-year-old who is being admitted to obstetrics from the emergency department.
You jot down what Dr. Martin knows about her:
Patient is in active labor with ruptured membranes.
First pregnancy.
Estimated gestational age (EGA) 38 weeks based on last menstrual period.
Multiple sexual partners.
No prenatal care.
You read in the OB team admission note that Rose’s weight gain has been limited when her current weight is compared to her self-reported pre-pregnancy weight. Her fundal height is less than expected, and her fetus is possibly small for dates. In preparation for meeting with Dr. Martin to present Rose’s case information you quickly review factors that affect fetal growth.
You now organize the maternal history:
20-year-old female at estimated 38 weeks’ gestation based on last menstrual period. Membranes ruptured; in active labor. G1P0. No previous prenatal care.
Meds: Tylenol prn. No prescribed medications; no vitamins, supplements, or complementary or alternative medicines.
PMHx: Asthma, last attack several years ago.
SHx: Living with friends. No insurance. Unemployed. Food insecure.
ROS: Four previous partners. No history of sexually transmitted infection (STI). Smokes 1-3 cigarettes daily (started smoking half pack per day at age 15. Cut back in early pregnancy). Drinks beer on weekends. Smokes marijuana occasionally. No ankle swelling. No headache/vision changes. No abdominal pain until today.
PE: BP 115/70 mm Hg; fundal height: 33 cm; fetal heart tones 135 bpm.
Lab results: Urinalysis (UA) negative protein and glucose.
You ask Dr. Martin whether or not it is too late to check Rose for group B streptococcal (GBS) colonization, as she is already in labor. She discusses the basics of GBS infections with you, noting that Rose does not meet the criteria for empiric intrapartum antibiotic treatment (see the Deep Dive below) if she is considered to be 38 weeks as per Rose’s last menstrual period dates. On the other hand, if the gestation is actually only 35 weeks, then GBS prophylaxis is indicated. Dr. Martin will discuss this with the OB team.
Dr. Martin points out that routine prenatal labs include testing for potential congenital infections.
In addition to affecting fetal growth, congenital infections can impact the health of the fetus in many significant ways. Dr. Martin shares this table, comparing the key clinical findings of each of the congenital (or TORCHZ) infections.
You review the results of Rose’s screening labs. The rapid HIV antibody test, hepatitis B surface antigen test, rapid plasma reagin (RPR), urine nucleic acid amplification testing (NAAT) for chlamydia and gonorrhea are negative. The serum rubella IgM titer is negative and IgG titer is positive indicating that Rose has acquired rubella immunity. The urine analysis finds no protein or glucose. A urine drug screen is negative.
Rose’s labor progresses without further complication and with no signs of fetal distress. Her membranes have now been ruptured for 10 hours, and the amniotic fluid has been clear. She remains afebrile and normotensive.
The baby is delivered vaginally in vertex position with clear amniotic fluid. The OB team reports that there are no apparent placental abnormalities.
The baby, a boy, is transferred to the warmer bed crying and wet. You assist by drying the infant quickly and vigorously to minimize heat loss and stimulate the infant to cry.
Rose names the baby Thomas. Dr. Martin asks you to assign an Apgar score.
At five minutes of life you reassess Thomas’s Apgar score and take his measurements.
One-minute Apgar score: 9
Five-minute Apgar score: 9
Weight: 2100 grams
Length: 43 centimeters
Head circumference: 32 centimeters
When plotted on a newborn growth chart, Thomas’s weight is below the 10th percentile at 38 weeks. You wonder whether Rose’s dates were inaccurate and Thomas is really premature.
When you show the growth chart to Dr. Martin, she asks you to perform a Ballard exam to estimate the gestational age.
You’ve determined that Thomas is term, SGA, and normocephalic.
You proceed with Thomas’s physical exam:
Vital signs:
Temperature is 36.9 C (98.4 F)
Respiratory rate is 44 breaths/minute
General: Lying quietly in the crib, alert.
Head: Normal appearing face and skull shape; no obvious dysmorphic features. Anterior fontanelle is soft and flat; sagittal, coronal, and lambdoidal sutures are palpable.
Eyes: Red reflex present bilaterally.
Ears: Position and size of pinnae normal. No pits or tags.
Mouth: Normal palate. No teeth or tongue tie.
Cardiac: Regular rate and rhythm; no murmurs; strong femoral pulses bilaterally.
Lungs: Clear to auscultation bilaterally. No retractions, nasal flaring, or grunting.
Abdomen: Flat appearance. No masses palpable; liver edge is palpated 1 cm below right costal margin; three vessel umbilical cord.
Extremities: Moves all extremities equally; hips have full range of motion; Ortolani and Barlow examinations demonstrate no instability of the hips; no “clicks” or “clunks” heard or palpated.
Genitourinary: Normal appearing penis. Testicles are descended bilaterally.
Neurological: Primitive reflexes are intact. General posture of flexion with normal muscle tone (not “floppy”).
Skin: Normal vernix and lanugo.
SUMMARY STATEMENT
Thomas is a term normocephalic SGA male newborn with normal vital signs and physical exam. He is born to a 20-year-old mother with a history of tobacco and alcohol use during pregnancy and no prenatal care. Predelivery ultrasound and screening labs for infection are normal.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Epidemiology and risk factors: Thomas is a term neonate with in utero exposure to alcohol and tobacco. Mother is normotensive and received no prenatal care. HIV, Hepatitis B and urine drug screens are negative.
Key clinical findings about the present illness using qualifying adjectives and transformative language: Term, SGA, Normal vital signs, Normal physical exam, Normocephaly
Based on your summary statement, choose the two most likely causes of Thomas’ small size: Poor maternal nutrition and weight gain and Tobacco use
Blood glucose: 50 mg/dL (2.8 mmol/L)
(Blood glucose > 40 mg/dL (2.5 mmol/L) is normal for a newborn infant in the first 4 hours of life.)
Because, as an SGA infant, Thomas is at risk for hypoglycemia, you recheck Thomas’s glucose level several more times over the first 24 hours of life. They are all above the minimal threshold for his age.
You and Dr. Martin also place orders for routine newborn medications.
Over the next 24 hours, Thomas continues to do well. He has maintained his bedside blood glucose levels above 50 mg/dL (2.8 mmol/L) and has also maintained a normal body temperature in an open crib.
You recall that Thomas and his mother are at risk in that Rose is financially insecure, unemployed, medically uninsured, and estranged from her family.
You discuss your concerns with Dr. Martin and decide to consult social services.There are a number of resources that could be helpful for your patients, some of which may be locally operated and some which are available more broadly.
Some possible suggestions include assistance with:
Food (WIC, Food pantries)
Housing
Affordable health insurance
Employment
Daycare
Education
On rounds on the day of discharge, Rose’s nurse reports that despite his small size Thomas is breastfeeding well and maintaining his body temperature.With Dr. Martin you explain that all of Thomas’ routine newborn screening tests have been normal, including transcutaneous bilirubin measurement, hearing screening, and critical congenital heart disease screening. You also explain that a blood sample has been sent to the state health department lab to test for inborn errors of metabolism.Rose then asks how she will know if her baby is ill and when she should bring him in for medical care.Dr. Martin reviews routine newborn discharge instruction with Rose.
Unformatted Attachment Preview
Pediatrics 01: Newborn male infant evaluation and care
User: Janessa Pamintuan
Email: [email protected]
Date: February 29, 2024 1:20 PM
Learning Objectives
Upon completion of the case, the student should be able to:
List elements of the maternal prenatal history that are relevant to the care of the newborn.
Discuss the potential effect of maternal use of tobacco, alcohol, marijuana, and other drugs on the fetus.
Discuss the epidemiology and approach to prevention of neonatal group B streptococcal sepsis.
Summarize clinical findings in the infant that are associated with intrauterine (TORCHZ) infections.
Outline initial steps in neonatal resuscitation.
Describe the components of the APGAR score and explain its significance.
Describe and perform components of a complete physical examination of a newborn infant, including primitive reflexes and red reflex.
Discuss the use of the Ballard Gestational Age Assessment Tool in the evaluation of the newborn infant.
Define the terms small for gestational age (SGA) and intrauterine growth restriction (IUGR). Differentiate symmetric and asymmetric IUGR.
Outline a differential diagnosis for an infant noted to be small for gestational age.
List potential complications in infants who are born small for gestational age.
List medications and immunizations routinely given in the immediate newborn period and explain the rationale for their use.
Summarize elements of routine discharge teaching for parents of newborns.
Discuss the potential role of social work in facilitating the transition from newborn nursery to home.
Identify signs of respiratory distress in a newborn.
Describe signs of respiratory distress in newborns and infants.
Describe types and prevention of hemorrhagic diseases of the newborn.
Describe guidelines for the prevention of vertical transmission of hepatitis B infection.
List strategies to assess and mitigate the effect of poverty on health care outcomes.
Knowledge
Adverse Effects of Prenatal Substance Use
Tobacco
Maternal tobacco use during pregnancy increases the risk for low birth weight in the fetus.
There are no characteristic facial abnormalities associated with maternal tobacco use during pregnancy.
Alcohol
There is no “safe” amount of alcohol that can be consumed during pregnancy to ensure that fetal alcohol spectrum disorders (FASDs) do not
occur.
Fetal alcohol spectrum disorders include a range of physical, intellectual and behavioral disabilities. These can include a distinct pattern of
facial abnormalities (microcephaly, smooth philtrum, thin upper lip), growth deficiency, and evidence of central nervous system dysfunction.
Children with FASDs may exhibit cognitive disability and learning problems (i.e., difficulties with memory, attention, and judgment) as well as
neurobehavioral deficits such as poor motor skills and impaired hand-eye coordination.
Marijuana
Marijuana increases the risk of stillbirth, preterm birth and fetal growth restriction.
Infants born to mothers who smoked marijuana during pregnancy are at risk for long-term brain development issues affecting memory,
learning and behavior.
Heroin and other opiate medications
Maternal heroin use is associated with increased risk of fetal growth restriction, placental abruption, fetal death, preterm labor and intrauterine
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passage of meconium.
All infants born to women who use opioids during pregnancy should be monitored for symptoms of neonatal opioid withdrawal syndrome (i.e.,
uncoordinated sucking reflexes leading to poor feeding, irritability, and high-pitched cry) and treated if indicated.
Cocaine and Other Stimulants
These cause vasoconstriction leading to placental insufficiency and low birth weight, premature delivery, smaller head circumferences and
shorter lengths.
In addition, the National Institute on Drug Abuse notes that “exposure to cocaine during fetal development may lead to subtle, yet significant,
later deficits in some children, including deficits in some aspects of cognitive performance, information processing, and attention to tasks
abilities that are important for success in school.”
Small for Gestational Age
Newborns who are noted to be smaller than expected for their gestational age are considered small for gestational age (SGA).
Although they are not synonymous, this term is often used interchangeably with:
Fetal growth restriction (FGR) and/or
Intrauterine growth restriction (IUGR)
SGA: An infant is diagnosed as being SGA at time of birth. There are varying definitions for SGA, ranging from less than the third percentile to less
than the 10th percentile for weight. Depending on the cutoff level used, up to 70% of SGA infants are small simply due to constitutional factors
determined by maternal ethnicity, parity, weight, or height.
IUGR: A fetus is noted to be IUGR during the pregnancy. A growth-restricted fetus is one that has not reached its growth potential at a given
gestational age due to one or more causative factors.
Etiologies of SGA at Birth
Both young and advanced maternal age
Maternal prepregnancy short stature and thinness
Poor maternal weight gain during the latter third of pregnancy
Nulliparity
Lack of medical care during pregnancy
Cigarette smoking, cocaine use, other substance use
Lower socioeconomic status (a proxy for limited access to good nutrition, health care, and structural biases)
Polyhydramnios
Short interpregnancy interval
Maternal factors
Preeclampsia and/or chronic hypertension
Chronic maternal illness, such as:
Chronic kidney disease
Pregestational diabetes mellitus
Systemic lupus erythematosus and antiphospholipid syndrome
Cyanotic heart disease
Chronic pulmonary disease
Severe chronic anemia
Sickle cell disease
Chromosomal abnormalities (e.g., trisomies) and syndromes
Metabolic disorders
Fetal factors
Congenital infections (e.g., “TORCH” infections: toxoplasmosis, rubella, cytomegalovirus, herpes simplex 2, and
“others” including HIV, hepatitis B, human parvovirus, syphilis, and Zika.
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Amphetamines
Antimetabolites (e.g., aminopterin, busulfan, methotrexate)
Bromides
Cocaine
Ethanol
Heroin and other narcotics (e.g., morphine, methadone)
Hydantoin
Isotretinoin
Medications and other
exposures
Metal (e.g., mercury, lead)
Phencyclidine
Polychlorinated biphenyls (PCBs)
Propranolol
Steroids
THC
Tobacco (carbon monoxide, nicotine, thiocyanate)
Toluene
Trimethadione
Warfarin
Avascular villi
Decidual or spiral artery arteritis
Multiple gestation (limited endometrial surface area, vascular anastomoses)
Multiple infarctions
Partial molar pregnancy
Placenta previa and abruption
Uterine and placental
abnormalities
Single umbilical artery
Umbilical thrombosis
Abnormal umbilical vascular insertions
Syncytial knots
Tumors, including chorioangioma and hemangiomas
Uterine and placental abnormalities
Uterine malformations
Congenital Infections
Diagnosis of congenital rubella
Detection of rubella-specific IgM antibodies usually indicates recent postnatal infection or congenital infection.
Because false-positives can occur, diagnosis can also be confirmed by stable or increasing serum concentrations of rubella IgG over several
months.
Diagnosis is difficult after one year of age.
Diagnosis of congenital toxoplasmosis
The serologic diagnosis of congenital toxoplasmosis is based on positive toxoplasma-specific IgM, IgG, or IgA assay in the newborn period,
increasing IgG titers in the first year, or persistently positive IgG titers beyond the first year of life.
Diagnosis of congenital cytomegalovirus (CMV)
Because newborn infants with congenital cytomegalovirus (CMV) shed large amounts of virus in the saliva and urine, urine or saliva culture is
sufficient for diagnosis.
Polymerase chain reaction (PCR) may also be used for diagnosis.
Detection of CMV in urine, oral fluids, respiratory tract secretions, blood, or cerebral spinal fluid (CSF) obtained within 2 to 3 weeks of life is
considered proof of congenital CMV infection.
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Newborn Resuscitation
In addition to remembering the ABCs (or airway-breathing-circulation), keep in mind some of the special features of newborn resuscitation:
Use universal precautions
Warm and dry the infant and remove any wet linens immediately. Infants have a large surface area relative to their body weight and can
thus experience significant hypothermia from evaporation.
Stimulate the infant to elicit a vigorous cry. This helps clear the lungs and mobilize secretions.
Position airway
Suction amniotic fluid from the infant’s mouth and nose. This helps clear the upper airway.
Initiate further resuscitation if required. This may include using blow-by oxygen, continuous positive airway pressure (CPAP), placement of
an alternate airway, chest compressions, and medications.
While approximately 10% of newborns require some assistance to initiate breathing, fewer than 1% require extensive resuscitation.
Growth Terms Reviewed
Small for gestational age (SGA) = Weight below the 10th percentile for gestational age
Preterm = < 37 weeks of gestation
Early term = Born at 37 0/7 to 38 6/7 weeks of gestation
Term = 39 0/7 to 40 6/7 weeks of gestation
Late term = 41 0/7 to 41 6/7 weeks of gestation
Post Term = > 42 0/7 weeks of gestation
See this Committee Opinion from the American College of Obstetricians and Gynecologists from 2017 for a suggested revision of the “term”
nomenclature.
Symmetric versus Asymmetric Intrauterine Growth Restriction (IUGR)
Symmetric IUGR refers to a growth pattern in which head, length, and weight are decreased proportionately. Congenital infections or other
fetal factors may adversely affect brain growth and often result in symmetrical IUGR.
Asymmetric IUGR refers to a greater decrease in length and/or weight without affecting head circumference (“head-sparing phenomenon”).
Poor delivery of nutrition to the fetus caused by maternal factors (maternal smoking, for example) often results in asymmetric IUGR.
Risks for Small for Gestational Age (SGA) Newborns
Risk
Etiology
Symptoms
Decreased
glycogen stores
Heat loss
Hypoglycemia
Possible hypoxia
Commonly asymptomatic, though may exhibit seizures, poor feeding, jitteriness, irritability,
tachypnea, pallor and listlessness
Decreased
gluconeogenesis
Cold stress
Hypoxia
Hypoglycemia
Hypothermia
Increased
surface area
Commonly asymptomatic, though may exhibit poor feeding and listlessness
Decreased
subcutaneous
insulation
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“Ruddy” or red color to skin
Respiratory distress*
Chronic hypoxia
Poor feeding
Polycythemia
Maternal-fetal
transfusion
Hypoglycemia
*Infants with sluggish blood flow (hyperviscosity syndrome) because of a critically elevated
hemoglobin/hematocrit may have respiratory distress secondary to inadequate oxygenation of end-organ
tissues.
The Role of the Social Worker
Social workers are invaluable members of the health care team. They assist people by helping them cope with issues in their everyday lives and deal
with their relationships, and they can help solve personal and family problems. Social workers are particularly skilled listeners and can serve as
impartial third parties to assist with negotiation and clarification of issues. They often uncover critical information to provide the best care for the
patient and their family.
One important way that social workers assist families is by helping them find resources to meet their immediate and long-term needs. In addition,
social workers often coordinate team conversations with families who have multiple care providers, provide crisis interventions in emergency settings,
develop discharge plans, and explore community resources for patients with complex medical needs, including chronic illnesses or palliative care.
Depending on the care setting, some social workers have additional training caring for patients who have experienced trauma, including sexual
assault or child abuse. They may be responsible for providing grief counseling, assisting law enforcement with investigations, or providing
psychosocial support.
Clinical Skills
Apgar Scores
The Apgar score is an assessment of the condition of the newborn immediately after birth.
Components of Apgar score include:
Appearance (skin color)
Pulse (heart rate)
Grimace (reflex irritability)
Activity (muscle tone)
Respiration
A newborn receives a score of 0, 1, or 2 for each component, with the final Apgar score ranging from 0 to 10.
Expanded Apgar score reporting form
The score is reported at 1 minute and 5 minutes after birth for all infants.
The change in Apgar score between 1 and 5 minutes may be a useful indicator of response to resuscitation. According to Neonatal Resuscitation
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Program (NRP) guidelines, a score below 7 at 5 minutes should prompt continued resuscitation, with reassessment every 5 minutes, up to 20
minutes, until a score of 7 is achieved.
The Apgar score does not identify birth asphyxia and does not predict individual neurologic outcome or mortality.
Newborn Respiratory Distress
Signs of respiratory distress in the newborn include:
Apnea
Poor respiratory effort
Tachypnea (rapid respiratory rate): a normal newborn’s respiratory rate will be in the 30s to 50s.
Nasal flaring
Chest wall retractions: Retractions are observed when the skin over the chest wall is “sucking in”; this is usually noted as intercostal (between
the ribs), suprasternal (above the sternum) or subcostal (below the ribcage) retractions.
Grunting; Grunting is a noise that is heard on expiration when an infant in respiratory distress is working to keep his or her alveoli open to
increase oxygenation and/or ventilation. This is sometimes referred to as “auto-PEEP (positive end-expiratory pressure).”
Ballard Gestational Age Assessment Tool
The Ballard assessment tool uses signs of physical and neuromuscular maturity to estimate gestational age.
This can be particularly helpful if there is no early prenatal ultrasound to help confirm dates, or if the gestational age is in question because of
uncertain maternal dates.
View an interactive version of the Ballard assessment tool.
Demonstration of Primitive Reflexes and Red Reflex
Rooting
Newborn turns his head toward your finger when you touch his cheek.
Sucking
Newborn sucks on your finger when you touch the roof of his mouth.
Startle (Moro)
The reflex is elicited by pulling up on the infant’s arms while in a supine position and quickly letting go of the arms causing the sensation of
falling. Production of the reflex is by the suddenness of the stimuli and not the distance of the drop. There is no need to lift the infant’s head off
of the bed to elicit this reflex. In response, the newborn will flex his thighs and knees, fan and then clench his fingers, with arms first thrown
outward and then brought together as though embracing something.
A video of the Moro reflex can be seen here: Moro Reflex
Palmar and plantar grasps
Newborn grasps your finger when you stroke it against the palm of their hand or plantar surface of their foot.
Asymmetrical tonic neck response
Turning the newborn’s head to one side causes gradual extension of arm toward direction of infant’s gaze with contralateral arm flexion–like a
fencer.
Stepping response
Newborn’s legs make a stepping motion when you hold him vertically above the table and stroke the dorsum of his foot against the table
edge.
Red reflex examination in neonates
The best method for evaluating the red reflex is to turn off the room lights and stand at least a foot away from the child’s face with the illuminated
ophthalmoscope; this allows the examiner to look for both red reflexes simultaneously.
Infants with more darkly pigmented skin will have a light golden colored or silver-tinged “red reflex.”
An absent red reflex (no reflection noted) may be caused by:
A cataract
An opacified cornea (such as in mucopolysaccharidosis)
Inflammation of the anterior chamber
Developmental anomalies of the eye
Retinoblastoma, a potentially lethal malignancy (careful examination of the eye of an infant with retinoblastoma often identifies a white,
irregular mass within the globe).
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Treating Neonates to Prevent Gonococcal Eye Infection
Although N. gonorrhoeae causes ophthalmia neonatorum relatively infrequently in the United States, identifying and treating this infection is
especially important because ophthalmia neonatorum can result in perforation of the globe of the eye and blindness.
Chlamydia trachomatis conjunctivitis in newborns is more common than gonococcal, but chlamydia typically occurs at 7-14 days after birth,
and neonatal prophylaxis does little to prevent chlamydia conjunctivitis.
Management
Prenatal Lab Screening
Look for the following prenatal screening lab tests in the maternal record:
Maternal blood type, Rh and antibody screen
Rubella IgG
Hepatitis B surface antigen (HBSAg)
HIV antibody
RPR or VDRL
Urinalysis
Urine nucleic acid amplification testing (NAAT) for chlamydia and gonococcus
Urine or vaginal culture for group B streptococcus
Hepatitis C antibody (in women with a history of IV drug use)
Tuberculosis skin test (e.g., Mantoux) or TB blood test (e.g. Quantiferon) (in women with HIV or who live in a household with someone with active
TB)
Early Onset Group B Streptococcal (GBS) Disease
Neonatal GBS facts
GBS infection is a major cause of neonatal bacterial sepsis.
The incidence of early onset GBS disease is 0.23/1000 live births.
20-30% of pregnant women have vaginal or rectal colonization of GBS.
Without antibacterial prophylaxis 1-2% of infants born to colonized women develop invasive disease (sepsis, pneumonia and meningitis).
Risk factors for early onset GBS disease include rupture of membranes > 18 hours, prematurity, intrapartum fever and previous delivery of an infant
who developed GBS disease.
Newborn management
The management of babies born to mothers who are colonized with Group B streptococcus depends on a number of factors:
Clinical appearance
Evidence of maternal chorioamnionitis
Receipt of appropriate GBS prophylactic antibiotics by mother during labor
Duration of membrane rupture
Gestational age less than 37 weeks
Any infant who is ill appearing should undergo a full diagnostic evaluation (complete blood count (CBC), blood culture, chest x-ray and lumbar
puncture) and receive IV antibiotics.
Well-appearing infants may undergo a limited laboratory evaluation (CBC and blood culture) or simply be closely monitored over the first few days of
life.
Routine Newborn Medications
Vitamin K: Newborns routinely receive an intramuscular injection of vitamin K to prevent hemorrhagic disease of the newborn (also referred to as
vitamin K deficiency bleeding, or, VKDB). The efficacy of oral vitamin K is unknown.
Hepatitis B vaccine: For all infants with birth weight of at least 2,000 g born to HBsAg-negative mothers, the American Academy of Pediatrics (AAP)
recommends the practitioner administer hepatitis B vaccine as a universal routine prophylactic treatment within 24 hours of birth.
Erythromycin (also tetracycline or silver nitrate): One of these antibiotics is administered topically to prevent gonococcal conjunctivitis.
Treating Neonates to Prevent Hemorrhagic Disease of the Newborn
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American Academy of Pediatrics (AAP), Center for Disease Control (CDC), and the World Health Organization (WHO) recommend
intramuscular administration of vitamin K at birth. There are no standardized oral solution preparations of vitamin K in the United States and
therefore efficacy is unknown.
Early and classical vitamin K deficient bleeding (VKDB) occur in 1/60 to 1/250 newborns, although the risk is much higher for early VKDB
among those infants whose mothers used certain medications during the pregnancy.
Late VKDB is rarer, occurring in 1/14,000 to 1/25,000 infants.
Infants who do not receive a vitamin K shot at birth are 81 times more likely to develop late VKDB than infants who do receive a vitamin K shot
at birth.
Type of
When it occurs
VKDB
Characteristics
Severe
Early
0-24 hours after birth
Mainly found in infants whose mothers used medications (e.g antiepileptic
drugs or isoniazid) that interfere with how the body uses vitamin K
Bruising
Classical 1-7 days after birth
Bleeding from the umbilical cord
30-60% of infants have bleeding within the brain
Late
2-12 weeks after birth is typical, but can occur up to 6
months of age in previously healthy infants
Tends to occur in breastfed only babies who have not received the vitamin K
shot
Warning bleeds are rare
Treating Neonates to Prevent Vertical Transmission of Hepatitis B
Infants weighing more than 2000 grams born to mothers positive for hepatitis B surface antigen (HBsAg):
Should receive the hepatitis B vaccine as well as hepatitis B immune globulin (HBIG) within 12 hours of delivery, regardless of antenatal
anitviral treatment.
Additionally, these infants should receive the routine series of the vaccine beginning at age 1 month.
Vertical transmission can be prevented in 85-95% of cases using these interventions.
At 9-18 months of age, the child should be tested for anti-HBs (antibody to hepatitis B surface antigen) and HBsAg, and, if found to have
inadequate antibody protection, should be re-immunized.
Infants born to mothers not tested for HBsAg:
Should receive hepatitis B vaccine within 12 hours of delivery.
For infants with a birth weight of at least 2,000 g, administer HBIG by 7 days of age or by hospital discharge (whichever occurs first) if maternal
HBsAg status is confirmed positive or remains unknown.
For infants with a birth weight of less than 2,000 g, administer HBIG by 12 hours of birth unless maternal HBsAg status is confirmed negative
by that time.
Special considerations and guidelines for premature infants and/or infants less than 2,000 grams are provided by the American Academy of
Pediatrics (AAP). For all infants with a birth weight of less than 2,000 g born to HBsAg-negative mothers, administer hepatitis B vaccine as a
universal routine prophylactic treatment at 1 month of age or at hospital discharge (whichever is first).
Addressing Parents’ Questions about the Administration of Medications to their Baby
Many families have concerns about the routine medications recommended for their babies. These concerns may include the following
misperceptions:
That the recommended dose is too high to be given safely
That the medication may contain preservatives which are toxic
That there may be unforeseen consequences later in life
That it is unnatural to cause a painful experience
Studies have shown parents may not be aware of serious and even life threatening risks of the diseases that these medications are intended to
prevent. For example: vitamin K deficiency bleeding can result in severe cerebral hemorrhage, hepatitis B can lead to chronic hepatitis and liver
failure, and gonococcal eye infection can cause blindness.
The clinician should actively but respectfully elicit parents’ concerns and fears about medications. Verbal and written information should be provided
to the family that targets those concerns and fears.
When parents feel fully informed and yet still refuse to allow recommended medications, refusal should be documented on a medication refusal form
signed by the parent.
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Routine Newborn Discharge Instructions for Parents
Discharge teaching should include the following:
Reasons to seek immediate medical care, including fever, signs of poor feeding, worsening jaundice
Expectations for normal feeding, stooling, urine output
Safety issues (including placing the newborn on his back to sleep, proper infant auto restraint, avoiding cigarette smoke exposure.)
Plan for physician outpatient followup in 48-72 hours
Social Services follow-up plan
24 hour emergency contact information
Adjusting to having a new infant can be challenging. For more detailed guidance for parents of newborns, see the Bright Futures Parent Handout,
which is often provided at the first outpatient visit after newborn discharge.
References
Preventing Perinatal Transmission of HIV https://hivinfo.nih.gov/understanding-hiv/fact-sheets/preventing-perinatal-transmission-hiv. Accessed November
17, 2023.
ACOG Practice Bulletin No. 204: Fetal Growth Restriction. Obstetrics & Gynecology 133(2):p e97-e109, February 2019. | DOI:
10.1097/AOG.0000000000003070 https://journals.lww.com/greenjournal/fulltext/2019/02000/acog_practice_bulletin_no__204__fetal_growth.39.aspx
American Academy of Pediatrics. Red Book: 2018 Report of the Committee on Infectious Diseases, 31st Edition. Kimberlin, Brady, Jackson
American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics and the Society forMaternal-FetalMedicin. ACOG
Practice Bulletin No. 204: Fetal Growth Restriction. Obstet Gynecol. 2019;133(2):e97-e109. doi:10.1097/AOG.0000000000003070
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1
Aquifer Essay Title
Your Name
United States University
Course name
Instructor name
Date
2
Aquifer Essay Title
The introduction should be a paragraph that provides a brief overview of the case and
main diagnosis with rationale and supporting evidence. You do not need to discuss
pathophysiology or summarize the entire case. The entire paper should be between one and three
pages long.
Differential Diagnoses
This section will identify your two differentials with the rationale and supporting
evidence. Also explain why these differentials were not the main diagnosis.
Diagnostics
Identify the lab, radiology, or other tests needed for the main diagnosis with supporting
evidence. Do not include excessive or non-pertinent testing.
Treatment, Education, and Follow-Up
This section should include the elements of an initial treatment plan for the main
diagnosis. It should include medication names, dosages, frequencies; patient/family education;
appropriate follow up plan; and hospitalizations and consults when appropriate.
3
References
The supporting evidence for this paper should be derived from at least two primary sources (not
M
