Applied Evidence

A guide to providing wide-ranging care to newborns

J Fam Pract. 2018 April;67(4):E4-E15

Author(s):

Here’s how to refine your care, which includes an assessment of neonatal feedings, the evaluation of jaundice and fever, and the prevention of SIDS.

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PRACTICE RECOMMENDATIONS

› Include a full work-up and empiric antibiotics in the initial management of all febrile infants ≤28 days of age. A

› Recommend that newborns breastfeed exclusively (in the absence of contraindications) for 6 months and continue some breastfeeding until the baby is at least 12 to 24 months of age. A

› Screen all newborns for jaundice before discharge by 1) clinical assessment or 2) testing for total serum bilirubin (TSB) or transcutaneous bilirubin (TcB); measurement of TcB provides a reasonable estimate of the TSB level in healthy newborns at levels <15 mg/dL. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

From The Journal of Family Practice | 2018;67(4):E4-E15.

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15. Chantry CJ, Dewey KG, Peerson JM, et al. In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. J Pediatr. 2014;164:1339-1345.

16. Patel S, Patel S. The effectiveness of lactation consultants and lactation counselors on breastfeeding outcomes. J Hum Lact. 2015;32:530-541.

17. Position Paper: Breastfeeding, family physicians supporting. American Academy of Family Physicians Breastfeeding Advisory Committee. Available at: www.aafp.org/about/policies/all/breastfeeding-support.html. 2017. Accessed February 1, 2018.

18. Eidelman AI, Schanler RJ; Section on Breastfeeding. Policy Statement: Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827-e841.

19. Ip S, Chung M, Raman G, et al. A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries. Breastfeed Med. 2009;4 Suppl 1:S17-S30.

20. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113:974-982.

21. Luan NN, Wu QJ, Gong TT, et al. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Am J Clin Nutr. 2013;98:1020-1031.

22. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007;(153):1-186.

23. Hartman S, Barnett J, Bonuck KA. Implementing international board-certified lactation consultants intervention into routine care: barriers and recommendations. Clinical Lactation. 2012;3:131-137.

24. Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;7:CD003766.

25. Lassi ZS, Das JK, Salam RA, et al. Evidence from community-level inputs to improve quality of care for maternal and newborn health: interventions and findings. Reprod Health. 2014;11(Suppl 2):S2.

26. Chapman DJ, Pérez-Escamilla R. Breastfeeding among minority women: moving from risk factors to interventions. Adv Nutr. 2012;3:95-104.

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28. Tanner-Smith EE, Steinka-Fry KT, Lipsey MW. Effects of CenteringPregnancy group prenatal care on breastfeeding outcomes. J Midwifery Womens Health. 2013;58:389-395.

29. Singhal A, Kennedy K, Lanigan J, et al. Dietary nucleotides and early growth in formula-fed infants: a randomized controlled trial. Pediatrics. 2010;126:e946-e953.

30. Demirci JR, Bogen DL, Holland C, et al. Characteristics of breastfeeding discussions at the initial prenatal visit. Obstet Gynecol. 2013;122:1263-1270.

31. Ingram J, Johnson D, Copeland M, et al. The development of a tongue assessment tool to assist with tongue tie identification. Arch Dis Child Fetal Neonatal Ed. 2015;100:F344-F348.

32. Power RF, Murphy JF. Tongue tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Arch Dis Child. 2015;100:489-494.

33. Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics. 2011;128:280-288.

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Caring for a newborn can be a source of joy for family physicians (FPs). In this article, we examine care provided in the first month of life, including a thorough physical examination, safe hospital discharge procedures, assessment of neonatal feeding, evaluation of jaundice and fever, and prevention of sudden infant death syndrome (SIDS). In addition, we describe how FPs can support women of childbearing age between pregnancies, with the goal of reducing the risk of adverse outcomes in future pregnancies. (See “Your role in risk assessment and interventions during the interconception period.”)

SIDEBAR
Your role in risk assessment and interventions during the interconception period

Interconception care is the care of women of childbearing age between pregnancies (from the end of a pregnancy to conception of the next). It includes medical and psychological interventions to modify their risk factors to improve future birth outcomes. In 2006, the Centers for Disease Control and Prevention Work Group and Select Panel on Preconception Care recommended risk assessment and intervention in the interconception period, especially for women who have experienced previous adverse outcomes of pregnancy.¹

After the birth of a child, many women who had been receiving regular prenatal care stop seeing providers for their health care or return to a pattern of fragmented care.^2-4 They often revert to behaviors, such as smoking and substance abuse, that put future pregnancies at risk.^2,4,5 In addition, the maternal and family focus often shifts from caring for the woman to caring for the newborn, ignoring the health care needs of the mother.^2,4,5

The IMPLICIT (Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques) Network is a perinatal quality collaborative of family medicine residency programs and community health centers that uses continuous quality improvement processes to improve the health of women and decrease preterm birth and infant mortaility.^6,7 The IMPLICIT interconception care model targets 4 risk factors that not only meet the model's requirements, but have a solid base of evidence^5-8 by which to mitigate those risk factors and thus improve birth outcomes:

tobacco use
depression risk
use of contraception to prolong interpregnancy interval
use of a multivitamin with folic acid.

During newborn and well-child visits, screening for maternal health in these 4 key areas and providing point-of-care interventions can markedly improve maternal and perinatal health outcomes. Although the IMPLICIT Network continues to engage in the study of this model of addressing maternal health during newborn and infant visits, initial evidence demonstrates that these interventions exert positive effects on modifiable risk factors.^6,8,9

Sidebar references

1. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care---United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. April 21, 2006. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm. Accessed February 1, 2018.
2. DiBari JN, Yu SM, Chao SM, et al. Use of postpartum care: predictors and barriers. J Pregnancy. 2014;2014:530769.
3. Liberto TL. Screening for depression and help-seeking in postpartum women during well-baby pediatric visits: an integrated review. J Pediatr Health Care. 2012;26:109-117.
4. Fung WL, Goldstein AO, Butzen AY, et al. Smoking cessation in pregnancy: a review of postpartum relapse prevention strategies. J Am Board Fam Prac. 2004;17:264-275.
5. Fang W, Goldstein AO, Butzen AY, et al. Smoking cessation in pregnancy: a review of postpartum relapse prevention strategies. J Am Board Fam Pract. 2004;17:264-275.
6. Rosener SE, Barr WB, Frayne DJ, et al. Interconception care for mothers during well-child visits with family physicians: an IMPLICIT Network Study. Ann Fam Med. 2016;14:350-355.
7. Bennett IM, Coco A, Anderson J, et al. Improving maternal care with a continuous quality improvement strategy: a report from the Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network. J Am Board Fam Med. 2009;22:380-386.
8. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006;295:1809-1823.
9. Ebbert JO, Jacobson RM. Reducing childhood tobacco smoke exposure. JAMA. 2016;315:2610-2611.