A guide to providing wide-ranging care to newborns

,; ,; ,; ,

Applied Evidence

A guide to providing wide-ranging care to newborns

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

By

Scott Hartman, MD

Elizabeth Loomis, MD

Holly Russell, MD

Elizabeth Brown, MD

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.

PDF Download

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.

References

1. Langan RC. Discharge procedures for healthy newborns. Am Fam Physician. 2006;73:849-852.

2. Hartman S, Taylor A. Problems of the newborn and infant. In: Paulman PM, Taylor RB, Paulman AA, et al, eds. Family Medicine: Principles and Practice. 7th ed. Cham, Switzerland: Springer Cham; 2016:217-239.

3. Meara E, Kotagal UR, Atherton HD, et al. Impact of early newborn discharge legislation and early follow-up visits on infant outcomes in a state Medicaid population. Pediatrics. 2004;113:1619-1627.

4. Benitz WE; Committee on Fetus and Newborn, American Academy of Pediatrics. Hospital stay for healthy term newborn infants. Pediatrics. 2015;135:948-953.

5. Escobar GJ, Greene JD, Hulac P, et al. Rehospitalisation after birth hospitalisation: patterns among infants of all gestations. Arch Dis Child. 2005;90:125-131.

6. Escobar GJ, Braveman PA, Ackerson L, et al. A randomized comparison of home visits and hospital-based group follow-up visits after early postpartum discharge. Pediatrics. 2001;108:719-727.

7. Meara E, Kotagal UR, Atherton HD, et al. Impact of early newborn discharge legislation and early follow-up visits on infant outcomes in a state Medicaid population. Pediatrics. 2004;113:1619–1627.

8. Benitz WE; Committee on Fetus and Newborn, American Academy of Pediatrics. Hospital stay for healthy term newborn infants. Pediatrics. 2015;135:948-953.

9. Maisels MJ, Vinod VK, Bhutani D, et al. Hyperbilirubinemia in the newborn infant ≥35 weeks’ gestation: an update with clarifications. Pediatrics. 2009;124:1193-1198.

10. Crossland DS, Richmond S, Hudson M, et al. Weight change in the term baby in the first 2 weeks of life. Acta Paediatrica. 2008;97:425-429.

11. Noel-Weiss J, Courant G, Woodend AK. Physiological weight loss in the breastfed neonate: a systematic review. Open Med. 2008;2:e99-e110.

12. Holmes AV, McLeod AY, Bunik M. ABM Clinical Protocol #5: Peripartum breastfeeding management for the healthy mother and infant at term. Breastfeed Med. 2013;8:469-473.

13. National Library of Medicine. Drugs and Lactation Database (LactMed). Available at: http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm. Accessed February 1, 2018.

14. World Health Organization. Guideline: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Available at: http://www.who.int/nutrition/publications/guidelines/breastfeeding-facilities-maternity-newborn/en/. Accessed March 23, 2018.

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.

27. Rosen-Carole C, Hartman S; Academy of Breastfeeding Medicine. ABM Clinical Protocol #19: Breastfeeding promotion in the prenatal setting, revision 2015. Breastfeed Med. 2015;10:451-457.

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.

34. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics. 2015;135:e1458-e1466.

35. Amir LH, James JP, Donath SM. Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function. Int Breastfeed J. 2006;1:3.

36. Misra M, Pacaud D, Petryk A, et al; Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122:398-417.

37. Hollis BW, Wagner CL, Howard CR, et al. Maternal versus infant vitamin D supplementation during lactation: a randomized controlled trial. Pediatrics. 2015;136:625-634.

38. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114;297-316 [erratum: Pediatrics. 2004;114:1138].

39. Ip S, Chung M, Kulig J, et al; American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. An evidence-based review of important issues concerning neonatal hyperbilirubinemia. Pediatrics. 2004;114:e130-e153.

40. Taylor JA, Burgos AE, Flaherman V, et al. Discrepancies between transcutaneous and serum bilirubin measurements. Pediatrics. 2015:135:224-231.

41. Newman TB. Data suggest visual assessment of jaundice in newborns is helpful. J Pediatr. 2009;154:466; author reply 466-467.

42. Roberts KB. Young, febrile infants: a 30-year odyssey ends where it started. JAMA. 2004;291:1261-1262.

43. Bhatti M, Chu A, Hageman JR, et al. Future directions in the evaluation and management of neonatal sepsis. NeoReviews. 2012;13:e103-e110.

44. American College of Emergency Physicians Clinical Policies Committee; American College of Emergency Physicians Clinical Policies Subcommittee on Pediatric Fever. Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med. 2003;42:530-545.

45. Schrag SJ, Farley MM, Petit S, et al. Epidemiology of invasive early-onset neonatal sepsis, 2005 to 2014. Pediatrics. 2016;138:pii: e20162013.

46. Bonadio W, Maida G. Urinary tract infection in outpatient febrile infants younger than 30 days of age: a 10-year evaluation. Pediatr Infect Disease J. 2014;33:342-344.

47. Bressan S, Gomez B, Mintegi S, et al. Diagnostic performance of the lab-score in predicting severe and invasive bacterial infections in well-appearing young febrile infants. Pediatr Infect Dis J. 2012;31:1239-1244.

48. Milcent K, Faesch S, Gras-Le Guen C, et al. Use of procalcitonin assays to predict serious bacterial infection in young febrile infants. JAMA Pediatr. 2016;170:62-69.

49. Kuppermann N, Mahajan P. Role of serum procalcitonin in identifying young febrile infants with invasive bacterial infections: one step closer to the Holy Grail? JAMA Pediatr. 2016;170:17-18.

50. England JT, Del Vecchio MT, Aronoff SC. Use of serum procalcitonin in evaluation of febrile infants: a meta-analysis of 2317 patients. J Emerg Med. 2014;47:682-688.

51. Schroeder AR, Chang PW, Shen MW, et al. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135:965-971.

52. Salm Ward TC, Balfour GM. Infant safe sleep interventions, 1990-2015: a review. J Community Health. 2016;41:180-196.

53. Goldstein RD, Trachtenberg FL, Sens MA, et al. Overall postneonatal mortality and rates of SIDS. Pediatrics. 2016;137:e20152298.

54. Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128:e1341-1367.

55. Smith LA, Geller NL, Kellams AL, et al. Infant sleep location and breastfeeding practices in the United States: 2011-2014. Acad Pediatr. 2016;16:540-549.

56. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138;e20162938.

57. Corriveau SK, Drake, EE. Kellams AL, et al. Evaluation of an office protocol to increase exclusivity of breastfeeding. Pediatrics. 2013;131:942-950.

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.