CLIPP 01: Evaluation and care of the newborn infant -

Thomas

Learning Objectives

List elements of the maternal prenatal history that are relevant to the care of the newborn.
Discuss the potential effect on the fetus of maternal use of tobacco, alcohol, marijuana, and other drugs.
Discuss the epidemiology and approach to prevention of neonatal Group B Streptococcal sepsis.
Summarize clinical findings in the infant that are associated with intrauterine( TORCH) infections.
Outline 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.
Ssummarize elements of routine discharge teaching for parents of newborns.
Dscuss the potential role of social work in facilitating the transition from newborn nursery to home.

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
syndrome does not occur.
Fetal alcohol syndrome is a distinct pattern of facial abnormalities, growth deficiency, and evidence of
central nervous system dysfunction.
Victims of fetal alcohol syndrome 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

Distinctive effects of marijuana have not been identified.

Heroin and other opiate medications

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 Maternal heroin use is associated with increased risk of fetal growth restriction, placental abruption, fetal
death, preterm labor and intrauterine passage of meconium.
All infants born to women who use opioids during pregnancy should be monitored for symptoms of neonatal
abstinence 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.
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

Intrauterine growth retardation 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.

Etilogies 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

Maternal Failure to obtain normal medical care during pregnancy

factors Cigarette smoking, cocaine use, other substance abuse

Lower socioeconomic status

African-American ethnicity (in the U.S.)

Uterine and placental abnormalities (see below)

Polyhydramnios

Chromosomal abnormalities (e.g., trisomies) and syndromes

Metabolic disorders
Fetal Congenital infections (e.g., "TORCH" infections: Toxoplasmosis, "Others", Rubella,
factors Cytomegalovirus, and Herpes simplex type 2. Examples of "Others" include HIV, Hepatitis
B, Human parvovirus, Syphilis and Zika. )

Structural abnormalities
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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 Metal (e.g., mercury, lead)
exposures
Phencyclidine

Polychlorinated biphenyls (PCBs)

Propranolol

Steroids

Tobacco (carbon monoxide, nicotine, thiocyanate)

Toluene

Trimethadione

Warfarin

Avascular villi

Decidual or spiral artery arteritis

Infectious villitis (as with congenital or TORCH* infections)

Multiple gestation (limited endometrial surface area, vascular anastomoses)

Multiple infarctions

Uterine and Partial molar pregnancy

placental
abnormalities Placenta previa and abruption

Single umbilical artery

Umbilical thrombosis

Abnormal umbilical vascular insertions

Syncytial knots

Tumors, including chorioangioma and hemangiomas

Early onset Group B streptococcal disease

Maternal GBS Facts

GBS infection is a major cause of neonatal bacterial sepsis.

The incidence of early onset GBS disease is 0.6/1000 live births.

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 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 prolonged rupture of membranes, prematurity, intrapartum fever
and previous delivery of 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 GBS prophylactic antibiotics by mother during labor
Duration of membrane rupture greater than 18 hours
Gestational age less than 37 weeks

Any infant who is ill appearing should undergo a full diagnostic evaluation (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.

Refer to the Management of Neonates for Prevention of Early-Onset Group B Streptococcal (GBS) Disease
American Academy of Pediatrics RedBook 2015 Report of the Committee of Infectious Diseases 30th Edition pg
749.

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.

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 Program guidelines, a score below 7 at 5 minutes should prompt continued
resuscitation, with re-assessment 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.

AAP Policy Statement: Apgar Score PEDIATRICS Volume 136, number 4, October 2015

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.

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 Growth Terms Reviewed

Small for gestational age (SGA) = Weight below the 10th percentile for gestational age

Term = Born at > 37 weeks' gestation

(See this Committee Opinion from the American College of Obstetricians and Gynecologists from November 2013
for a suggested revision of the "term" nomenclature:

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Definition-
of-Term-Pregnancy.)

Symmetric vs Asymmetric IUGR

Symmetric IUGR refers to a growth pattern in which head, length, and weight are decreased
proportionately. Congenital infections may adversely affect brain growth and often result in symmetrical
IUGR.
Asymmetric IUGR refers to a greater decrease in the size of the length and/or weight without affecting head
circumference ("head-sparing phenomenon"). Poor delivery of nutrition to the fetus (example maternal
smoking) often results in asymmetric IUGR.

Risks for SGA Newborns

Risk Etiology Symptoms

Decreased
glycogen stores

Heat loss Commonly asymptomatic, though may exhibit poor feeding and
Hypoglycemia
Possible hypoxia listlessness

Decreased
gluconeogenesis

Cold stress

Hypoxia

Hypoglycemia
Commonly asymptomatic, though may exhibit poor feeding and
Hypothermia Increased listlessness
surface area

Decreased
subcutaneous
insulation

"Ruddy" or red color to skin

Respiratory distress*

Chronic hypoxia Poor feeding

Polycythemia Maternal-fetal Hypoglycemia
transfusion
*Infants with sluggish blood flow (hyperviscosity syndrome) because of a

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 critically elevated hemoglobin/hematocrit may have respiratory distress
secondary to inadequate oxygenation of end-organ tissues.

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, link to
the following Bright Futures Parent Handout - often provided at the first outpatient visit after newborn discharge.

https://brightfutures.aap.org/Bright%20Futures%20Documents/A.Inf.PH.2-5day.pdf

Clinical Skills

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.
Suction amniotic fluid from the infant's nose and mouth. This helps clear the upper airway.
Initiate further resuscitation if required. This may include using blow-by oxygen, positive pressure (bag-
valve mask) ventilation with oxygen, chest compressions, and medications.

While approximately 10% of newborns require some assistance to initiate breathing, fewer than 1% require
extensive resuscitation.

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)

Support the newborn's head with one hand and buttocks with the other. With the head in a midline position,
the hand supporting it is quickly dropped to a position approximately 10 cm below its original supporting
position, and the head is caught in its new position. 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.

Palmar and Plantar Grasps

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 Newborn grasps your finger when you stroke it against the palm of his hand or plantar surface of his 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).

Treating Neonates to Prevent Hemorrhagic Disease of the Newborn

AAP, CDC, and 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 VKDB occur in 1/60-1/250 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- 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 Characteristics
VKDB

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

2-12 weeks after birth is typical, but can
Tends to occur in breastfed only babies who have not
Late occur up to 6 months of age in previously
received the vitamin K shot
healthy infants
Warning bleeds are rare

http://www.cdc.gov/ncbddd/vitamink/facts.html

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 http://www.cdc.gov/ncbddd/blooddisorders/documents/vitamin-k.pdf

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.
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.

Administration of HBIG can be delayed until the maternal HBsAg is known, and is effective if given within 7
days following delivery if the patient is greater than 2 kg at birth.

Special considerations and guidelines for premature babies are discussed in the reference.

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.

http://www.cdc.gov/std/treatment/2010/gonococcal-infections.htm

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, and 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
documented on a medication refusal form signed by the parent.

Management

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: One must consider maternal Hepatitis B status (HBsAg positive, status unknown or HBsAg
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 negative) as well as the weight of the newborn (greater or less than 2000 grams) when deciding the timing of the
first dose of Hepatitis B vaccine and whether or not Hepatitis B immunoglobulin is needed to decrease risk for
vertical transmission.

Erythromycin (also tetracycline or silver nitrate): One of these antibiotics is administered topically to prevent
gonococcal conjunctivitis.

American Academy of Pediatrics. Red Book: 2015 Report of the Committee on Infectious Diseases. Pickering LK,
ed. 30th ed. 2015. Elk Grove Village, IL: American Academy of Pediatrics.

Mast EE, Margolis HS, Fiore AE, et al. Hepatitis B Vaccination Recommendations for Infants, Children, and
Adolescents. MMWR 2005;54(RR-16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm?
s_cid=rr5416a1_e

Studies

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)

References

Joffe A, Blythe MJ. Adolescent medicine: state of the art reviews. Handbook of adolescent medicine. 2nd
edition.Adolesc Med State Art Rev. 2009 Aug;20(2):261-859.

About teen pregnancy. CDC. http://www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm. Accessed May 5, 2017.

Lin CC. Current concepts of fetal growth restriction: Part I. Causes, classification, and pathophysiology. Obstet
Gynecol. 1992;1044:1045-1047.

American Academy of Pediatrics. Red Book: 2015 Report of the Committee on Infectious Diseases. Pickering LK, ed.
30th ed. 2015. Elk Grove Village, IL: American Academy of Pediatrics.

Link to patient information on routine testing during pregnancy

World Health Organization guidelines

U.S. Centers for Disease Control and Prevention guidelines

Recommendations for use of antiretrovirals in pregnant HIV-infected women for maternal health and interventions to
reduce perinatal HIV transmission in the United States
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Centers for Disease Control and Prevention website

World Health Organization Global Update on the Health Sector Response to HIV, 2014, Executive Summary, page 3

Verani J, McGee L, Schrag S. Prevention of Perinatal Group B Streptococcal Disease. MMWR: recommendations and
reports. November 2010;59(RR10):1-32.

American Academy of Pediatrics. Red Book: 2015 Report of the Committee on Infectious Diseases. Pickering LK, ed.
30th ed. 2015. Elk Grove Village, IL: American Academy of Pediatrics.

Plosa, et al. Cytomegalovirus infections. Pediatrics in Review. 2012;33:156-163.

Kattwinkel J, Perlman JM, et al. American Academy of Pediatrics. Special Report-Neonatal Resuscitation: 2010
American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
http://pediatrics.aappublications.org/content/126/5/e1400.full.pdf

Ballard JL, Khoury JC, Wedig K, Wang L. et al. New Ballard score: expanded to include extremely premature infants.
Journal of Pediatrics 1991;119(3):417-423.

Maulik D. Fetal Growth compromise: definitions standards and classification. Clin Obstet Gynecol. June
2006;49(2):214-18.

Thureen PJ, Anderson MS, Hay WW. The small-for-gestational age infant. Pediatrics In Review. June 2001;2(8):143-
145.

American Academy of Pediatrics. Red Book: 2015 Report of the Committee on Infectious Diseases. Pickering LK, ed.
30th ed. 2015. Elk Grove Village, IL: American Academy of Pediatrics.

Mast EE, Margolis HS, Fiore AE, et al. Hepatitis B Vaccination Recommendations for Infants, Children, and
Adolescents. MMWR 2005;54(RR-16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm?s_cid=rr5416a1_e

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