Care of the Newborn - Clinical Tree

Key Points

Prenatal ultrasonography can diagnose multiple newborn conditions early. However, the natural history of many common ultrasound findings is variable, and the findings may or may not represent markers of serious disease.
The short-term and long-term benefits of breastfeeding are clear. The effects on breastfeeding rates from interventions such as formula supplementation, frenotomy, and restriction of pacifiers remain controversial, as does breastfeeding among HIV-positive mothers.
Comprehensive guidelines for the management of common newborn conditions such as jaundice, suspected sepsis, and hypoglycemia allow standardization of care. Ongoing research is needed to optimize guidelines to improve long-term outcomes.
With the implementation of universal maternal screening for group B streptococcus and the use of intrapartum antibiotic prophylaxis, rates of sepsis in term newborns have fallen significantly. Online aids are available to assist clinicians in assessing the risk of sepsis and developing institutional guidelines for the identification and management of infants at risk for sepsis.
Pulse oximetry screening for critical congenital heart disease is recommended for healthy newborns.
Late preterm infants are at risk of complications associated with prematurity and require close monitoring for respiratory problems, feeding issues, hypoglycemia, hyperbilirubinemia, infection, and thermoregulation in the postnatal period.

Introduction

Optimal newborn care facilitates a successful transition from intrauterine to extrauterine life without overmedicalization of care, provides low-risk preventive care, and identifies “high-risk” infants who would benefit from increased monitoring, testing, or intervention, thereby decreasing early preventable morbidity and mortality. Systems of care should be designed to align with the concept that the majority of newborns are healthy and require little intervention beyond the promotion of breastfeeding, and interventions for which there is clear evidence that benefits outweigh risks should be provided as unobtrusively as possible. Simultaneously, the system must maintain space and opportunity for healthcare providers to quickly and efficiently identify those neonates at risk of developing serious or life-threatening conditions.

The goal of this chapter is to provide a framework for developing an approach to the initial assessment of the apparently well newborn. This includes the identification of common neonatal problems, indications for additional monitoring, and risk-benefit analysis of testing and treatments commonly employed in the newborn nursery. Rather than providing a comprehensive prescription on how to care for healthy newborns, we hope that the reader will integrate the information provided in this chapter with expert opinion and his or her own clinical experience to provide thoughtful, evidence-based management for this unique patient population.

Initial Newborn Evaluation

In the mother-baby unit or well-baby nursery, the primary goal is to identify the small minority of babies with significant problems that may cause serious morbidity if not detected promptly, including psychosocial problems that may adversely impact both “normal” and “at risk” newborns. This goal must be accomplished with the understanding that the vast majority of babies encountered in the newborn nursery are completely healthy, despite wide variations in presentation and findings.

The Initial Assessment

The timing of the initial assessment of a healthy-appearing newborn is dependent on the condition of the newborn and parental preference. In most instances, a healthcare professional who is present at the birth will make a general appraisal of the newborn and alert the child's provider if there is an acute problem necessitating an immediate evaluation. The newborn’s weight, length, and head circumference should be measured and plotted on a standardized chart; the WHO growth chart is used for term (≥37 weeks) infants, and the Fenton growth chart for preterm infants (<37 weeks). This assessment can usually be timed so as not to interfere with breastfeeding, bonding with the family, and routine care.

The Newborn History

Before a well newborn is examined, the maternal medical history should be reviewed to identify issues that could affect the care or prognosis of the newborn. For example, a history of diabetes (gestational or prepregnancy) would lead to glucose monitoring in the newborn; and maternal medication use may prompt an assessment for possible teratogenic effects or signs of neonatal drug withdrawal or compatibility with breastfeeding. It is equally important to review the pregnancy history, including the estimated gestational age (GA), the results of prenatal screening for genetic conditions, and the results of prenatal ultrasound examinations. Positive findings on the prenatal ultrasound deserve particular attention, as they may have implications for postnatal management. Perinatal events such as the type of delivery, length of time that membranes were ruptured, and Apgar scores should also be reviewed. Finally, it is critical to review the mother’s social history to identify psychosocial risk factors that may preclude safe discharge home, or for which interventions are indicated before, or shortly after, discharge from the newborn nursery. An outline of relevant prenatal and newborn history is presented in Table 16.1 .

Table 16.1

Key Components of the Maternal Medical, Pregnancy, and Perinatal History

Category	Components
Maternal identification	Age, gravida, parity, weeks in gestation
Maternal medical history	Significant co-morbidities, illness, medications
Current pregnancy	Singleton or multiple fetuses
	Pertinent results of laboratory tests and imaging studies
	Fetal growth (IUGR; LGA; hydrops)
Labor	Rupture of membrane (duration)
	Amniotic fluid (oligohydramnios/polyhydramnios; bloody; purulent; meconium; foul smelling)
	Signs of infection (maternal fever, elevated WBC count, tachycardia, uterine tenderness)
	Fetal tracing (tachycardia, decelerations, etc.)
Delivery	Indication if emergent delivery (abruption; preeclampsia, fetal distress/intolerance to labor)
	Route of delivery
	Method of anesthesia (general versus local)
	Medications administered
Newborn	Apgar scores and resuscitation at delivery
	Growth parameters
	Desired feeding method

IUGR , Intrauterine growth restriction; LGA , large for gestational age; WBC , white blood cell.

Prenatal Ultrasound Findings

Ultrasound screening for fetal anomalies has become increasingly routine. Major fetal organ system abnormalities can be identified, for the most part, and the mother can be referred for counseling and appropriate fetal and neonatal management. There are, however, a number of ultrasound findings that have a variable natural history and may or may not be markers for serious conditions. Moreover, these ultrasound findings may or may not result in a definitive prenatal diagnosis, highlighting the importance of post-natal assessment and management. Here we present common prenatal ultrasound findings, organized by organ system, including recommendations for prenatal and postnatal evaluation.

Central Nervous System Findings

Choroid plexus cysts are found in 2% to 4% of second-trimester fetal ultrasound examinations. They are transient, functionally benign in nature, and generally resolve spontaneously before term. Isolated choroid plexus cysts on prenatal ultrasound examination are not associated with adverse effects on fetal growth or development. Thus, without other risk factors, no further evaluation is needed in an infant with this isolated finding who has had a benign prenatal and a normal postnatal course. Choroid plexus cysts may be a soft marker for aneuploidy (particularly trisomy 18) when associated with other fetal anomalies or with maternal risk factors, such as advanced maternal age. In such situations, current recommendations are to begin an appropriate prenatal evaluation, such as karyotyping.

Agenesis of the corpus callosum is reported to occur in 0.3% to 0.7% of unselected postnatal populations. Aneuploidies have been reported in 10% to 20% of children with this prenatal ultrasound finding, and major organ system abnormalities are reported in up to 60% of affected fetuses. Therefore, fetal magnetic resonance imaging can be considered to further assess for associated anomalies and offer enhanced risk stratification. Encouragingly, the absence of the corpus callosum in an otherwise anatomically normal fetus is associated with a normal developmental outcome in 50% to 75% of cases. Postnatal management for infants with a history of agenesis of the corpus callosum on prenatal ultrasound should include a thorough physical examination, close clinical assessment, and consideration of additional imaging if not already completed prenatally.

Mild, isolated ventriculomegaly is a relatively uncommon fetal ultrasound finding and may be a soft marker for aneuploidy, fetal infection, or other central nervous system abnormalities. As such, serial prenatal imaging studies and, in some cases, more extensive work-up are recommended. In the presence of a benign fetal assessment, most newborns appear to do well following delivery. It is important to consider close developmental follow-up and serial imaging studies, often beginning with an early postnatal cranial ultrasound, if there are additional concerns.

Cardiac Findings

Echogenic cardiac focus is an incidental ultrasound finding in 3% to 4% of normal fetuses. Notably, there is an increased incidence (10% to 30%) in Asian populations. It may be a soft marker for chromosomal abnormalities (trisomy 21 and trisomy 13) when associated with other screening abnormalities. Further work-up may be indicated in high-risk populations. If the physical examination findings for a newborn are unremarkable and there are no other ultrasound findings, no further evaluation is suggested.

Gastrointestinal Findings

Grade 0 or 1 echogenic bowel on a second-trimester ultrasound examination (i.e., less echogenic than bone) is considered a normal variant with a good prognosis. No special prenatal or postnatal work-up is recommended. Anything of density equal to or greater than that of bone (grade 2–3) is abnormal; differential diagnoses include cystic fibrosis (CF), trisomy 21, gastrointestinal anomalies, in utero infection, bowel ischemia or bleeding, intrauterine growth restriction, and/or impending in utero demise. Oftentimes, further prenatal work-up will have been performed, including parental CF testing, maternal serologic testing for cytomegalovirus (CMV) and toxoplasmosis, and amniocentesis, which allows for narrowing of the differential. If unrevealing, postnatal assessment should include consideration of aneuploidy, congenital infection, and identification of associated structural anomalies. Management often entails close monitoring for feeding tolerance, with or without abdominal imaging and additional targeted testing.

Cholelithiasis is an uncommon third-trimester fetal ultrasound finding that needs to be differentiated from hepatic calcification. Cholelithiasis is considered a benign condition requiring no special evaluation or treatment prenatally or postnatally, but careful clinical follow-up is recommended. An imaging examination at 1 year of age for a child with this prenatal finding may be helpful in documenting expected resolution.

Hepatic calcifications are uncommon fetal ultrasound findings. They are often isolated, single, and, in a low-risk mother, of no significance. However, when numerous, hepatic calcifications may be markers for fetal aneuploidy, infection, meconium peritonitis, hepatic tumor, or vascular insult. A significant percentage are associated with some form of fetal disease. Neonatal management depends on the prenatal work-up and the clinical presentation in the newborn period.

Urinary Tract Findings

Mild fetal pelviectasis is one of the more common abnormalities detected by second-trimester ultrasound, with a reported incidence of 0.5% to 5%. Diagnostic criteria differ but generally include a second-trimester renal pelvis diameter of 4 to 10 mm or a third-trimester renal pelvis diameter of 7 to 10 mm; renal pelvis diameters of ≥10 mm are always considered abnormal. Some experts consider mild fetal pelviectasis to be a soft marker for aneuploidy, especially trisomy 21. When mild fetal pelviectasis is an isolated finding, the prognosis is good, and the condition often resolves either in utero or during early childhood. In fact, the majority of children with a prenatal finding of hydronephrosis demonstrate no postnatal disease. Experts thus recommend a postnatal follow-up renal ultrasound examination approximately 1 week after birth and, if necessary, at 1 month of life to document resolution.

Evidence of hydronephrosis on prenatal ultrasound will need a postnatal evaluation with a renal ultrasound in order to identify obstructive lesions and determine the need for further evaluation for urinary reflux. The ultrasound is recommended to occur at greater than 48 hours after birth, as earlier evaluation can lead to false-negative results due to the relative oliguria that occurs on the first day of age in newborns. An ultrasound should be considered immediately after birth if evidence of obstructive uropathy is seen on the prenatal ultrasound.

The Physical Examination

For the healthy newborn, the admission examination is done after the newborn completes transition and within 24 hours of birth. A complete physical examination at this time—in an orderly sequence—is designed to efficiently detect problems that were initially unapparent or are likely to soon develop ( Box 16.1 ). The pediatrician should review the infant’s growth chart to determine whether there are discrepancies in the weight, height, and head circumference percentiles and stated GA. Although the most common reason for a discrepancy is an inaccurate measurement, a valid discrepancy warrants close clinical observation or testing. If the estimated GA of the newborn is inconsistent with the growth parameters, a formal evaluation by a Dubowitz–Ballard assessment should be performed. This scoring tool is probably the most widely used GA assessment tool in contemporary practice. Detailed descriptions and a video demonstration of this examination are available online. For greater detail on organ-specific aspects of the newborn physical exam, readers are referred to relevant sections and chapters in this textbook.

Box 16.1

Example Examination Sequence

1.
Observation (is the baby sick or well?)
2.
Auscultation of the anterior chest and abdomen (if the newborn is quiet and cooperative).
3.
Inspect and palpate the head (the back of the head and neck will be inspected later).
4.
Gently turn the head to each side (noting any restricted range of motion).
5.
Inspect each ear when the head is turned.
6.
Palpate the neck and clavicular areas (for masses and/or crepitus).
7.
Determine overall features of facial shape and symmetry.
8.
Confirm the presence or absence of abnormal findings involving skin, eyes, nose, mouth, and oral cavity.
9.
Assess respiratory pattern.
10.
Inspect and palpate the anterior chest and abdomen (including the umbilicus).
11.
Open the diaper and palpate the femoral pulses.
12.
Examine the genitalia and perineum.
13.
Inspect the lower extremities for abnormal positioning to check alignment, plantar grasp, and the Babinski reflex (start by placing the thumbs on the soles of the feet with the fingers around the back of the ankles).
14.
Perform the Barlow and Ortolani maneuvers.
15.
Lift and abduct the legs into a frog-leg position to provide a full view of the perineum and anus. Evaluate the newborn for appropriate positioning of the anus and its patency.
16.
Inspect the genitalia by gently retracting the labia majora in females or depressing the skin at the base of the penis in males. Inspect and palpate the scrotum and testes. Refasten the diaper.
17.
Take an unobstructed observation of the overall shape, symmetry, and movements of the arms and hands (shirt/clothing removed).
18.
Palpate each whole arm gently, starting with one of the examiner’s hands on each of the baby’s shoulders, and then slide down to the baby’s hands, noting any swelling or discontinuities.
19.
With the newborn supine, turn the head to elicit the asymmetric tonic neck reflex on each side.
20.
Inspect the hands, fingers, nails, and palms. If the newborn’s hand is tightly fisted, do not attempt to pry the fingers open. Instead, gently flex the wrist to 90 degrees, which will cause the fingers to relax naturally. Inspect the palms, and then elicit the palmar grasp reflex.
21.
Without releasing the baby’s hands, one can then perform the pull-to-sit maneuver. The pediatrician places his/her hand behind the newborn’s head and neck to provide support as the newborn is gently lowered back toward the bed. When the newborn’s head and shoulders are a few inches from the bed, the examiner drops his/her hand rapidly to elicit the Moro reflex. (Parents may be alerted to this portion of the examination to avoid unnecessary distress/anxiety.)
22.
Next, place the hands on either side of the chest, under the arms at the shoulders, and raise the baby to an upright position. Note the strength and tone of the shoulder muscles.
23.
Lower the newborn, still in an upright position, and try to elicit the supporting and stepping reflexes.
24.
Turn the newborn to a prone position, suspended on the examiner’s hand. Observe the newborn’s posture and tone, and elicit the incurvation response (again, explanation in advance of these actions to parents who may be observing is helpful).
25.
Inspect the newborn’s back, from the vertex of the head down to the sacrum (pulling the diaper down, if needed).
26.
Gently place the newborn back in the crib, and fully redress the newborn. Attempt to successfully soothe newborn by swaddling if the newborn has cried during the more active portions of the examination.
27.
Red reflex examination can be performed at this time or at any suitable time when the eyes are open spontaneously.

Routine Management of the Newborn

Prevention of Ophthalmia Neonatorum and Conjunctivitis

Approximately 1% to 12% of babies will develop conjunctivitis in the first 4 weeks of life. Conjunctivitis can be caused by a sexually transmitted bacterium, normal skin or nasopharyngeal flora, or chemical irritation. In addition, eye discharge can be caused by obstruction of the nasolacrimal duct rather than from conjunctivitis. The most worrisome infection is that of Neisseria gonorrhea , which can invade the cornea in a matter of hours and lead to blindness. Despite effective preventive measures known since the 1880s, thousands of children are still blinded by this infection worldwide each year.

Most states in the United States have laws or regulations requiring the administration of topical antibiotic ointment to the conjunctivae of babies within a few hours of birth. This practice has been effective in reducing the cases of blindness caused by gonococcal conjunctivitis. It is moderately effective in preventing conjunctivitis caused by chlamydia. The main risk of antibiotic ointment application is chemical conjunctivitis. Silver nitrate solution instilled into both eyes immediately after birth was the standard of care for many years, but it caused a high rate of chemical conjunctivitis.

A search for alternative, non-ointment-based prophylaxis that causes less irritation is ongoing. A variety of prophylactic treatments have been recommended, including 1% nitrate solution, 1% tetracycline solution, 1% erythromycin solution, 2.5% povidone-iodine solution, fusidic acid, and freshly expressed breast milk. Among those, tetracycline has been reported as the most effective. There is lay literature recommending the instillation of colostrum or breast milk into the eyes of babies to prevent or treat conjunctivitis, and limited scientific literature addressing the feasibility and efficacy of this approach. A randomized controlled trial from Iran comparing the efficacy of colostrum versus erythromycin ointment versus placebo in preventing neonatal conjunctivitis demonstrated some degree of protection conferred by colostrum, but results should be interpreted cautiously and are insufficient to recommend practice change in the United States.

Studies demonstrate that povidone-iodine solution is more effective and causes less irritation than erythromycin ointment. It is also less expensive but is not yet approved for this use by the US Food and Drug Administration. A major concern is that medical errors can occur if povidone-iodine soap is mistakenly substituted for the solution; it can cause eye damage. Fusidic acid has been used for preoperative prophylaxis for a number of surgical procedures in adults; however, data on its use in newborns are limited.

Vitamin K Prophylaxis

Vitamin K is necessary for biologic activation of several human proteins, most notably coagulation factors II (prothrombin), VII, IX, and X. Since placental transfer is limited, umbilical cord blood levels of vitamin K ₁ (phylloquinone) are 30-fold lower than maternal levels. Intestinal bacteria synthesize menaquinone (vitamin K ₂ ), which has 60% of the activity of phylloquinone. However, neonates have a decreased number of bacteria in their gut that manufacture vitamin K ₂ ; thus, newborns are deficient in vitamin K at birth and are at risk of significant bleeding within the first days to months of life. There are three presentations of vitamin K–deficient bleeding (VKDB) in the neonate, with the risk dramatically reduced when intramuscular (IM) vitamin K is administered shortly after birth.

“Early” VKDB presents in the first 24 hours after birth, is not prevented by postnatal administration of vitamin K, and usually occurs in newborns born to mothers who are taking medications that cross the placenta and interfere with vitamin K metabolism. The most common of these medications include many anticonvulsants (such as phenytoin), isoniazid, rifampin, warfarin, and some antibiotics (especially cephalosporins). Early VKDB is frequently serious because of intracranial or intraabdominal hemorrhage. It is estimated that in neonates at risk of early VKDB, the incidence is as high as 12%.

“Classic” VKDB occurs in newborns during the first week of life. Although the presentation is often mild, blood loss can be significant, and intracranial hemorrhages have been reported. Although estimates differ, the incidence of classic VKDB, in the absence of vitamin K supplementation, is 0.25% to 1.7%.

“Late” VKDB occurs between the ages of 2 and 12 weeks and is usually severe. The mortality rate from late VKDB is approximately 20%, and half of infants with this disorder develop intracranial hemorrhages. Late VKDB is associated with exclusive breastfeeding. Human milk contains only 1 to 4 μg of vitamin K per liter, while commercially available formula contains 50 μg/L or more. In exclusively breastfed neonates who do not receive supplemental vitamin K, the incidence of late VKDB is estimated at 4.4 to 7.2 per 100,000 (or 1 per 15,000 to 1 per 20,000).

IM vitamin K administered shortly after birth is effective in preventing classic and late VKDB by rapidly activating clotting factors. Since 1961, the United States has recommended 1 mg IM vitamin K for term newborns. In the early 1990s, controversy about this recommendation began after a study was published suggesting an association between IM vitamin K given at birth and childhood cancer. The results of subsequent studies strongly suggested that there is no increased risk of solid tumors in children given IM vitamin K. However, enough concern was raised over this possible association that in some countries vitamin K prophylaxis was transitioned to an oral preparation. While helping to allay fears about childhood malignancies, it was unclear whether an oral dosing regimen provided the same degree of protection against all forms of VKDB as the IM injection. Specifically, studies demonstrate that the efficacy of a single oral dose of vitamin K is similar to that of an IM dose in preventing classic VKDB, but offers less protection against late VKDB.

In a multination review, the rate of late VKDB in infants receiving various regimens of orally administered vitamin K ranged from 1.2 to 1.8 per 100,000, compared with no cases in 325,000 children receiving an IM dose. The rates of VKDB in newborns receiving 2 mg orally at birth plus repeated doses over the ensuing weeks are relatively low, but still higher than in neonates administered a single dose of IM vitamin K. Early data from the Netherlands suggested that infants receiving an oral vitamin K regimen of 1 mg at birth and 25 μg daily for up to 12 weeks was as effective as a single IM dose at birth in preventing both classic and late VKDB. However, a subsequent study from the Netherlands documented a higher rate of late VKDB (3.2 per 100,000) with the 1 mg/25 μg dosing regimen among a group of infants later diagnosed with biliary atresia, a significant risk factor for VKDB. This study raised questions about the ability of an oral vitamin K regimen to offer adequate protection against VKDB for higher-risk populations when the identification of risk factors may be delayed. Finally, no cases of late VKDB were found among 396,000 Danish infants who received an oral dose of 2 mg of vitamin K at birth and 1 mg weekly until the age of 3 months.

Highlighted by the reports of intracranial hemorrhages in four newborns from Tennessee who did not receive vitamin K at birth, there are concerns that the rate of parental refusal of vitamin K in the United States has been increasing. Although there has been little widespread surveillance of the rates of vitamin K refusals, recent studies suggest that rates in North America may range from 0.5% to 3%, and that rates are higher for newborns born in birthing centers than in hospitals. Rather than being concerned about the reports linking vitamin K with childhood cancers, parents who refuse vitamin K treatment for the newborn are also more likely to refuse vaccines for their children at later ages and share many of the beliefs of other parents refusing vaccines for their children. In one study the most commonly cited reason for parents refusing vitamin K treatment for their newborns was “synthetic or toxic ingredients,” followed by concerns about an “excessive dose” and side effects; only 7% of those surveyed were concerned about the risks of cancer.

The risks of IM vitamin K include pain at the injection site and the possibility of a serious medication error. The risks of a significant complication from the injection are probably negligible; in one study, no significant complications were reported after 420,000 injections. In the United States, oral administration is complicated by the lack of an oral vitamin K preparation licensed for newborns. In some settings, infants have received the IM preparation orally. However, tolerability may be a problem, and the efficacy of this preparation when given orally may not be comparable with the oral formulations used in Europe. In addition, adherence to repeated doses of orally administered vitamin K in infants may be suboptimal. Finally, it is unknown whether the use of repeated administration of an oral vitamin K preparation in the dose range of 1 to 2 mg each week is associated with an increased risk of childhood cancers.

For parents who have questions regarding the best method to prevent classic and late VKDB, we suggest the clinician discuss the pros and cons of IM versus oral administration of vitamin K. If the parents decline IM vitamin K administration but agree to oral administration, a dose of 2 mg should be given shortly after birth, with subsequent doses until the newborn is at least 4 weeks old if breastfed. These recommendations are based on a policy report developed by the American Academy of Pediatrics (AAP) addressing prophylactic vitamin K administration, which states that if an oral vitamin K formulation becomes licensed for use in the United States , providers may administer 2 mg by mouth at birth, at 1 to 2 weeks of age, and at 4 weeks of age.

Universal Hepatitis B Immunization

The implementation of routine hepatitis B virus (HBV) immunization during infancy has been associated with a dramatic decrease in the incidence of this infection. Between 1990 (before routine vaccination of infants) and 2004, the overall incidence of acute hepatitis B infection in the United States declined by 75% and by 94% among children and adolescents, respectively. Both the Centers for Disease Control and Prevention and the AAP recommend that the initial dose of the three-dose HBV immunization series be given within the first 24 hours of life for medically stable infants with birth weight ≥ 2 kg and at day of life 30 or discharge (whichever is sooner) for infants with birth weight less than 2 kg.

There are at least two advantages of providing the first dose of HBV vaccine during the initial hospital stay. First, newborns who receive a birth dose are more likely to complete their HBV immunization series on time than those who receive the first dose later. Second, since a dose of HBV vaccine given within 12 hours of birth can prevent vertical transmission of HBV infections in 75% to 90% of cases, early provision of immunization serves as a “safety net” in cases where there has been an error in identifying a mother who is HBV surface antigen positive. There is no evidence that administration of a birth dose of HBV vaccine leads to more evaluations for sepsis because of adverse events related to the immunization.

Newborn Feeding

Breastfeeding

There is voluminous evidence that the optimal nutrition for healthy neonates is human milk provided via the mother’s breast. Growing evidence supports the role of human milk in the prevention of the early onset of allergies, prevention of adult obesity, reduction in severity and frequency of infections (including those leading to hospitalization in developed countries and those leading to death in developing countries), and increased intellectual functioning. It is a public health imperative and incumbent on our society to provide systems that support breastfeeding.

Support of Breastfeeding

Breastfeeding is not always the “easy and natural” undertaking it is touted to be. Primiparous mothers report more difficulties than multiparous mothers. Breastfeeding support begins with encouragement and education at prenatal visits. After birth, in-person lactation support is helpful in promoting both initiation and continuation of nursing. Places of employment should provide support by having adequate maternity care leave policies, improving facilities for nursing women, and having policies allowing time and space for nursing and pumping for lactating women at the workplace. Fathers and grandparents should provide a supportive social network by performing home care tasks to facilitate rest for lactating mothers. Problems with nursing should trigger additional intervention with lactation specialist evaluation and advice.

In 1991, the WHO and the United Nations Children’s Fund developed a program to promote breastfeeding called the Baby-Friendly Hospital Initiative (BFHI). As a comprehensive program, implementation of the 10 steps of the BFHI ( Box 16.2 ) has been shown to significantly increase the rates of breastfeeding. In addition, there is evidence of a “dose-response” relationship between the number of BFHI steps that women are exposed to and improved breastfeeding outcomes.

Box 16.2

Baby-Friendly Hospital Initiative: Ten Steps to Successful Breastfeeding

1.
Maintain a written breastfeeding policy that is routinely communicated to all healthcare staff.
2.
Train all healthcare staff in the skills necessary to implement this policy.
3.
Inform all pregnant women about the benefits and management of breastfeeding.
4.
Help mothers initiate breastfeeding within 1 h of birth.
5.
Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their newborns.
6.
Give newborns no food or drink other than breast milk unless medically indicated.
7.
Practice “rooming-in”—allow mothers and newborns to remain together 24 h/day.
8.
Encourage unrestricted breastfeeding (breastfeeding on demand).
9.
Give no pacifiers or artificial nipples to breastfeeding newborns.
10.
Foster the establishment of breastfeeding support groups and refer mothers to them on their discharge from the hospital or clinic.

For some of the individual steps of the BFHI, such as excluding the use of pacifiers, the evidence is contradictory. There are a number of epidemiologic studies showing cessation of breastfeeding is associated with pacifier use, but the few randomized prospective trials done give different results. The authors of a review concluded that among mothers who were motivated to breastfeed, pacifier use did not significantly affect the prevalence or duration of breastfeeding. Sucking is a primitive brain self-soothing process. Babies with certain temperaments may benefit more than others by using sucking to self-soothe. Pacifier use has been shown in some studies since the 1970s to decrease the risk of sudden infant death syndrome (SIDS), and in premature infants, nonnutritive sucking actually enhances weight gain. The AAP developed a policy statement supporting pacifier use but recommended waiting until approximately 1 month of age. The important issue is whether or not the use of a pacifier is replacing feedings, so if a mother is motivated to breastfeed and maintains a frequency of 8 to 12 feedings per day, the use of a pacifier between meals is reasonable.

Another contentious issue is the use of supplemental formula during the initial newborn period. The results of a randomized prospective trial indicated that use of limited supplemental formula was associated with increased breastfeeding rates at 3 months of age. That seems contradictory to earlier studies showing a decline in nursing when formula samples or discharge packages were given to families. One key difference is that in the trial, formula use was limited to 10 mL after feedings, administered via a syringe, and supplement was discontinued once mature milk was produced. More research is needed to determine which mother–infant dyads will benefit from supplement while avoiding sabotage of breastfeeding.

From a practical standpoint, there are several evidence-based interventions during the newborn nursery stay that increase the rate and/or duration of breastfeeding. These include the use of frequent demand feedings as opposed to a rigid feeding schedule, early skin-to-skin contact between the mother and the newborn, professional advice on breastfeeding techniques, and exclusion of commercial formula from discharge packs.

Challenges With Breastfeeding

Breast milk development is divided into three phases. The first, lactogenesis I, begins during pregnancy with breast enlargement due to the proliferation of ducts and lobules and concludes with colostrum production. Lactogenesis II occurs usually about 56 to 72 hours after delivery; gonadotropin and progesterone levels decline and prolactin level increases. This phase is characterized by a rapid increase in milk volume—sometimes this is exuberant to the point of engorgement. Lactogenesis III occurs after approximately one month of nursing when the milk composition and volume are responsive to the reciprocal relationship between the mother and her baby—a demand and supply feedback loop. Some experts combine lactogenesis II and lactogenesis III into one phase.

Delays in lactogenesis II may occur after cesarean birth, in poorly controlled diabetic mothers, when there is stress during delivery, when there are retained placental fragments, and when there is pituitary failure. There are some situations when no milk production occurs, leading to frustration and feelings of failure in mothers. The timing of lactogenesis II is biologically fixed and cannot be accelerated by pumping or frequent nursing.

More than 90% of mothers report concern and difficulty with nursing during the first 10 days after delivery ( Fig. 16.1 ). Combined with hormonal changes and sleep deprivation, this can compound the risk of postpartum depression and early cessation of nursing. Postpartum depression screening should be conducted at pediatric health supervision visits until the infant is 6 to 12 months of age.

Fig. 16.1, Prevalence of reported breastfeeding concerns by mothers by newborn age.

Common issues that may lead to early cessation of breastfeeding include nipple pain, newborn jaundice, excessive weight loss or poor weight gain, concern about maternal medications, and lack of social support. There are also conditions associated with low milk volume production, including maternal factors (lack of social support, prenatal confidence and expectations about breastfeeding, timing of return to work, inadequate frequency of nursing, inadequate breast tissue, flat or inverted nipples, large breasts) and infant factors (hypotonia, drug withdrawal, asymmetric jaw, high arched palate, poor tongue motor abilities, temperamental issues).

For nipple pain, there is no treatment that is clearly advantageous (e.g., hydrogel, lanolin, breast milk, shields), but education on latch position is helpful. For most, the pain decreases within the first 7 days regardless of the treatment selected. Nipple shields can be used to help decrease nipple pain, but there is some concern that their use could interfere with milk transfer.

There has been a recent increase in the use of frenotomy to alleviate pain with nursing, presumably due to a tight lingual frenulum (tongue-tie or ankyloglossia). With the use of objective rating scales, the rate of tongue-tie in newborns is about 1% to 4%, but more infants are undergoing frenotomy, and there are concerns that this may be more due to anecdotal reports rather than more rigorous study. Sometimes frenotomy is done to alleviate the frustrations of mothers (and lactation specialists) who are dealing with breastfeeding problems of unknown origin. There are few prospective studies evaluating frenotomy, and two recent systematic reviews did not find a consistent positive effect of lingual frenotomy on infant breastfeeding. It may be prudent to wait until the physiologic process of lactogenesis II and early nipple pain have passed before frenotomy is considered. Although the procedure is simple and relatively free of side effects, unnecessary interventions should be avoided in newborn care whenever possible. Frenotomy for posterior tongue-tie has received extra scrutiny because evidence is lacking to support improved outcomes after treatment, and the procedure is more invasive.

Jaundice became more prevalent with the resurgence of breastfeeding and is discussed in more detail elsewhere in this textbook. Consistent with efforts to promote breastfeeding, a rising bilirubin level should serve as a call for action to emphasize lactation support rather than lead to a separation of the newborn from the mother and artificial feeding to lower the bilirubin level.

The normal newborn is born with a surplus of extracellular free water, and in cesarean delivery births, mothers are often given additional boluses of fluids that may further hydrate the newborn. It is normal, expected, and perhaps preferable that babies will lose this free water in the first 72 hours of life. This free water is protective of the newborn’s fluid balance while the mother’s milk comes in. In cases of extra hydration, extra weight loss may be expected. The average term newborn loses about 7% of birthweight, with 12% of newborns born vaginally losing more than 10% of birthweight ( Fig. 16.2 ). The loss during the first 24 hours of life can predict those who will lose more. This is not a state of dehydration but is a normal physiologic adaption to extrauterine life, so healthcare providers should not alarm parents or suggest that there is something wrong with their baby.

Fig. 16.2, Nomograms of weight loss in exclusively breastfed newborns born vaginally (A) or by cesarean delivery (B).

With the onset of copious production of mature milk, neonates begin to gain weight and their serum sodium levels fall. Newborns fed human milk regain their birthweight, on average, by the age of 8.3 days; 97.5% have regained their birthweight by 21 days. In newborns who lose substantially more than 10% of their birthweight because of breastfeeding difficulties, there is the potential for significant hypernatremia, and these infants should be monitored closely.

Supplementation of Breastfeeding

It is usually unnecessary to provide any nutrition or fluid to breastfed term newborns beyond human milk. Oral dextrose or commercial formula may be needed in neonates with hypoglycemia whose blood glucose levels are not responsive to breastfeeding alone. Supplementation may also be indicated in newborns who have lost more than 10% of their birthweight and/or have decreased urine and stool output or in the presence of significant hyperbilirubinemia. Supplementation should be considered a temporary intervention, and its provision should not interfere with the initiation of successful breastfeeding.

Temporary supplemental formula or expressed breast milk when available can be provided via a supplemental nursing system, finger feeding, or a bottle. Of greatest importance is close monitoring of the change in weight of the baby and continued lactation support. The use of banked or donor milk is increasing, and human milk banks have now been established in over 60 countries globally. However, there remains little authoritative guidance on the implementation, operation, and regulation of human milk banks and appropriate the use of donor milk. The importance of safe operational guidelines and a coordinating body to collate and communicate data have been recently highlighted by the milk-banking community, and efforts to create the evidence base necessary for guideline development are ongoing. However, in the absence of existing evidence and guidelines, there remains concern about the routine use of donated human milk outside of the hospital setting, especially for otherwise healthy term newborns for whom there is a paucity of evidence to support its value in promoting health and mitigating illness.

Contraindications to Breastfeeding

The few absolute contraindications to breastfeeding include untreated maternal tuberculosis, evidence of current maternal cocaine use or antimetabolite drugs, and neonatal galactosemia. Hepatitis C virus RNA has been found in the milk of mothers infected with this virus; however, the transmission of infection via breastfeeding has not been documented. Therefore, maternal hepatitis C is not considered a contraindication to breastfeeding.

Maternal HIV infection has historically been considered an absolute contraindication to breastfeeding. However, in more recent years, there has been an increase in the number of HIV-positive mothers expressing a desire to breastfeed. Oftentimes, mothers are from low- and middle-income countries where the risk-benefit analysis of breastfeeding is different, due to high rates of infant mortality and limited access to safe water and affordable infant formulas. In this context, although the risk of HIV transmission with breastfeeding is present, it is lower than the risk of infant morbidity and mortality from other causes, especially with strict maternal adherence to an antiretroviral medication regimen and persistently undetectable viral loads. In many instances, these mothers have breastfed previous children in their home country, and are confused or resistant when breastfeeding is not recommended upon relocation to the United States. Lastly, in some cultural communities, especially enclaves of families originally from Africa, the maternal HIV diagnosis is not disclosed to the extended family, and the mother choosing to formula feed and avoid breastfeeding raises suspicion of maternal HIV infection and stigmatizes the mother.

Although breastfeeding among HIV-positive mothers in the United States remains strongly discouraged, there are some mothers who will decide to breastfeed, despite extensive counseling. In these instances, risk-reduction strategies should be implemented to reduce the possibility of HIV transmission. For more detail, readers are referred to Chapter 34 , Viral Infections of the Fetus and Newborn. In addition, comprehensive recommendations and further details regarding risk-reduction strategies can be found on the Center for Disease Control and Prevention’s website. Due to the complexity and clinical equipoise surrounding this issue, decision-making should include outpatient pediatric providers who will be responsible for follow-up care.

There are a number of drugs that raise concern for adversely impacting infant long-term neurodevelopment. Selective serotonin reuptake inhibitors are commonly used to treat depression and anxiety in young women. Among the drugs in this category, sertraline and paroxetine are thought to be the safest for use in breastfeeding mothers, while fluoxetine and citalopram are felt to have the most potential for toxicity in the neonate. Overall, few adverse effects have been noted with the use of any of these drugs, and generally the potential risks associated with these medications are thought to be outweighed by the benefits of breastfeeding. Similarly, although methadone is detectable in the breast milk of women receiving this medication, serum levels in neonates are quite low and unlikely to have a significant effect. Online references are available detailing the current scientific knowledge of the effects of toxins and medications in breast milk.

Formula Feeding

Commercial formula that provides adequate nutrition, vitamins, and minerals is available for infants of mothers who do not choose (or are unable) to breastfeed their infants or in those rare instances when breastfeeding is contraindicated. There are three major categories of formula used in neonates: cow’s milk-based, soy, and hydrolyzed formula. Of these, cow’s milk-based formula is the most commonly used. The main carbohydrate in cow’s milk-based formula is lactose. Soy formulas were developed for infants with suspected cow’s milk allergy. Because the main carbohydrate in soy formulas is sucrose or corn syrup, soy formula can be used in neonates with suspected galactosemia. Protein hydrolysate formulas were initially developed for use in infants who are highly intolerant to cow’s milk protein. They are purported to lead to fewer allergies in babies and children than cow’s milk-based formula, but the evidence for this is limited. All extensively hydrolyzed formulas are lactose-free. Extensively hydrolyzed formulas are indicated in infants with definitive evidence of cow’s milk protein allergy because 10% to 14% of such children also have a soy allergy.

Traditionally, standard preparations of formulas available for use in healthy term neonates provided 0.67 kcal/mL. This caloric density was based on the calories in human milk. However, the results of some studies indicate that the average caloric density of human milk may be closer to 0.64 to 0.65 kcal/mL. Based on these additional data, some infant formulas have been modified to provide 0.643 kcal/mL (19 kcal/oz). Most commercially available formulas are fortified with iron at a concentration of 10 to 12 mg/L and vitamin D at a concentration of 400 IU/L.

Mothers who elect to give their babies formula report feeling unsupported in their decision by healthcare professionals, and up to 50% feel pressured to breastfeed. Although the benefits of breastfeeding should be provided to mothers who have not decided how to feed their babies, the role of healthcare providers is also to support the decision of those who have elected to provide formula feedings to their babies. It is also important to provide practical education about formula feeding to these parents; this is frequently not done in many newborn nurseries.

Newborns who are fed formula can feed ad lib beginning shortly after birth. The average formula intake in term newborns during the first day of life is 15 to 20 mL/kg and is 40 to 45 mL/kg during the second day. Term newborns who are formula fed during their birth hospitalization typically lose less weight than breastfed infants. The median weight loss in formula-fed term newborns at 48 hours of life has been reported to be 2.9% of birthweight for those born vaginally and 3.7% among those born by cesarean delivery; weight loss of 7% or more during a typical newborn nursery stay in formula-fed infants is uncommon.

Umbilical Cord Care

Bacterial colonization of the umbilical cord can lead to omphalitis, and in some cases may be associated with thrombophlebitis, cellulitis, or necrotizing fasciitis. To decrease the risk of bacterial infection and serious illness, many methods of umbilical cord care have been developed worldwide. Although various topical substances continue to be used, the more recent practice in high-resource settings has been towards dry umbilical cord care. Based on the results of multiple meta-analyses, dry cord care without the application of topical substances is currently recommended for hospital births and those in high resource settings; for infants born outside of the hospital in communities with high neonatal mortality rates, application of topical chlorhexidine is recommended. Regardless of the method of cord care used, parents and healthcare providers should monitor for redness around the umbilical cord stump, and seek medical attention and further intervention to avoid serious bacterial illness.

Tetanus neonatorum, with the infection occurring via the umbilical cord, continues to be reported in more than 20 developing countries, resulting in 58,000 neonatal deaths per year. The condition is related to low vaccination rates in women of childbearing age, home deliveries, and certain cultural care practices. Public health efforts focusing on effective vaccination programs and the use of “clean bed” deliveries are needed to eliminate the disease.

Circumcision

Neonatal circumcision is a polarizing issue for both healthcare professionals and parents. Those who favor routine circumcision highlight health benefits such as the decreased risk of urinary tract infections (UTIs), reduced risk of penile cancer, and possibly lower rates of sexually transmitted infections, including HIV. Those who oppose the procedure point out that the number of circumcisions needed to be performed to prevent one of these outcomes (number needed to treat) is large, that the risks of the procedure balance out the benefits, that circumcision may lead to loss of sexual sensation, and that subjecting a neonate to a painful procedure without clear benefits may be unethical. In 2012, the AAP published a policy statement concluding that the benefits of circumcision outweighed the risks of the procedure. However, these health benefits were not great enough to recommend routine circumcision in all male neonates.

It is clear that circumcision reduces the risk of UTI by 3- to 10-fold. However, given the low incidence of UTI in male newborns, 100 boys need to be circumcised to prevent one UTI. Similarly, although circumcision has been shown to prevent penile cancer, this is an extremely rare condition, and the number needed to treat is about 900. The results of studies in three African countries indicate that circumcision reduces the risk of HIV infection by 56%. In the United States, where HIV infection rates are lower, it has been estimated that circumcision might decrease the acquisition of HIV through heterosexual transmission by 16%; 298 boys would need to be circumcised to prevent one case of HIV infection. There is also limited evidence suggesting that circumcision might reduce the risk of other sexually transmitted infections, including syphilis and genital herpes. However, there is no compelling evidence that circumcision reduces the risk of chlamydia or gonorrhea.

Circumcision is generally a safe procedure. Although some increased bleeding is reported after 1% of circumcisions, the rate of significant complications is about 0.2%. Bleeding, sometimes requiring suturing of a vessel, is the most common significant complication, followed by penile injury and infection. Infection is more common following a circumcision using a Plastibell rather than a Gomco clamp; the incidence of hemorrhage is reportedly similar after either technique.

Circumcision is an uncomfortable experience for the neonate. Small amounts of sucrose solutions can be offered to the baby for soothing. Pain from the actual surgery can be significantly decreased with the use of a dorsal penile nerve block or ring block. In one study, 65% of newborns who received a dorsal nerve block had no or minimal response to the initial clamping of the foreskin. However, the results of a randomized controlled trial suggest that ring block provides superior analgesia compared with a dorsal penile nerve block. Although topical anesthesia may be better than no anesthesia, it provides inferior pain relief compared with a dorsal penile nerve block.

A poor cosmetic outcome can be caused by the removal of too little foreskin. It has been estimated that 1% to 9.5% of circumcisions are redone because of parental concern regarding the appearance. In a prospective study among boys younger than 3 years who had been circumcised with the use of either a Plastibell clamp or a Mogen clamp, the glans were fully exposed in only 35.6%. However, in older circumcised boys, the glans was fully exposed in more than 90%. This suggests that parents of a circumcised infant should be counseled that the vast majority of properly done circumcisions will lead to an acceptable cosmetic appearance over time.

In the United States, the Gomco clamp is the most commonly used apparatus for performing circumcisions, followed by the Plastibell clamp and the Mogen clamp. The use of the Mogen clamp, which was designed by a Jewish mohel, leads to shorter procedures and, reportedly, less pain and bleeding than the other techniques. However, less foreskin is removed with the use of the Mogen clamp than with the other two techniques.

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